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Zeltzer D, Einav L, Rashba J, Waisman Y, Haimi M, Balicer RD. Adoption and utilization of device-assisted telemedicine. J Health Econ 2023; 90:102780. [PMID: 37331155 DOI: 10.1016/j.jhealeco.2023.102780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/20/2023]
Abstract
We estimate the effect of adopting a digital device for performing medical exams at home during telehealth visits. We match visits of adopters and non-adopters who used the same virtual care clinic but without the device and compare healthcare utilization after the matched visits. We find that device adoption, partially offset by decreased use of other primary care modalities, results in a 12% higher utilization rate of primary care and increased use of antibiotics. But - particularly among adults - adoption lowers the use of urgent care, the emergency room, and hospital care, resulting in no increase in total cost.
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Affiliation(s)
- Dan Zeltzer
- School of Economics, Tel Aviv University, Israel.
| | - Liran Einav
- Department of Economics, Stanford University, United States of America; NBER, United States of America.
| | - Joseph Rashba
- School of Economics, Tel Aviv University, Israel; Clalit Health Services, Israel.
| | - Yehezkel Waisman
- Clalit Health Services, Israel; School of Medicine, Tel Aviv University, Israel.
| | - Motti Haimi
- Clalit Health Services, Israel; Faculty of Medicine, Technion - Israel Institute of Technology, Israel; School of Public Health, the University of Haifa, Israel.
| | - Ran D Balicer
- Clalit Health Services, Israel; Department of Epidemiology, Ben Gurion University, Israel.
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2
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Flaks-Manov N, Shadmi E, Yahalom R, Perry-Mezre H, Balicer RD, Srulovici E. Identification of elderly patients at risk for 30-day readmission: Clinical insight beyond big data prediction. J Nurs Manag 2022; 30:3743-3753. [PMID: 34661943 DOI: 10.1111/jonm.13495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/13/2021] [Accepted: 10/13/2021] [Indexed: 12/30/2022]
Abstract
AIM This study explores the potential benefit of combining clinicians' risk assessments and the automated 30-day readmission prediction model. BACKGROUND Automated readmission prediction models based on electronic health records are increasingly applied as part of prevention efforts, but their accuracy is moderate. METHODS This prospective multisource study was based on self-reported surveys of clinicians and data from electronic health records. The survey was performed at 15 internal medicine wards of three general Clalit hospitals between May 2016 and June 2017. We examined the degree of concordance between the Preadmission Readmission Detection Model, clinicians' readmission risk classification and the likelihood of actual readmission. Decision trees were developed to classify patients by readmission risk. RESULTS A total of 694 surveys were collected for 371 patients. The disagreement between clinicians' risk assessment and the model was 34.5% for nurses and 33.5% for physicians. The decision tree algorithms identified 22% and 9% (based on nurses and physicians, respectively) of the model's low-medium-risk patients as high risk (accuracy 0.8 and 0.76, respectively). CONCLUSIONS Combining the Readmission Model with clinical insight improves the ability to identify high-risk elderly patients. IMPLICATIONS FOR NURSING MANAGEMENT This study provides algorithms for the decision-making process for selecting high-risk readmission patients based on nurses' evaluations.
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Affiliation(s)
- Natalie Flaks-Manov
- Institute for Computational Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Efrat Shadmi
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel.,Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Rina Yahalom
- Hospital Division, Clalit Health Services, Tel Aviv, Israel
| | | | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel
| | - Einav Srulovici
- Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
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Steinberg DM, Balicer RD, Benjamini Y, De-Leon H, Gazit D, Rossman H, Sprecher E. The role of models in the covid-19 pandemic. Isr J Health Policy Res 2022; 11:36. [PMID: 36266704 PMCID: PMC9584247 DOI: 10.1186/s13584-022-00546-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/04/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022] Open
Abstract
Mathematical and statistical models have played an important role in the analysis of data from COVID-19. They are important for tracking the progress of the pandemic, for understanding its spread in the population, and perhaps most significantly for forecasting the future course of the pandemic and evaluating potential policy options. This article describes the types of models that were used by research teams in Israel, presents their assumptions and basic elements, and illustrates how they were used, and how they influenced decisions. The article grew out of a “modelists’ dialog” organized by the Israel National Institute for Health Policy Research with participation from some of the leaders in the local modeling effort.
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Affiliation(s)
- David M Steinberg
- Department of Statistics and Operations Research, Tel Aviv University, Tel Aviv, Israel.
| | - Ran D Balicer
- Innovation Division, Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel.,School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Yoav Benjamini
- Department of Statistics and Operations Research, Tel Aviv University, Tel Aviv, Israel
| | - Hilla De-Leon
- Faculty of Biology, Technion-Israel Institute of Technology, Haifa, Israel
| | - Doron Gazit
- Racah Institute of Physics, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hagai Rossman
- Department of Computer Science and Applied Mathematics, Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Eli Sprecher
- Division of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Velosa M, Hochner H, Yerushalmi B, Harel S, Friss C, Calderon-Margalit R, Paltiel O, Manor O, Balicer RD, Greenfeld S, Kariv R, Ledderman N, Matz E, Peter I, Friedlander Y, Turner D. Pre- and Perinatal Factors Predicting Inflammatory Bowel Disease: A Population-Based Study with Fifty Years of Follow-Up. J Crohns Colitis 2022; 16:1397-1404. [PMID: 35299254 DOI: 10.1093/ecco-jcc/jjac043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 12/29/2021] [Accepted: 03/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pre- and perinatal events may be associated with an increased risk of inflammatory bowel disease [IBD]. We aimed to investigate the role of pre- and perinatal factors as potential risk factors for the development of IBD in a population with a follow-up of 50 years. METHODS We conducted a nested case-control study, reporting IBD incidence among individuals born in 1964-76, for whom pre- and perinatal exposures were reported as part of the Jerusalem Perinatal Study [JPS], by linking them to the database of the epidemiology group of the Israeli IBD Research Nucleus [epi-IIRN], including all IBD patients in Israel since 2005 and their matched controls. RESULTS We identified 2789 individuals within the epi-IIRN cohort who were also included in the JPS cohort [n = 90 079]: 746 IBD patients (405 with Crohn's disease [CD] and 341 with ulcerative colitis [UC]) and 2043 non-IBD controls. Those with a 'Non-western' family origin had decreased odds of developing CD and UC. High socioeconomic status was associated with CD but not UC. Low birth weight [≤2500 g] occurred less frequently in IBD cases compared to controls, especially in UC patients, showing a protective effect. Being the first born was associated with CD, and having older siblings lowered the odds of developing CD, decreasing 7% with each additional sibling. Smoking and breastfeeding data were available for a subset of individuals, but neither was associated with IBD development. CONCLUSION This population-based study identifies several pre- and perinatal variables as predictors of IBD development. This information may be helpful to facilitate implementation of early diagnosis interventions and family follow-up protocols.
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Affiliation(s)
- Monica Velosa
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | - Hagit Hochner
- Braun School of Public Health, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Baruch Yerushalmi
- Department of Gastroenterology and Hepatology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Sasha Harel
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | - Chagit Friss
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | | | - Ora Paltiel
- Hadassah, Hebrew University Braun School of Public Health, Jerusalem, Israel
| | - Orly Manor
- Braun School of Public Health, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ran D Balicer
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv, Israel
| | | | | | | | - Eran Matz
- Leumit Health Services, Tel Aviv, Israel
| | - Inga Peter
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Yechiel Friedlander
- Braun School of Public Health, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
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5
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Cohen-Stavi CJ, Magen O, Barda N, Yaron S, Peretz A, Netzer D, Giaquinto C, Judd A, Leibovici L, Hernán MA, Lipsitch M, Reis BY, Balicer RD, Dagan N. BNT162b2 Vaccine Effectiveness against Omicron in Children 5 to 11 Years of Age. N Engl J Med 2022; 387:227-236. [PMID: 35767475 PMCID: PMC9258754 DOI: 10.1056/nejmoa2205011] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Limited evidence is available on the real-world effectiveness of the BNT162b2 vaccine against coronavirus disease 2019 (Covid-19) and specifically against infection with the omicron variant among children 5 to 11 years of age. METHODS Using data from the largest health care organization in Israel, we identified a cohort of children 5 to 11 years of age who were vaccinated on or after November 23, 2021, and matched them with unvaccinated controls to estimate the vaccine effectiveness of BNT162b2 among newly vaccinated children during the omicron wave. Vaccine effectiveness against documented severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and symptomatic Covid-19 was estimated after the first and second vaccine doses. The cumulative incidence of each outcome in the two study groups through January 7, 2022, was estimated with the use of the Kaplan-Meier estimator, and vaccine effectiveness was calculated as 1 minus the risk ratio. Vaccine effectiveness was also estimated in age subgroups. RESULTS Among 136,127 eligible children who had been vaccinated during the study period, 94,728 were matched with unvaccinated controls. The estimated vaccine effectiveness against documented infection was 17% (95% confidence interval [CI], 7 to 25) at 14 to 27 days after the first dose and 51% (95% CI, 39 to 61) at 7 to 21 days after the second dose. The absolute risk difference between the study groups at days 7 to 21 after the second dose was 1905 events per 100,000 persons (95% CI, 1294 to 2440) for documented infection and 599 events per 100,000 persons (95% CI, 296 to 897) for symptomatic Covid-19. The estimated vaccine effectiveness against symptomatic Covid-19 was 18% (95% CI, -2 to 34) at 14 to 27 days after the first dose and 48% (95% CI, 29 to 63) at 7 to 21 days after the second dose. We observed a trend toward higher vaccine effectiveness in the youngest age group (5 or 6 years of age) than in the oldest age group (10 or 11 years of age). CONCLUSIONS Our findings suggest that as omicron was becoming the dominant variant, two doses of the BNT162b2 messenger RNA vaccine provided moderate protection against documented SARS-CoV-2 infection and symptomatic Covid-19 in children 5 to 11 years of age. (Funded by the European Union through the VERDI project and others.).
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Affiliation(s)
- Chandra J Cohen-Stavi
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Ori Magen
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Noam Barda
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Shlomit Yaron
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Alon Peretz
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Doron Netzer
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Carlo Giaquinto
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Ali Judd
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Leonard Leibovici
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Miguel A Hernán
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Marc Lipsitch
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Ben Y Reis
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Ran D Balicer
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
| | - Noa Dagan
- From the Clalit Research Institute, Innovation Division (C.J.C.-S., O.M., R.D.B., N.D.), and the Community Medicine Division (S.Y., A.P., D.N.), Clalit Health Services, and the Faculty of Medicine, Tel-Aviv University (L.L.), Tel Aviv, the Research Authority, Rabin Medical Center, Petah-Tiqva (L.L.), the ARC (Accelerate Redesign Collaborate) Innovation Center, Chaim Sheba Medical Center at Tel HaShomer, Ramat-Gan (N.B.), Software and Information Systems Engineering (N.B., N.D.), and the School of Public Health (R.D.B.), Ben Gurion University of the Negev, Be'er Sheva, and the School of Public Health, University of Haifa, Haifa (A.P.) - all in Israel; the Departments of Biomedical Informatics (N.B., B.Y.R., N.D.) and Pediatrics (B.Y.R.), Harvard Medical School, CAUSALab, Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston; the Department of Women and Child Health, University of Padua, Padua, Italy (C.G.); and the Medical Research Council Clinical Trials Unit, University College London, London (A.J.)
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Bielopolski D, Libresco G, Barda N, Dagan N, Steinmetz T, Yahav D, Charytan DM, Balicer RD, Rozen-Zvi B. BNT162b2 vaccine effectiveness in chronic kidney disease patients – an observational study. Clin Kidney J 2022; 15:1838-1846. [PMID: 36147707 PMCID: PMC9384353 DOI: 10.1093/ckj/sfac166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
chronic kidney disease (CKD) is a risk factor for severe COVID-19. We aimed to evaluate real-life effectiveness of the BNT162b2 mRNA vaccine for a range of outcomes in patients with CKD compared to matched controls.
Methods
Data from Israel's largest healthcare organization were retrospectively used. Vaccinated CKD (eGFR<60ml/min/1.73m2) and maintenance dialysis patients were matched to vaccinated controls without CKD (eGFR> = 60ml/min/1.73m2) according to demographic and clinical characteristics. Study outcomes included documented infection with SARS-CoV-2, symptomatic infection, COVID-19 related hospitalization, severe disease, and death. Vaccine effectiveness was estimated as the risk ratio [RR] at days 7-28 following the second vaccine dose, using the Kaplan–Meier estimator. Effectiveness measures were also evaluated separately for various stages of CKD.
Results
There were 67,861 CKD patients not treated with dialysis, 2,606 hemodialysis patients, and 70,467 matched controls. The risk of sever disease (RR1.84, 95% CI 0.95-2.67) and death (RR 2.00, 95% CI 0.99-5.20) was increased in non-dialysis CKD patients compared with controls without CKD following vaccination.
For the subgroup of patients with eGFR below 30 ml/min/1.73m2, the risk of severe disease and death was increased compared to controls (RR 6.42, 95% CI 1.85-17.51 and RR 8.81, 95% CI 1.63-13.81, respectively). The risks for all study outcomes was increased in hemodialysis patients, compared with controls.
Conclusion
Two doses of the BNT162b2 vaccine were found less efficient for patients with eGFR<30ml/min/1.73m2. Risk in hemodialysis patients is increased for all outcomes. These results suggest prioritizing patients with eGFR<30ml/min/1.73m2 for booster shots, pre and post exposure prophylaxis, and early COVID-19 therapy.
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Affiliation(s)
| | - Gilad Libresco
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel
| | - Noam Barda
- ARC Innovation Center, Sheba Medical Center, Ramat-Gan, Israel
- Department of Software and Information Systems Engineering, Ben Gurion University, Be'er Sheva, Israel
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Noa Dagan
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel
- Department of Software and Information Systems Engineering, Ben Gurion University, Be'er Sheva, Israel
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Ramat-Gan, Israel
| | - Tali Steinmetz
- Department of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dafna Yahav
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Infectious Diseases Unit, Rabin Medical Center, Petah-Tikva, Israel
| | - David M Charytan
- Nephrology Division, New York University Langone Medical Center and Grossman School of Medicine, New York, NY, USA
| | - Ran D Balicer
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel
- Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Ramat-Gan, Israel
- School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Benaya Rozen-Zvi
- Department of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Magen O, Waxman JG, Makov-Assif M, Vered R, Dicker D, Hernán MA, Lipsitch M, Reis BY, Balicer RD, Dagan N. Fourth Dose of BNT162b2 mRNA Covid-19 Vaccine in a Nationwide Setting. N Engl J Med 2022; 386:1603-1614. [PMID: 35417631 PMCID: PMC9020581 DOI: 10.1056/nejmoa2201688] [Citation(s) in RCA: 169] [Impact Index Per Article: 84.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND With large waves of infection driven by the B.1.1.529 (omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), alongside evidence of waning immunity after the booster dose of coronavirus disease 2019 (Covid-19) vaccine, several countries have begun giving at-risk persons a fourth vaccine dose. METHODS To evaluate the early effectiveness of a fourth dose of the BNT162b2 vaccine for the prevention of Covid-19-related outcomes, we analyzed data recorded by the largest health care organization in Israel from January 3 to February 18, 2022. We evaluated the relative effectiveness of a fourth vaccine dose as compared with that of a third dose given at least 4 months earlier among persons 60 years of age or older. We compared outcomes in persons who had received a fourth dose with those in persons who had not, individually matching persons from these two groups with respect to multiple sociodemographic and clinical variables. A sensitivity analysis was performed with the use of parametric Poisson regression. RESULTS The primary analysis included 182,122 matched pairs. Relative vaccine effectiveness in days 7 to 30 after the fourth dose was estimated to be 45% (95% confidence interval [CI], 44 to 47) against polymerase-chain-reaction-confirmed SARS-CoV-2 infection, 55% (95% CI, 53 to 58) against symptomatic Covid-19, 68% (95% CI, 59 to 74) against Covid-19-related hospitalization, 62% (95% CI, 50 to 74) against severe Covid-19, and 74% (95% CI, 50 to 90) against Covid-19-related death. The corresponding estimates in days 14 to 30 after the fourth dose were 52% (95% CI, 49 to 54), 61% (95% CI, 58 to 64), 72% (95% CI, 63 to 79), 64% (95% CI, 48 to 77), and 76% (95% CI, 48 to 91). In days 7 to 30 after a fourth vaccine dose, the difference in the absolute risk (three doses vs. four doses) was 180.1 cases per 100,000 persons (95% CI, 142.8 to 211.9) for Covid-19-related hospitalization and 68.8 cases per 100,000 persons (95% CI, 48.5 to 91.9) for severe Covid-19. In sensitivity analyses, estimates of relative effectiveness against documented infection were similar to those in the primary analysis. CONCLUSIONS A fourth dose of the BNT162b2 vaccine was effective in reducing the short-term risk of Covid-19-related outcomes among persons who had received a third dose at least 4 months earlier. (Funded by the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute.).
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Affiliation(s)
- Ori Magen
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Jacob G Waxman
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Maya Makov-Assif
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Roni Vered
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Dror Dicker
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Miguel A Hernán
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Marc Lipsitch
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Ben Y Reis
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Ran D Balicer
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Noa Dagan
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
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Waxman JG, Makov-Assif M, Reis BY, Netzer D, Balicer RD, Dagan N, Barda N. Comparing COVID-19-related hospitalization rates among individuals with infection-induced and vaccine-induced immunity in Israel. Nat Commun 2022; 13:2202. [PMID: 35459237 PMCID: PMC9033865 DOI: 10.1038/s41467-022-29858-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/30/2022] [Indexed: 11/09/2022] Open
Abstract
With the COVID-19 pandemic ongoing, accurate assessment of population immunity and the effectiveness of booster and enhancer vaccine doses is critical. We compare COVID-19-related hospitalization incidence rates in 2,412,755 individuals across four exposure levels: non-recent vaccine immunity (two BNT162b2 COVID-19 vaccine doses five or more months prior), boosted vaccine immunity (three BNT162b2 doses), infection-induced immunity (previous COVID-19 without a subsequent BNT162b2 dose), and enhanced infection-induced immunity (previous COVID-19 with a subsequent BNT162b2 dose). Rates, adjusted for potential demographic, clinical and health-seeking-behavior confounders, were assessed from July-November 2021 when the Delta variant was predominant. Compared with non-recent vaccine immunity, COVID-19-related hospitalization incidence rates were reduced by 89% (87–91%) for boosted vaccine immunity, 66% (50–77%) for infection-induced immunity and 75% (61–83%) for enhanced infection-induced immunity. We demonstrate that infection-induced immunity (enhanced or not) provides more protection against COVID-19-related hospitalization than non-recent vaccine immunity, but less protection than booster vaccination. Additionally, our results suggest that vaccinating individuals with infection-induced immunity further enhances their protection. The relative degree of immunity to SARS-CoV-2 provided by combinations of natural infection, vaccination, and booster doses is unknown. Here, the authors show that infection-induced immunity provides more protection against COVID-19-related hospitalization than non-recent vaccine immunity, but less than booster vaccination.
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Affiliation(s)
- Jacob G Waxman
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel.
| | - Maya Makov-Assif
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel
| | - Ben Y Reis
- Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA
| | - Doron Netzer
- Community Medical Services Division, Clalit Health Services, Tel Aviv, Israel
| | - Ran D Balicer
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel.,The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA.,School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Noa Dagan
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel.,The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA.,Software and Information Systems Engineering, Ben Gurion University, Be'er Sheva, Israel.,Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Noam Barda
- Software and Information Systems Engineering, Ben Gurion University, Be'er Sheva, Israel.,Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA.,Arc Innovation Center, Sheba Medical Center, Ramat-Gan, Israel
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9
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Auster O, Finkel U, Dagan N, Barda N, Laufer A, Balicer RD, Ben-Shachar S. Short-term Adverse Events After the Third Dose of the BNT162b2 mRNA COVID-19 Vaccine in Adults 60 Years or Older. JAMA Netw Open 2022; 5:e227657. [PMID: 35435973 PMCID: PMC9016488 DOI: 10.1001/jamanetworkopen.2022.7657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This survey study assesses the occurrence of short-term adverse events in adults 60 years or older who received a booster dose of the BNT162B2 mRNA vaccine.
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Affiliation(s)
- Oren Auster
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel
| | - Uriah Finkel
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel
| | - Noa Dagan
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel
- Software and Information Systems Engineering, Ben Gurion University, Be'er Sheva, Israel
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
- The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, at Harvard Medical School and Clalit Research Institute, Boston, Massachusetts
| | - Noam Barda
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel
- Software and Information Systems Engineering, Ben Gurion University, Be'er Sheva, Israel
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
- The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, at Harvard Medical School and Clalit Research Institute, Boston, Massachusetts
| | - Alon Laufer
- Clalit Health Services, Tel Aviv, Israel
- School of Public Health, University of Haifa, Haifa, Israel
| | - Ran D. Balicer
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel
- Clalit Health Services, Tel Aviv, Israel
- School of Public Health, Ben Gurion University, Be'er Sheva, Israel
| | - Shay Ben-Shachar
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel
- The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, at Harvard Medical School and Clalit Research Institute, Boston, Massachusetts
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Hayek S, Shaham G, Ben-Shlomo Y, Kepten E, Dagan N, Nevo D, Lipsitch M, Reis BY, Balicer RD, Barda N. Indirect protection of children from SARS-CoV-2 infection through parental vaccination. Science 2022; 375:1155-1159. [PMID: 35084938 DOI: 10.1126/science.abm3087] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Children not vaccinated against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may still benefit from vaccines through protection from vaccinated contacts. We estimated the protection provided to children through parental vaccination with the BNT162b2 vaccine. We studied households without prior infection consisting of two parents and unvaccinated children, estimating the effect of parental vaccination on the risk of infection for unvaccinated children. We studied two periods separately-an early period (17 January 2021 to 28 March 2021; Alpha variant, two doses versus no vaccination) and a late period (11 July 2021 to 30 September 2021; Delta variant, booster dose versus two vaccine doses). We found that having a single vaccinated parent was associated with a 26.0 and a 20.8% decreased risk in the early and late periods, respectively, and having two vaccinated parents was associated with a 71.7 and a 58.1% decreased risk, respectively. Thus, parental vaccination confers substantial protection on unvaccinated children in the household.
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Affiliation(s)
- Samah Hayek
- Clalit Research Institute, Clalit Health Services, Ramat Gan, Israel
| | - Galit Shaham
- Clalit Research Institute, Clalit Health Services, Ramat Gan, Israel
| | - Yatir Ben-Shlomo
- Clalit Research Institute, Clalit Health Services, Ramat Gan, Israel
| | - Eldad Kepten
- Clalit Research Institute, Clalit Health Services, Ramat Gan, Israel
| | - Noa Dagan
- Clalit Research Institute, Clalit Health Services, Ramat Gan, Israel
- Software and Information Systems Engineering, Ben Gurion University, Be'er Sheva, Israel
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA
| | - Daniel Nevo
- Department of Statistics and Operations Research, Tel Aviv University, Tel Aviv, Israel
| | - Marc Lipsitch
- Center for Communicable Disease Dynamics, Department of Epidemiology, and Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ben Y Reis
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA
- Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA, USA
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Ramat Gan, Israel
- School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheba, Israel
| | - Noam Barda
- Clalit Research Institute, Clalit Health Services, Ramat Gan, Israel
- Software and Information Systems Engineering, Ben Gurion University, Be'er Sheva, Israel
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA
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11
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Katz MA, Harlev EB, Chazan B, Chowers M, Greenberg D, Peretz A, Tshori S, Levy J, Yacobi M, Hirsch A, Amichay D, Weinberger R, Dor AB, Taraday EK, Reznik D, Chayat CB, Sagas D, Zvi HB, Berdinstein R, Rashid G, Avni YS, Mandelboim M, Zuckerman N, Rainy N, Akriv A, Dagan N, Kepten E, Barda N, Balicer RD. Early effectiveness of BNT162b2 Covid-19 vaccine in preventing SARS-CoV-2 infection in healthcare personnel in six Israeli hospitals (CoVEHPI). Vaccine 2022; 40:512-520. [PMID: 34903372 PMCID: PMC8662353 DOI: 10.1016/j.vaccine.2021.11.092] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Methodologically rigorous studies on Covid-19 vaccine effectiveness (VE) in preventing SARS-CoV-2 infection are critically needed to inform national and global policy on Covid-19 vaccine use. In Israel, healthcare personnel (HCP) were initially prioritized for Covid-19 vaccination, creating an ideal setting to evaluate early real-world VE in a closely monitored population. METHODS We conducted a prospective study among HCP in 6 hospitals to estimate the effectiveness of the BNT162b2 mRNA Covid-19 vaccine in preventing SARS-CoV-2 infection. Participants filled out weekly symptom questionnaires, provided weekly nasal specimens, and three serology samples - at enrollment, 30 days and 90 days. We estimated VE against PCR-confirmed SARS-CoV-2 infection using the Cox Proportional Hazards model and against a combined PCR/serology endpoint using Fisher's exact test. RESULTS Of the 1567 HCP enrolled between December 27, 2020 and February 15, 2021, 1250 previously uninfected participants were included in the primary analysis; 998 (79.8%) were vaccinated with their first dose prior to or at enrollment, all with Pfizer BNT162b2 mRNA vaccine. There were four PCR-positive events among vaccinated participants, and nine among unvaccinated participants. Adjusted two-dose VE against any PCR-confirmed infection was 94.5% (95% CI: 82.6%-98.2%); adjusted two-dose VE against a combined endpoint of PCR and seroconversion for a 60-day follow-up period was 94.5% (95% CI: 63.0%-99.0%). Five PCR-positive samples from study participants were sequenced; all were alpha variant. CONCLUSIONS Our prospective VE study of HCP in Israel with rigorous weekly surveillance found very high VE for two doses of Pfizer BNT162b2 mRNA vaccine against SARS-CoV-2 infection in recently vaccinated HCP during a period of predominant alpha variant circulation. FUNDING Clalit Health Services.
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Affiliation(s)
- Mark A Katz
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel; School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel; University of Michigan, School of Public Health, Ann Arbor, MI, USA
| | - Efrat Bron Harlev
- Schneider Children's Medical Center of Israel, Petach Tikvah, Israel
| | - Bibiana Chazan
- Infectious Diseases and Infection Control Unit, Ha'Emek Medical Center, Afula, Israel; Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Michal Chowers
- Infectious Diseases, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - David Greenberg
- Pediatric Infectious Disease Unit the Pediatric Division, Soroka University Medical Center, Beer Sheva, Israel; Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Alon Peretz
- Occupational Medicine Clinic, Rabin Medical Center, Petah Tikva, Israel
| | - Sagi Tshori
- Research Authority, Kaplan Medical Center, Rehovot, Israel; The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joseph Levy
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel
| | - Mili Yacobi
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel
| | - Avital Hirsch
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel
| | - Doron Amichay
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel; Clalit Central Laboratory, Clalit Health Services, Tel Aviv, Israel
| | - Ronit Weinberger
- Clalit Central Laboratory, Clalit Health Services, Tel Aviv, Israel
| | - Anat Ben Dor
- Clalit Central Laboratory, Clalit Health Services, Tel Aviv, Israel
| | | | - Dana Reznik
- Schneider Children's Medical Center of Israel, Petach Tikvah, Israel
| | - Chen Barazani Chayat
- Multidisciplinary Laboratory, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel
| | - Dana Sagas
- Clinical Microbiology Laboratory, Ha'Emek Medical Center, Afula, Israel
| | - Haim Ben Zvi
- Microbiology Department, Rabin Medical Center, Petah Tikva, Israel
| | - Rita Berdinstein
- The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Microbiology Department, Kaplan Medical Center, Rehovot, Israel
| | - Gloria Rashid
- Department of Clinical Laboratories, Meir Medical Center, Kfar Saba, Israel
| | | | - Michal Mandelboim
- Central Virology Laboratory, Chaim Sheba Medical Center, Ministry of Health, Ramat Gan, Israel; Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, School of Public Health, Tel Aviv University, Tel Aviv, Israel
| | - Neta Zuckerman
- Central Virology Laboratory, Chaim Sheba Medical Center, Ministry of Health, Ramat Gan, Israel
| | - Nir Rainy
- Laboratory Division, Shamir Medical Center, Zerifin, Israel
| | - Amichay Akriv
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel
| | - Noa Dagan
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel; Software and Information Systems Engineering, Ben Gurion University, Beer Sheva, Israel; Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA; Ivan and Francesca Berkowitz Family Living Laboratory at Harvard Medical School, Boston, MA, USA
| | - Eldad Kepten
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel
| | - Noam Barda
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel; Software and Information Systems Engineering, Ben Gurion University, Beer Sheva, Israel; Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA; Ivan and Francesca Berkowitz Family Living Laboratory at Harvard Medical School, Boston, MA, USA
| | - Ran D Balicer
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel; School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel.
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12
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Lipsitch M, Krammer F, Regev-Yochay G, Lustig Y, Balicer RD. SARS-CoV-2 breakthrough infections in vaccinated individuals: measurement, causes and impact. Nat Rev Immunol 2022; 22:57-65. [PMID: 34876702 PMCID: PMC8649989 DOI: 10.1038/s41577-021-00662-4] [Citation(s) in RCA: 163] [Impact Index Per Article: 81.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 02/04/2023]
Abstract
Breakthrough infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in fully vaccinated individuals are receiving intense scrutiny because of their importance in determining how long restrictions to control virus transmission will need to remain in place in highly vaccinated populations as well as in determining the need for additional vaccine doses or changes to the vaccine formulations and/or dosing intervals. Measurement of breakthrough infections is challenging outside of randomized, placebo-controlled, double-blind field trials. However, laboratory and observational studies are necessary to understand the impact of waning immunity, viral variants and other determinants of changing vaccine effectiveness against various levels of coronavirus disease 2019 (COVID-19) severity. Here, we describe the approaches being used to measure vaccine effectiveness and provide a synthesis of the burgeoning literature on the determinants of vaccine effectiveness and breakthrough rates. We argue that, rather than trying to tease apart the contributions of factors such as age, viral variants and time since vaccination, the rates of breakthrough infection are best seen as a consequence of the level of immunity at any moment in an individual, the variant to which that individual is exposed and the severity of disease being considered. We also address key open questions concerning the transition to endemicity, the potential need for altered vaccine formulations to track viral variants, the need to identify immune correlates of protection, and the public health challenges of using various tools to counter breakthrough infections, including boosters in an era of global vaccine shortages.
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Affiliation(s)
- Marc Lipsitch
- Center for Communicable Disease Dynamics, Department of Epidemiology and Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Florian Krammer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gili Regev-Yochay
- Infection Prevention & Control Unit, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaniv Lustig
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Central Virology Laboratory, Public Health Services, Ministry of Health, Sheba Medical Center, Tel-Hashomer, Israel
| | - Ran D Balicer
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel
- The School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
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13
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Affiliation(s)
- Noa Dagan
- Clalit Research Institute, Tel Aviv, Israel
| | - Noam Barda
- Clalit Research Institute, Tel Aviv, Israel
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14
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Barda N, Dagan N, Cohen C, Hernán MA, Lipsitch M, Kohane IS, Reis BY, Balicer RD. Effectiveness of a third dose of the BNT162b2 mRNA COVID-19 vaccine for preventing severe outcomes in Israel: an observational study. Lancet 2021; 398:2093-2100. [PMID: 34756184 PMCID: PMC8555967 DOI: 10.1016/s0140-6736(21)02249-2] [Citation(s) in RCA: 578] [Impact Index Per Article: 192.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/17/2021] [Accepted: 10/01/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many countries are experiencing a resurgence of COVID-19, driven predominantly by the delta (B.1.617.2) variant of SARS-CoV-2. In response, these countries are considering the administration of a third dose of mRNA COVID-19 vaccine as a booster dose to address potential waning immunity over time and reduced effectiveness against the delta variant. We aimed to use the data repositories of Israel's largest health-care organisation to evaluate the effectiveness of a third dose of the BNT162b2 mRNA vaccine for preventing severe COVID-19 outcomes. METHODS Using data from Clalit Health Services, which provides mandatory health-care coverage for over half of the Israeli population, individuals receiving a third vaccine dose between July 30, 2020, and Sept 23, 2021, were matched (1:1) to demographically and clinically similar controls who did not receive a third dose. Eligible participants had received the second vaccine dose at least 5 months before the recruitment date, had no previous documented SARS-CoV-2 infection, and had no contact with the health-care system in the 3 days before recruitment. Individuals who are health-care workers, live in long-term care facilities, or are medically confined to their homes were excluded. Primary outcomes were COVID-19-related admission to hospital, severe disease, and COVID-19-related death. The third dose effectiveness for each outcome was estimated as 1 - risk ratio using the Kaplan-Meier estimator. FINDINGS 1 158 269 individuals were eligible to be included in the third dose group. Following matching, the third dose and control groups each included 728 321 individuals. Participants had a median age of 52 years (IQR 37-68) and 51% were female. The median follow-up time was 13 days (IQR 6-21) in both groups. Vaccine effectiveness evaluated at least 7 days after receipt of the third dose, compared with receiving only two doses at least 5 months ago, was estimated to be 93% (231 events for two doses vs 29 events for three doses; 95% CI 88-97) for admission to hospital, 92% (157 vs 17 events; 82-97) for severe disease, and 81% (44 vs seven events; 59-97) for COVID-19-related death. INTERPRETATION Our findings suggest that a third dose of the BNT162b2 mRNA vaccine is effective in protecting individuals against severe COVID-19-related outcomes, compared with receiving only two doses at least 5 months ago. FUNDING The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute.
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Affiliation(s)
- Noam Barda
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel; Software and Information Systems Engineering, Ben Gurion University of the Negev, Be'er Sheva, Israel; Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA; The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA
| | - Noa Dagan
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel; Software and Information Systems Engineering, Ben Gurion University of the Negev, Be'er Sheva, Israel; Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA; The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA
| | - Cyrille Cohen
- The Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
| | - Miguel A Hernán
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA; CAUSALab, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Marc Lipsitch
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Center for Communicable Disease Dynamics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Isaac S Kohane
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA; The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Ben Y Reis
- The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA; Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Ran D Balicer
- Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel; School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel; The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA.
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15
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Witberg G, Barda N, Hoss S, Richter I, Wiessman M, Aviv Y, Grinberg T, Auster O, Dagan N, Balicer RD, Kornowski R. Myocarditis after Covid-19 Vaccination in a Large Health Care Organization. N Engl J Med 2021; 385:2132-2139. [PMID: 34614329 PMCID: PMC8531986 DOI: 10.1056/nejmoa2110737] [Citation(s) in RCA: 383] [Impact Index Per Article: 127.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Reports have suggested an association between the development of myocarditis and the receipt of messenger RNA (mRNA) vaccines against coronavirus disease 2019 (Covid-19), but the frequency and severity of myocarditis after vaccination have not been extensively explored. METHODS We searched the database of Clalit Health Services, the largest health care organization (HCO) in Israel, for diagnoses of myocarditis in patients who had received at least one dose of the BNT162b2 mRNA vaccine (Pfizer-BioNTech). The diagnosis of myocarditis was adjudicated by cardiologists using the case definition used by the Centers for Disease Control and Prevention. We abstracted the presentation, clinical course, and outcome from the patient's electronic health record. We performed a Kaplan-Meier analysis of the incidence of myocarditis up to 42 days after the first vaccine dose. RESULTS Among more than 2.5 million vaccinated HCO members who were 16 years of age or older, 54 cases met the criteria for myocarditis. The estimated incidence per 100,000 persons who had received at least one dose of vaccine was 2.13 cases (95% confidence interval [CI], 1.56 to 2.70). The highest incidence of myocarditis (10.69 cases per 100,000 persons; 95% CI, 6.93 to 14.46) was reported in male patients between the ages of 16 and 29 years. A total of 76% of cases of myocarditis were described as mild and 22% as intermediate; 1 case was associated with cardiogenic shock. After a median follow-up of 83 days after the onset of myocarditis, 1 patient had been readmitted to the hospital, and 1 had died of an unknown cause after discharge. Of 14 patients who had left ventricular dysfunction on echocardiography during admission, 10 still had such dysfunction at the time of hospital discharge. Of these patients, 5 underwent subsequent testing that revealed normal heart function. CONCLUSIONS Among patients in a large Israeli health care system who had received at least one dose of the BNT162b2 mRNA vaccine, the estimated incidence of myocarditis was 2.13 cases per 100,000 persons; the highest incidence was among male patients between the ages of 16 and 29 years. Most cases of myocarditis were mild or moderate in severity. (Funded by the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute.).
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Affiliation(s)
- Guy Witberg
- From the Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), the Faculty of Medicine, Tel Aviv University (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), and the Innovation Division, Clalit Research Institute, Clalit Health Services (N.B., O.A., N.D., R.D.B.), Tel Aviv, and the Department of Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben Gurion University, Be'er Sheva - all in Israel; and the Department of Biomedical Informatics, Harvard Medical School (N.B., N.D.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., R.D.B.) - both in Boston
| | - Noam Barda
- From the Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), the Faculty of Medicine, Tel Aviv University (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), and the Innovation Division, Clalit Research Institute, Clalit Health Services (N.B., O.A., N.D., R.D.B.), Tel Aviv, and the Department of Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben Gurion University, Be'er Sheva - all in Israel; and the Department of Biomedical Informatics, Harvard Medical School (N.B., N.D.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., R.D.B.) - both in Boston
| | - Sara Hoss
- From the Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), the Faculty of Medicine, Tel Aviv University (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), and the Innovation Division, Clalit Research Institute, Clalit Health Services (N.B., O.A., N.D., R.D.B.), Tel Aviv, and the Department of Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben Gurion University, Be'er Sheva - all in Israel; and the Department of Biomedical Informatics, Harvard Medical School (N.B., N.D.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., R.D.B.) - both in Boston
| | - Ilan Richter
- From the Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), the Faculty of Medicine, Tel Aviv University (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), and the Innovation Division, Clalit Research Institute, Clalit Health Services (N.B., O.A., N.D., R.D.B.), Tel Aviv, and the Department of Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben Gurion University, Be'er Sheva - all in Israel; and the Department of Biomedical Informatics, Harvard Medical School (N.B., N.D.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., R.D.B.) - both in Boston
| | - Maya Wiessman
- From the Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), the Faculty of Medicine, Tel Aviv University (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), and the Innovation Division, Clalit Research Institute, Clalit Health Services (N.B., O.A., N.D., R.D.B.), Tel Aviv, and the Department of Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben Gurion University, Be'er Sheva - all in Israel; and the Department of Biomedical Informatics, Harvard Medical School (N.B., N.D.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., R.D.B.) - both in Boston
| | - Yaron Aviv
- From the Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), the Faculty of Medicine, Tel Aviv University (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), and the Innovation Division, Clalit Research Institute, Clalit Health Services (N.B., O.A., N.D., R.D.B.), Tel Aviv, and the Department of Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben Gurion University, Be'er Sheva - all in Israel; and the Department of Biomedical Informatics, Harvard Medical School (N.B., N.D.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., R.D.B.) - both in Boston
| | - Tzlil Grinberg
- From the Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), the Faculty of Medicine, Tel Aviv University (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), and the Innovation Division, Clalit Research Institute, Clalit Health Services (N.B., O.A., N.D., R.D.B.), Tel Aviv, and the Department of Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben Gurion University, Be'er Sheva - all in Israel; and the Department of Biomedical Informatics, Harvard Medical School (N.B., N.D.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., R.D.B.) - both in Boston
| | - Oren Auster
- From the Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), the Faculty of Medicine, Tel Aviv University (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), and the Innovation Division, Clalit Research Institute, Clalit Health Services (N.B., O.A., N.D., R.D.B.), Tel Aviv, and the Department of Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben Gurion University, Be'er Sheva - all in Israel; and the Department of Biomedical Informatics, Harvard Medical School (N.B., N.D.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., R.D.B.) - both in Boston
| | - Noa Dagan
- From the Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), the Faculty of Medicine, Tel Aviv University (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), and the Innovation Division, Clalit Research Institute, Clalit Health Services (N.B., O.A., N.D., R.D.B.), Tel Aviv, and the Department of Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben Gurion University, Be'er Sheva - all in Israel; and the Department of Biomedical Informatics, Harvard Medical School (N.B., N.D.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., R.D.B.) - both in Boston
| | - Ran D Balicer
- From the Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), the Faculty of Medicine, Tel Aviv University (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), and the Innovation Division, Clalit Research Institute, Clalit Health Services (N.B., O.A., N.D., R.D.B.), Tel Aviv, and the Department of Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben Gurion University, Be'er Sheva - all in Israel; and the Department of Biomedical Informatics, Harvard Medical School (N.B., N.D.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., R.D.B.) - both in Boston
| | - Ran Kornowski
- From the Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), the Faculty of Medicine, Tel Aviv University (G.W., S.H., I.R., M.W., Y.A., T.G., R.K.), and the Innovation Division, Clalit Research Institute, Clalit Health Services (N.B., O.A., N.D., R.D.B.), Tel Aviv, and the Department of Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben Gurion University, Be'er Sheva - all in Israel; and the Department of Biomedical Informatics, Harvard Medical School (N.B., N.D.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., R.D.B.) - both in Boston
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Affiliation(s)
| | - Noam Barda
- Clalit Research Institute, Tel Aviv, Israel
| | | | | | | | - Marc Lipsitch
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - Noa Dagan
- Clalit Research Institute, Tel Aviv, Israel
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Stulman MY, Asayag N, Focht G, Brufman I, Cahan A, Ledderman N, Matz E, Chowers Y, Eliakim R, Ben-Horin S, Odes S, Dotan I, Balicer RD, Benchimol EI, Turner D. Epidemiology of Inflammatory Bowel Diseases in Israel: A Nationwide Epi-Israeli IBD Research Nucleus Study. Inflamm Bowel Dis 2021; 27:1784-1794. [PMID: 33438721 DOI: 10.1093/ibd/izaa341] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are currently no nationwide data on the epidemiology of inflammatory bowel diseases (IBD) in Israel. We aimed to determine the population-based epidemiological trends of IBD in the diverse Israeli population. METHODS Health-administrative data were retrieved from all 4 Israeli health maintenance organizations, insuring 98% of the population, using validated identification algorithms. National trends were determined using Joinpoint regression analysis calculating annual percent change and average annual percent change (AAPC). RESULTS By 2019, there were 46,074 patients with IBD in Israel, corresponding to a national prevalence of 519/100,000 (0.52%), of whom 54.1% had Crohn disease (CD) and 45.9% had ulcerative colitis (UC). The number of Jewish patients doubled from 18,701 in 2005 (354/100,000) to 38,950 (589/100,000) in 2018 (AAPC, +4.0%; P < 0.05), and the number of Arab patients increased 3-fold from 1096 (102.1/100,000) to 3534 (240.7/100,000; AAPC, +6.8%; P < 0.05) during the same years. However, the increase rate has gradually decelerated over time (annual percent change during 2005-2008, 2009-2014, and 2005-2018 was +6.7%, +4.2%, and +2.3%, respectively; P < 0.05). Pediatric prevalence increased from 37.4 to 52.2/100,000, with CD predominating in both Jews and Arabs. The incidence of CD remained stable (from 15.9/100,000 to 14.9/100,000) and the incidence of UC decreased (15.4/100,000 to 10.5/100,000 (AAPC, -3.2%; P < 0.001)). In contrast, pediatric incidence of CD increased from 7.3/100,000 to 8.3/100,000 (AAPC, +1.9%; P < 0.05) and that of UC increased from 2.6 to 4.4/100,000 (AAPC, +5.8%; P < 0.05). CONCLUSIONS The IBD prevalence rate in Israel is still increasing but gradually decelerating, probably due to the decreasing overall IBD incidence. Nonetheless, incidence rate in children is still increasing. Ongoing narrowing in the rates between Jews and Arabs over time may indicate shared environmental factors.
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Affiliation(s)
- Mira Y Stulman
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.,Braun School of Public and Community Medicine, The Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Noa Asayag
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gili Focht
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Brufman
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv, Israel
| | - Amos Cahan
- Maccabi Healthcare Services, Tel Aviv, Israel
| | | | - Eran Matz
- Leumit Health Services, Tel Aviv, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Healthcare Campus, Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Rami Eliakim
- Department of Gastroenterology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shmuel Odes
- Department of Gastroenterology and Hepatology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tivka, and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ran D Balicer
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv, Israel
| | - Eric I Benchimol
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,CHEO Inflammatory Bowel Disease Centre and CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Dan Turner
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
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Barda N, Dagan N, Ben-Shlomo Y, Kepten E, Waxman J, Ohana R, Hernán MA, Lipsitch M, Kohane I, Netzer D, Reis BY, Balicer RD. Safety of the BNT162b2 mRNA Covid-19 Vaccine in a Nationwide Setting. N Engl J Med 2021; 385:1078-1090. [PMID: 34432976 PMCID: PMC8427535 DOI: 10.1056/nejmoa2110475] [Citation(s) in RCA: 616] [Impact Index Per Article: 205.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Preapproval trials showed that messenger RNA (mRNA)-based vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had a good safety profile, yet these trials were subject to size and patient-mix limitations. An evaluation of the safety of the BNT162b2 mRNA vaccine with respect to a broad range of potential adverse events is needed. METHODS We used data from the largest health care organization in Israel to evaluate the safety of the BNT162b2 mRNA vaccine. For each potential adverse event, in a population of persons with no previous diagnosis of that event, we individually matched vaccinated persons to unvaccinated persons according to sociodemographic and clinical variables. Risk ratios and risk differences at 42 days after vaccination were derived with the use of the Kaplan-Meier estimator. To place these results in context, we performed a similar analysis involving SARS-CoV-2-infected persons matched to uninfected persons. The same adverse events were studied in the vaccination and SARS-CoV-2 infection analyses. RESULTS In the vaccination analysis, the vaccinated and control groups each included a mean of 884,828 persons. Vaccination was most strongly associated with an elevated risk of myocarditis (risk ratio, 3.24; 95% confidence interval [CI], 1.55 to 12.44; risk difference, 2.7 events per 100,000 persons; 95% CI, 1.0 to 4.6), lymphadenopathy (risk ratio, 2.43; 95% CI, 2.05 to 2.78; risk difference, 78.4 events per 100,000 persons; 95% CI, 64.1 to 89.3), appendicitis (risk ratio, 1.40; 95% CI, 1.02 to 2.01; risk difference, 5.0 events per 100,000 persons; 95% CI, 0.3 to 9.9), and herpes zoster infection (risk ratio, 1.43; 95% CI, 1.20 to 1.73; risk difference, 15.8 events per 100,000 persons; 95% CI, 8.2 to 24.2). SARS-CoV-2 infection was associated with a substantially increased risk of myocarditis (risk ratio, 18.28; 95% CI, 3.95 to 25.12; risk difference, 11.0 events per 100,000 persons; 95% CI, 5.6 to 15.8) and of additional serious adverse events, including pericarditis, arrhythmia, deep-vein thrombosis, pulmonary embolism, myocardial infarction, intracranial hemorrhage, and thrombocytopenia. CONCLUSIONS In this study in a nationwide mass vaccination setting, the BNT162b2 vaccine was not associated with an elevated risk of most of the adverse events examined. The vaccine was associated with an excess risk of myocarditis (1 to 5 events per 100,000 persons). The risk of this potentially serious adverse event and of many other serious adverse events was substantially increased after SARS-CoV-2 infection. (Funded by the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute.).
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Affiliation(s)
- Noam Barda
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
| | - Noa Dagan
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
| | - Yatir Ben-Shlomo
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
| | - Eldad Kepten
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
| | - Jacob Waxman
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
| | - Reut Ohana
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
| | - Miguel A Hernán
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
| | - Marc Lipsitch
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
| | - Isaac Kohane
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
| | - Doron Netzer
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
| | - Ben Y Reis
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
| | - Ran D Balicer
- From the Clalit Research Institute, Innovation Division (N.B., N.D., Y.B.-S., E.K., J.W., R.O., R.D.B.), and the Community Medical Services Division (D.N.), Clalit Health Services, Tel Aviv, and Software and Information Systems Engineering (N.B., N.D.) and the School of Public Health, Faculty of Health Sciences (R.D.B.), Ben-Gurion University of the Negev, Be'er Sheva - both in Israel; the Department of Biomedical Informatics (N.B., N.D., I.K.), and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (N.B., N.D., I.K., B.Y.R., R.D.B.), Harvard Medical School (B.Y.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), CAUSALab (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.) - all in Boston
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19
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Assa A, Assayag N, Balicer RD, Gabay H, Greenfeld S, Kariv R, Ledderman N, Matz E, Dotan I, Ledder O, Yerushalmy-Feler A, Turner D, Cohen S. Pediatric-onset Inflammatory Bowel Disease Has Only a Modest Effect on Final Growth: A Report From the epi-IIRN. J Pediatr Gastroenterol Nutr 2021; 73:223-230. [PMID: 33587410 DOI: 10.1097/mpg.0000000000003072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The impact of pediatric-onset inflammatory bowel disease (IBD) on growth is debated. We aimed to investigate the effect of IBD on anthropometric measures at young adulthood. METHODS Children diagnosed with Crohn disease (CD) or ulcerative colitis (UC) (2005-2019) were identified in a national database along with matched non-IBD controls. RESULTS Overall, 2229 IBD cases (68% CD) were matched to 4338 controls. Only females with CD differed in final height from controls (z scores: -0.37 ± 1.09 vs -0.25 ± 1.06, respectively; P = 0.01), corresponding to a mean difference of 0.7 ± 0.2 cm (all females) and 1.2 ± 0.3 cm in females diagnosed <14 years (P = 0.02). Final height was reduced in both sexes according to adjusted mean height difference analysis (-0.43 cm, 95% confidence interval -0.85 to -0.02; P = 0.04). This difference increased in patients with CD who underwent abdominal surgery (-0.91 cm, 95% confidence interval -1.39 to -0.42; P = 0.01). The proportion of patients with CD achieving final height z scores of -1 and zero differed significantly from controls for both males (71.1% and 34.8% vs 79.1% and 43.0%, respectively; P < 0.001) and females (67.7% and 30.4% vs 79.6%, and 43.3%, respectively; P < 0.001). Patients treated with anti-tumor necrosis factor agents during growth potential had similar height improvement to other regimens. Predominantly, patients with CD were leaner, with a greater proportion of subjects with underweight, compared with controls. CONCLUSIONS In pediatric-onset IBD, absolute final height was modestly affected by females with CD. Nevertheless, greater proportions of both sexes with early diagnosis of CD failed to achieve normal final height, compared with controls.
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Affiliation(s)
- Amit Assa
- Department of Pediatrics, Assuta Ashdod University Hospital, Ashdod
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva
| | - Noa Assayag
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem
| | - Ran D Balicer
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv
| | - Hagit Gabay
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv
| | | | - Revital Kariv
- Maccabi Healthcare Services, Tel Aviv
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oren Ledder
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem
| | - Anat Yerushalmy-Feler
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel-Aviv Sourasky Medical Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Turner
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem
| | - Shlomi Cohen
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel-Aviv Sourasky Medical Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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20
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Kustin T, Harel N, Finkel U, Perchik S, Harari S, Tahor M, Caspi I, Levy R, Leshchinsky M, Ken Dror S, Bergerzon G, Gadban H, Gadban F, Eliassian E, Shimron O, Saleh L, Ben-Zvi H, Keren Taraday E, Amichay D, Ben-Dor A, Sagas D, Strauss M, Shemer Avni Y, Huppert A, Kepten E, Balicer RD, Netzer D, Ben-Shachar S, Stern A. Evidence for increased breakthrough rates of SARS-CoV-2 variants of concern in BNT162b2-mRNA-vaccinated individuals. Nat Med 2021; 27:1379-1384. [PMID: 34127854 PMCID: PMC8363499 DOI: 10.1038/s41591-021-01413-7] [Citation(s) in RCA: 235] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/26/2021] [Indexed: 12/28/2022]
Abstract
The BNT162b2 mRNA vaccine is highly effective against SARS-CoV-2. However, apprehension exists that variants of concern (VOCs) may evade vaccine protection, due to evidence of reduced neutralization of the VOCs B.1.1.7 and B.1.351 by vaccine sera in laboratory assays. We performed a matched cohort study to examine the distribution of VOCs in infections of BNT162b2 mRNA vaccinees from Clalit Health Services (Israel) using viral genomic sequencing, and hypothesized that if vaccine effectiveness against a VOC is reduced, its proportion among breakthrough cases would be higher than in unvaccinated controls. Analyzing 813 viral genome sequences from nasopharyngeal swabs, we showed that vaccinees who tested positive at least 7 days after the second dose were disproportionally infected with B.1.351, compared with controls. Those who tested positive between 2 weeks after the first dose and 6 days after the second dose were disproportionally infected by B.1.1.7. These findings suggest reduced vaccine effectiveness against both VOCs within particular time windows. Our results emphasize the importance of rigorously tracking viral variants, and of increasing vaccination to prevent the spread of VOCs.
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Affiliation(s)
- Talia Kustin
- The Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
- Edmond J. Safra Center for Bioinformatics, Tel Aviv University, Tel Aviv, Israel
| | - Noam Harel
- The Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
- Edmond J. Safra Center for Bioinformatics, Tel Aviv University, Tel Aviv, Israel
| | - Uriah Finkel
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel
| | - Shay Perchik
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel
| | - Sheri Harari
- The Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
- Edmond J. Safra Center for Bioinformatics, Tel Aviv University, Tel Aviv, Israel
| | - Maayan Tahor
- The Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Itamar Caspi
- The Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Rachel Levy
- The Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Michael Leshchinsky
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel
| | - Shifra Ken Dror
- Clalit Health Services, Central Laboratories, Haifa and Western Galilee, Nesher, Israel
| | - Galit Bergerzon
- Clalit Health Services, Central Laboratories, Haifa and Western Galilee, Nesher, Israel
| | - Hala Gadban
- Clalit Health Services, Central Laboratories, Haifa and Western Galilee, Nesher, Israel
| | - Faten Gadban
- Clalit Health Services, Central Laboratories, Haifa and Western Galilee, Nesher, Israel
| | - Eti Eliassian
- Progenin Laboratories, Jerusalem District, Clalit Health Services, Tel Aviv, Israel
| | - Orit Shimron
- Progenin Laboratories, Jerusalem District, Clalit Health Services, Tel Aviv, Israel
| | - Loulou Saleh
- Microbiology lab, Rabin Medical Center, Beilinson Hospital, Petah Tiqva, Israel
| | - Haim Ben-Zvi
- Microbiology lab, Rabin Medical Center, Beilinson Hospital, Petah Tiqva, Israel
| | | | - Doron Amichay
- Central Laboratory, Clalit Health Services, Tel Aviv, Israel
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Anat Ben-Dor
- Central Laboratory, Clalit Health Services, Tel Aviv, Israel
| | - Dana Sagas
- Microbiology Laboratory, Emek Medical Center, Afula, Israel
| | - Merav Strauss
- Microbiology Laboratory, Emek Medical Center, Afula, Israel
| | - Yonat Shemer Avni
- Laboratory of Clinical Virology, Soroka University Medical Center, Beersheba, Israel
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Amit Huppert
- The Bio-statistical and Bio-mathematical Unit, The Gertner Institute for Epidemiology and Health Policy Research, Chaim Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Eldad Kepten
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel
| | - Ran D Balicer
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel
| | | | - Shay Ben-Shachar
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel.
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Adi Stern
- The Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel.
- Edmond J. Safra Center for Bioinformatics, Tel Aviv University, Tel Aviv, Israel.
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21
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Krause PR, Fleming TR, Longini IM, Peto R, Briand S, Heymann DL, Beral V, Snape MD, Rees H, Ropero AM, Balicer RD, Cramer JP, Muñoz-Fontela C, Gruber M, Gaspar R, Singh JA, Subbarao K, Van Kerkhove MD, Swaminathan S, Ryan MJ, Henao-Restrepo AM. SARS-CoV-2 Variants and Vaccines. N Engl J Med 2021; 385:179-186. [PMID: 34161052 PMCID: PMC8262623 DOI: 10.1056/nejmsr2105280] [Citation(s) in RCA: 244] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Viral variants of concern may emerge with dangerous resistance to the immunity generated by the current vaccines to prevent coronavirus disease 2019 (Covid-19). Moreover, if some variants of concern have increased transmissibility or virulence, the importance of efficient public health measures and vaccination programs will increase. The global response must be both timely and science based.
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Affiliation(s)
- Philip R Krause
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Thomas R Fleming
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Ira M Longini
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Richard Peto
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Sylvie Briand
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - David L Heymann
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Valerie Beral
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Matthew D Snape
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Helen Rees
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Alba-Maria Ropero
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Ran D Balicer
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Jakob P Cramer
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - César Muñoz-Fontela
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Marion Gruber
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Rogerio Gaspar
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Jerome A Singh
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Kanta Subbarao
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Maria D Van Kerkhove
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Soumya Swaminathan
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Michael J Ryan
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
| | - Ana-Maria Henao-Restrepo
- From the Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD (P.R.K., M.G.); the Department of Biostatistics, University of Washington, Seattle (T.R.F.); the Department of Biostatistics, University of Florida, Gainesville (I.M.L.); the Nuffield Department of Population Health, University of Oxford (R.P., V.B.), and the Oxford Vaccine Group, Department of Paediatrics, University of Oxford and National Institute for Health Research Oxford Biomedical Research Centre (M.D.S.), Oxford, and the Global Health Programme, Chatham House (D.L.H.), and the Coalition for Epidemic Preparedness Innovations (J.P.C.), London - all in the United Kingdom; the Howard College School of Law, University of KwaZulu-Natal, Durban (J.A.S.), and the Wits Reproductive Health and HIV Institute, Johannesburg (H.R.) - both in South Africa; the Dalla Lana School of Public Health, University of Toronto, Toronto (J.A.S.); the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel (R.D.B.); the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany (C.M.-F.); the World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (K.S.); and the World Health Organization, Geneva (S.B., A.-M.R., R.G., M.D.V.K., S.S., M.J.R., A.-M.H.-R.)
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22
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Zeltzer D, Einav L, Chasid A, Balicer RD. Supply-side variation in the use of emergency departments. J Health Econ 2021; 78:102453. [PMID: 33964651 DOI: 10.1016/j.jhealeco.2021.102453] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 03/11/2021] [Accepted: 03/11/2021] [Indexed: 06/12/2023]
Abstract
We study the role of person- and place-specific factors in explaining geographic variation in emergency department utilization using detailed data on 150,000 patients who moved regions within Israel. We document that about half of the destination-origin differences in the average emergency department utilization rate across districts translates to the change (up or down) in movers' propensity to visit the emergency department. In contrast, we find no change in the probability of having a hospital admission through the emergency department. Similar results are obtained in a complementary event study, which uses hospital entry as a source of variation. The results from both approaches suggest that supply-side variation in emergency department access affects only the less severe cases-for which close substitutes likely exist-and that variation across emergency physicians in their propensity to admit patients is not explained by place-specific factors, such as differences in incentives, capacity, or diagnostic quality.
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Affiliation(s)
- Dan Zeltzer
- Berglas School of Economics, Tel Aviv University, Tel Aviv 6997801, Israel.
| | - Liran Einav
- Department of Economics, Stanford University, Stanford, CA, United States; NBER, Cambridge, MA, United States.
| | - Avichai Chasid
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel.
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel; Department of Epidemiology, Faculty of Health Sciences, Ben Gurion University, Beersheba, Israel.
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23
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Rossman H, Shilo S, Barbash-Hazan S, Artzi NS, Hadar E, Balicer RD, Feldman B, Wiznitzer A, Segal E. Prediction of Childhood Obesity from Nationwide Health Records. J Pediatr 2021; 233:132-140.e1. [PMID: 33581105 DOI: 10.1016/j.jpeds.2021.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate body mass index (BMI) acceleration patterns in children and to develop a prediction model targeted to identify children at high risk for obesity before the critical time window in which the largest increase in BMI percentile occurs. STUDY DESIGN We analyzed electronic health records of children from Israel's largest healthcare provider from 2002 to 2018. Data included demographics, anthropometric measurements, medications, diagnoses, and laboratory tests of children and their families. Obesity was defined as BMI ≥95th percentile for age and sex. To identify the time window in which the largest annual increases in BMI z score occurs during early childhood, we first analyzed childhood BMI acceleration patterns among 417 915 adolescents. Next, we devised a model targeted to identify children at high risk before this time window, predicting obesity at 5-6 years of age based on data from the first 2 years of life of 132 262 children. RESULTS Retrospective BMI analysis revealed that among adolescents with obesity, the greatest acceleration in BMI z score occurred between 2 and 4 years of age. Our model, validated temporally and geographically, accurately predicted obesity at 5-6 years old (area under the receiver operating characteristic curve of 0.803). Discrimination results on subpopulations demonstrated its robustness across the pediatric population. The model's most influential predictors included anthropometric measurements of the child and family. Other impactful predictors included ancestry and pregnancy glucose. CONCLUSIONS Rapid rise in the prevalence of childhood obesity warrant the development of better prevention strategies. Our model may allow an accurate identification of children at high risk of obesity.
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Affiliation(s)
- Hagai Rossman
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel; Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Smadar Shilo
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel; Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel; Pediatric Diabetes Unit, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel
| | - Shiri Barbash-Hazan
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nitzan Shalom Artzi
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel; Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran D Balicer
- Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel; Department of Public Health, Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel
| | - Becca Feldman
- Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel
| | - Arnon Wiznitzer
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Segal
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel; Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel.
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24
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Affiliation(s)
- Ran D Balicer
- Ran D. Balicer is founding director at the Clalit Research Institute and Chief Innovation Officer, Clalit Health Services, Tel Aviv, Israel; a professor at the School of Public Health, Ben Gurion University of the Negev, Be'er Sheva, Israel; and the chairman of Israel's COVID-19 National Expert Advisory Panel.
| | - Reut Ohana
- Reut Ohana is deputy director at the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv, Israel.
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25
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Abstract
BACKGROUND As mass vaccination campaigns against coronavirus disease 2019 (Covid-19) commence worldwide, vaccine effectiveness needs to be assessed for a range of outcomes across diverse populations in a noncontrolled setting. In this study, data from Israel's largest health care organization were used to evaluate the effectiveness of the BNT162b2 mRNA vaccine. METHODS All persons who were newly vaccinated during the period from December 20, 2020, to February 1, 2021, were matched to unvaccinated controls in a 1:1 ratio according to demographic and clinical characteristics. Study outcomes included documented infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), symptomatic Covid-19, Covid-19-related hospitalization, severe illness, and death. We estimated vaccine effectiveness for each outcome as one minus the risk ratio, using the Kaplan-Meier estimator. RESULTS Each study group included 596,618 persons. Estimated vaccine effectiveness for the study outcomes at days 14 through 20 after the first dose and at 7 or more days after the second dose was as follows: for documented infection, 46% (95% confidence interval [CI], 40 to 51) and 92% (95% CI, 88 to 95); for symptomatic Covid-19, 57% (95% CI, 50 to 63) and 94% (95% CI, 87 to 98); for hospitalization, 74% (95% CI, 56 to 86) and 87% (95% CI, 55 to 100); and for severe disease, 62% (95% CI, 39 to 80) and 92% (95% CI, 75 to 100), respectively. Estimated effectiveness in preventing death from Covid-19 was 72% (95% CI, 19 to 100) for days 14 through 20 after the first dose. Estimated effectiveness in specific subpopulations assessed for documented infection and symptomatic Covid-19 was consistent across age groups, with potentially slightly lower effectiveness in persons with multiple coexisting conditions. CONCLUSIONS This study in a nationwide mass vaccination setting suggests that the BNT162b2 mRNA vaccine is effective for a wide range of Covid-19-related outcomes, a finding consistent with that of the randomized trial.
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Affiliation(s)
- Noa Dagan
- From the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv (N.D., N.B., E.K., O.M., S.P., M.A.K., R.D.B.), and the School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva (O.M., M.A.K., R.D.B.) - both in Israel; University of Michigan School of Public Health, Ann Arbor (M.A.K.); and the Department of Biomedical Informatics (N.D., N.B.), Harvard Medical School (B.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, Harvard-MIT Division of Health Sciences and Technology (M.A.H.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.R.) - all in Boston
| | - Noam Barda
- From the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv (N.D., N.B., E.K., O.M., S.P., M.A.K., R.D.B.), and the School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva (O.M., M.A.K., R.D.B.) - both in Israel; University of Michigan School of Public Health, Ann Arbor (M.A.K.); and the Department of Biomedical Informatics (N.D., N.B.), Harvard Medical School (B.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, Harvard-MIT Division of Health Sciences and Technology (M.A.H.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.R.) - all in Boston
| | - Eldad Kepten
- From the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv (N.D., N.B., E.K., O.M., S.P., M.A.K., R.D.B.), and the School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva (O.M., M.A.K., R.D.B.) - both in Israel; University of Michigan School of Public Health, Ann Arbor (M.A.K.); and the Department of Biomedical Informatics (N.D., N.B.), Harvard Medical School (B.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, Harvard-MIT Division of Health Sciences and Technology (M.A.H.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.R.) - all in Boston
| | - Oren Miron
- From the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv (N.D., N.B., E.K., O.M., S.P., M.A.K., R.D.B.), and the School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva (O.M., M.A.K., R.D.B.) - both in Israel; University of Michigan School of Public Health, Ann Arbor (M.A.K.); and the Department of Biomedical Informatics (N.D., N.B.), Harvard Medical School (B.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, Harvard-MIT Division of Health Sciences and Technology (M.A.H.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.R.) - all in Boston
| | - Shay Perchik
- From the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv (N.D., N.B., E.K., O.M., S.P., M.A.K., R.D.B.), and the School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva (O.M., M.A.K., R.D.B.) - both in Israel; University of Michigan School of Public Health, Ann Arbor (M.A.K.); and the Department of Biomedical Informatics (N.D., N.B.), Harvard Medical School (B.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, Harvard-MIT Division of Health Sciences and Technology (M.A.H.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.R.) - all in Boston
| | - Mark A Katz
- From the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv (N.D., N.B., E.K., O.M., S.P., M.A.K., R.D.B.), and the School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva (O.M., M.A.K., R.D.B.) - both in Israel; University of Michigan School of Public Health, Ann Arbor (M.A.K.); and the Department of Biomedical Informatics (N.D., N.B.), Harvard Medical School (B.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, Harvard-MIT Division of Health Sciences and Technology (M.A.H.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.R.) - all in Boston
| | - Miguel A Hernán
- From the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv (N.D., N.B., E.K., O.M., S.P., M.A.K., R.D.B.), and the School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva (O.M., M.A.K., R.D.B.) - both in Israel; University of Michigan School of Public Health, Ann Arbor (M.A.K.); and the Department of Biomedical Informatics (N.D., N.B.), Harvard Medical School (B.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, Harvard-MIT Division of Health Sciences and Technology (M.A.H.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.R.) - all in Boston
| | - Marc Lipsitch
- From the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv (N.D., N.B., E.K., O.M., S.P., M.A.K., R.D.B.), and the School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva (O.M., M.A.K., R.D.B.) - both in Israel; University of Michigan School of Public Health, Ann Arbor (M.A.K.); and the Department of Biomedical Informatics (N.D., N.B.), Harvard Medical School (B.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, Harvard-MIT Division of Health Sciences and Technology (M.A.H.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.R.) - all in Boston
| | - Ben Reis
- From the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv (N.D., N.B., E.K., O.M., S.P., M.A.K., R.D.B.), and the School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva (O.M., M.A.K., R.D.B.) - both in Israel; University of Michigan School of Public Health, Ann Arbor (M.A.K.); and the Department of Biomedical Informatics (N.D., N.B.), Harvard Medical School (B.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, Harvard-MIT Division of Health Sciences and Technology (M.A.H.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.R.) - all in Boston
| | - Ran D Balicer
- From the Clalit Research Institute, Innovation Division, Clalit Health Services, Tel Aviv (N.D., N.B., E.K., O.M., S.P., M.A.K., R.D.B.), and the School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva (O.M., M.A.K., R.D.B.) - both in Israel; University of Michigan School of Public Health, Ann Arbor (M.A.K.); and the Department of Biomedical Informatics (N.D., N.B.), Harvard Medical School (B.R.), the Departments of Epidemiology and Biostatistics (M.A.H.), and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, Harvard-MIT Division of Health Sciences and Technology (M.A.H.), and the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.R.) - all in Boston
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Avrahamy H, Shoval G, Hoshen M, Balicer RD, Kamhi-Nesher S, Zalsman G, Weizman A, Krivoy A. Association between Adherence to SSRI Treatment and Mortality among Individuals with Metabolic Syndrome Components. Pharmacopsychiatry 2021; 54:232-239. [PMID: 33853176 DOI: 10.1055/a-1425-7246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Depression and anxiety have been associated with type 2 diabetes mellitus and metabolic syndrome, major causes of cardiovascular morbidity and mortality. The effect of antidepressants in this association is unknown. This study aimed to examine the association between adherence to selective serotonin receptor inhibitors (SSRIs) and all-cause mortality among individuals with metabolic syndrome components (hypertension, obesity, and diabetes mellitus). METHODS Data on 201 777 patients who were prescribed SSRIs during the years 2008-2011 were analyzed retrospectively. Adherence was measured using prescription purchase records. The moderating effect of SSRI and statin adherence on the association between metabolic syndrome load and mortality hazard risk (HR) during the study period were analyzed. The Cox-proportional hazard model adjusted to background variables was used to this end. RESULTS During the study period, the maximal metabolic load was associated with mortality HR=1.89 (95% CI: 1.79-2) compared to participants without metabolic risk factors. A slight reduction in mortality HR was demonstrated among those with low and moderate SSRI adherence rates. Adherence to statins was negatively associated with the risk of mortality across all levels of adherence. A significant association (r=0.214, p<0.01) was found between adherence to statins and adherence to SSRIs, with higher rates of adherence to statins across all metabolic load categories. DISCUSSION While a high metabolic load is associated with a higher risk of mortality, adherence to SSRIs only partially moderated the risk of mortality, in contrast to the protective effect of statins. Adherence differences to statins and SSRIs among individuals prescribed both medications merit further investigation.
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Affiliation(s)
| | - Gal Shoval
- Geha Mental Health Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Clalit Research Institute, Clalit Health Services, Tel-Aviv, Israel
| | - Moshe Hoshen
- Clalit Research Institute, Clalit Health Services, Tel-Aviv, Israel
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Tel-Aviv, Israel.,Public Health Department, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Shiri Kamhi-Nesher
- Geha Mental Health Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Gil Zalsman
- Geha Mental Health Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Abraham Weizman
- Geha Mental Health Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Laboratory of Biological Psychiatry, Felsenstein Medical Research Center, Petah Tikva, Israel
| | - Amir Krivoy
- Geha Mental Health Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Clalit Research Institute, Clalit Health Services, Tel-Aviv, Israel.,Psychosis Studies Department, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, UK
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27
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Leventer-Roberts M, Dagan N, Berent JM, Brufman I, Hoshen M, Braun M, Balicer RD, Feldman BS. Using population-level incidence of hepatitis C virus and immigration status for data-driven screening policies: a case study in Israel. J Public Health (Oxf) 2020; 44:2-9. [PMID: 33348364 DOI: 10.1093/pubmed/fdaa215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 10/01/2020] [Accepted: 10/30/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Most studies estimate hepatitis C virus (HCV) disease prevalence from convenience samples. Consequently, screening policies may not include those at the highest risk for a new diagnosis. METHODS Clalit Health Services members aged 25-74 as of 31 December 2009 were included in the study. Rates of testing and new diagnoses of HCV were calculated, and potential risk groups were examined. RESULTS Of the 2 029 501 included members, those aged 45-54 and immigrants had lower rates of testing (12.5% and 15.6%, respectively), higher rates of testing positive (0.8% and 1.1%, respectively), as well as the highest rates of testing positive among tested (6.1% and 6.9%, respectively). DISCUSSION In this population-level study, groups more likely to test positive for HCV also had lower rates of testing. Policy makers and clinicians worldwide should consider creating screening policies using on population-based data to maximize the ability to detect and treat incident cases.
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Affiliation(s)
- Maya Leventer-Roberts
- Clalit Research Institute, Clalit Health Services, Tel Aviv 6209804, Israel.,Departments of Pediatrics, Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Noa Dagan
- Clalit Research Institute, Clalit Health Services, Tel Aviv 6209804, Israel.,Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Jenna M Berent
- Clalit Research Institute, Clalit Health Services, Tel Aviv 6209804, Israel.,Clalit Health Services, Tel Aviv 6209804, Israel
| | - Ilan Brufman
- Clalit Research Institute, Clalit Health Services, Tel Aviv 6209804, Israel
| | - Moshe Hoshen
- Clalit Research Institute, Clalit Health Services, Tel Aviv 6209804, Israel
| | - Marius Braun
- Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah Tiqwa 49100, Israel
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Tel Aviv 6209804, Israel.,Clalit Health Services, Tel Aviv 6209804, Israel.,Epidemiology Department, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, 8410501, Israel
| | - Becca S Feldman
- Clalit Research Institute, Clalit Health Services, Tel Aviv 6209804, Israel
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Cohen-Stavi CJ, Key C, Molcho T, Yacobi M, Balicer RD, Shadmi E. Mixed Methods Evaluation of Reasons Why Care Deviates From Clinical Guidelines Among Patients With Multimorbidity. Med Care Res Rev 2020; 79:102-113. [PMID: 33267740 DOI: 10.1177/1077558720975543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Reasons why care does not conform to single-disease guideline recommendations for multimorbid patients have not been systematically measured in practice. Using a mixed methods approach, we identified and quantified types of reasons why care deviates from nine sets of disease guideline recommendations for multimorbid patients. Utilizing a focus group concept mapping technique, we built on a categorization of reasons explaining guideline deviation, and surveyed treating nurses about these reasons for patients' specific care processes. Directed content analysis was conducted to classify the responses into reasons categories. Of 4,386 guideline-recommended care processes evaluated, 920 were not guideline-concordant (944 reasons). Three broad categories of reasons and 18 specific reasons were identified: Biomedical-related occurred 35.2% of the time, patient personal-related (30.4%), context-related (18.4%), and unknown (16.0%). Patient- and context-related factors are prevalent drivers for guideline deviation in multimorbidity, demonstrating that patient-centered aspects are as much a part of care decisions as biomedical aspects.
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Affiliation(s)
- Chandra J Cohen-Stavi
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel.,Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Calanit Key
- Community Nursing Division, Clalit Health Services, Tel Aviv, Israel
| | - Tchiya Molcho
- Community Nursing Division, Clalit Health Services, Tel Aviv, Israel
| | - Mili Yacobi
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel.,Public Health Department, Ben Gurion University of the Negev, Be'er Sheba, Israel
| | - Efrat Shadmi
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel.,Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
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Miron O, Zeltzer D, Shir T, Balicer RD, Einav L, Feldman BS. Rising opioid prescription fulfillment among non-cancer and non-elderly patients-Israel's alarming example. Reg Anesth Pain Med 2020; 46:455-456. [PMID: 33214218 DOI: 10.1136/rapm-2020-101924] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/19/2020] [Accepted: 10/25/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Oren Miron
- Clalit Research Institute, Clalit Health Services, Ramat Gan, Israel .,School of Public Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dan Zeltzer
- Berglas School of Economics, Tel-Aviv University, Tel-Aviv, Israel
| | - Tzvi Shir
- Clalit Research Institute, Clalit Health Services, Ramat Gan, Israel
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Ramat Gan, Israel.,School of Public Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Liran Einav
- Department of Economics, Stanford University, Stanford, California, USA
| | - Becca S Feldman
- Clalit Research Institute, Clalit Health Services, Ramat Gan, Israel
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Cohen-Stavi CJ, Key C, Giveon S, Molcho T, Balicer RD, Shadmi E. Assessing guideline-concordant care for patients with multimorbidity treated in a care management setting. Fam Pract 2020; 37:479-485. [PMID: 32219299 DOI: 10.1093/fampra/cmaa024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Disease-specific guidelines are not aligned with multimorbidity care complexity. Meeting all guideline-recommended care for multimorbid patients has been estimated but not demonstrated across multiple guidelines. OBJECTIVE Measure guideline-concordant care for patients with multimorbidity; assess in what types of care and by whom (clinician or patient) deviation from guidelines occurs and evaluate whether patient characteristics are associated with concordance. METHODS A retrospective cohort study of care received over 1 year, conducted across 11 primary care clinics within the context of multimorbidity-focused care management program. Patients were aged 45+ years with more than two common chronic conditions and were sampled based on either being new (≤6 months) or veteran to the program (≥1 year). MEASURES Three guideline concordance measures were calculated for each patient out of 44 potential guideline-recommended care processes for nine chronic conditions: overall score; referral score (proportion of guideline-recommended care referred) and patient-only score (proportion of referred care completed by patients). Guideline concordance was stratified by care type. RESULTS 4386 care processes evaluated among 204 patients, mean age = 72.3 years (standard deviation = 9.7). Overall, 79.2% of care was guideline concordant, 87.6% was referred according to guidelines and patients followed 91.4% of referred care. Guideline-concordant care varied across care types. Age, morbidity burden and whether patients were new or veteran to the program were associated with guideline concordance. CONCLUSIONS Patients with multimorbidity do not receive ~20% of guideline recommendations, mostly due to clinicians not referring care. Determining the types of care for which the greatest deviation from guidelines exists can inform the tailoring of care for multimorbidity patients.
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Affiliation(s)
- Chandra J Cohen-Stavi
- Clalit Research Institute, Clalit Health Services, Tel Aviv.,Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa
| | | | - Shmuel Giveon
- Community Medical Division, Clalit Health Services, Tel Aviv
| | | | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Tel Aviv.,Epidemiology Department, Ben Gurion University of the Negev, Be'er Sheba, Israel
| | - Efrat Shadmi
- Clalit Research Institute, Clalit Health Services, Tel Aviv.,Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa
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Dagan N, Elnekave E, Barda N, Bregman-Amitai O, Bar A, Orlovsky M, Bachmat E, Balicer RD. Automated opportunistic osteoporotic fracture risk assessment using computed tomography scans to aid in FRAX underutilization. Nat Med 2020; 26:77-82. [PMID: 31932801 DOI: 10.1038/s41591-019-0720-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022]
Abstract
Methods for identifying patients at high risk for osteoporotic fractures, including dual-energy X-ray absorptiometry (DXA)1,2 and risk predictors like the Fracture Risk Assessment Tool (FRAX)3-6, are underutilized. We assessed the feasibility of automatic, opportunistic fracture risk evaluation based on routine abdomen or chest computed tomography (CT) scans. A CT-based predictor was created using three automatically generated bone imaging biomarkers (vertebral compression fractures (VCFs), simulated DXA T-scores and lumbar trabecular density) and CT metadata of age and sex. A cohort of 48,227 individuals (51.8% women) aged 50-90 with available CTs before 2012 (index date) were assessed for 5-year fracture risk using FRAX with no bone mineral density (BMD) input (FRAXnb) and the CT-based predictor. Predictions were compared to outcomes of major osteoporotic fractures and hip fractures during 2012-2017 (follow-up period). Compared with FRAXnb, the major osteoporotic fracture CT-based predictor presented better receiver operating characteristic area under curve (AUC), sensitivity and positive predictive value (PPV) (+1.9%, +2.4% and +0.7%, respectively). The AUC, sensitivity and PPV measures of the hip fracture CT-based predictor were noninferior to FRAXnb at a noninferiority margin of 1%. When FRAXnb inputs are not available, the initial evaluation of fracture risk can be done completely automatically based on a single abdomen or chest CT, which is often available for screening candidates7,8.
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Affiliation(s)
- Noa Dagan
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel. .,Department of Computer Science, Ben-Gurion University, Beer Sheva, Israel. .,School of Public Health, Ben-Gurion University, Beer Sheva, Israel.
| | - Eldad Elnekave
- Department of Diagnostic Radiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Zebra Medical Vision, Ltd, Shefayim, Israel
| | - Noam Barda
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel.,Department of Computer Science, Ben-Gurion University, Beer Sheva, Israel.,School of Public Health, Ben-Gurion University, Beer Sheva, Israel
| | | | - Amir Bar
- Zebra Medical Vision, Ltd, Shefayim, Israel
| | | | - Eitan Bachmat
- Department of Computer Science, Ben-Gurion University, Beer Sheva, Israel
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel.,School of Public Health, Ben-Gurion University, Beer Sheva, Israel
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32
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Dankner R, Agay N, Olmer L, Murad H, Keinan Boker L, Balicer RD, Freedman LS. Metformin Treatment and Cancer Risk: Cox Regression Analysis, With Time-Dependent Covariates, of 320,000 Persons With Incident Diabetes Mellitus. Am J Epidemiol 2019; 188:1794-1800. [PMID: 31269196 PMCID: PMC6768811 DOI: 10.1093/aje/kwz157] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/14/2019] [Accepted: 06/18/2019] [Indexed: 12/15/2022] Open
Abstract
There is conflicting evidence regarding the association between metformin use and cancer risk in diabetic patients. During 2002–2012, we followed a cohort of 315,890 persons aged 21–87 years with incident diabetes who were insured by the largest health maintenance organization in Israel. We used a discrete form of weighted cumulative metformin exposure to evaluate the association of metformin with cancer incidence. This was implemented in a time-dependent covariate Cox model, adjusting for treatment with other glucose-lowering medications, as well as age, sex, ethnic background, socioeconomic status, smoking (for bladder and lung cancer), and parity (for breast cancer). We excluded from the analysis metformin exposure during the year before cancer diagnosis in order to minimize reverse causation of cancer on changes in medication use. Estimated hazard ratios associated with exposure to 1 defined daily dose of metformin over the previous 2–7 years were 0.98 (95% confidence interval (CI): 0.82, 1.18) for all-sites cancer (excluding prostate and pancreas), 1.05 (95% CI: 0.67, 1.63) for colon cancer, 0.98 (95% CI: 0.49, 1.97) for bladder cancer, 1.02 (95% CI: 0.59, 1.78) for lung cancer, and 0.88 (95% CI: 0.56, 1.39) for female breast cancer. Our results do not support an association between metformin treatment and the incidence of major cancers (excluding prostate and pancreas).
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Affiliation(s)
- Rachel Dankner
- Unit for Cardiovascular Epidemiology, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan, Israel
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, School of Public Health, Tel Aviv University, Tel Aviv, Israel
- Center for Patient-Oriented Research, Feinstein Institute for Medical Research, Manhasset, New York
| | - Nirit Agay
- Unit for Cardiovascular Epidemiology, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan, Israel
| | - Liraz Olmer
- Unit of Biostatistics and Biomathematics, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan, Israel
| | - Havi Murad
- Unit of Biostatistics and Biomathematics, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan, Israel
| | - Lital Keinan Boker
- Israel Center for Disease Control, Israel Ministry of Health, Ramat Gan, Israel
- School of Public Health, Faculty of Social Welfare and Health Sciences, Haifa University, Haifa, Israel
| | - Ran D Balicer
- Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel
- Public Health Department, Ben Gurion University of the Negev, Be’er Sheva, Israel
| | - Laurence S Freedman
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, School of Public Health, Tel Aviv University, Tel Aviv, Israel
- Unit of Biostatistics and Biomathematics, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan, Israel
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Shoval G, Balicer RD, Feldman B, Hoshen M, Eger G, Weizman A, Zalsman G, Stubbs B, Golubchik P, Gordon B, Krivoy A. Adherence to antidepressant medications is associated with reduced premature mortality in patients with cancer: A nationwide cohort study. Depress Anxiety 2019; 36:921-929. [PMID: 31332883 DOI: 10.1002/da.22938] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/24/2019] [Accepted: 05/25/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Depression and anxiety are common in cancer and antidepressants (AD) are efficacious treatment. The relationship between AD adherence and mortality in cancer is unclear. This study aimed to evaluate the association between adherence to AD and all-cause mortality in a population-based cohort of patients with cancer. MATERIALS AND METHODS We conducted a 4-year historical prospective cohort study including 42,075 patients with cancer who purchased AD at least once during the study period. Adherence to AD was modeled as nonadherence (<20%), poor (20-50%), moderate (50-80%), and good (>80%) adherence. We conducted multivariable survival analyses adjusted for demographic and clinical variables that may affect mortality. RESULTS During 1,051,489 person-years at risk follow-up, the adjusted hazard ratios (HR) for mortality were 0.89 (95% confidence interval [CI]: 0.83-0.95), 0.77 (95% CI: 0.66-0.72), and 0.80 (95% CI: 0.76-0.85) for the poor, moderate, and good adherence groups, respectively, compared to the nonadherent group. Analysis of the entire sample and a subgroup with depression, for cancer subtypes, revealed similar patterns for breast, colon, lung, and prostate cancers, but not for melanoma patients. Multivariate predictors of premature mortality included male gender (HR 1.48 [95% CI: 1.42-1.55]), current/past smoking status (HR 1.1, [95% CI: 1.04-1.15]; P < .0001), low socioeconomic status (HR 1.1, [95% CI: 1.03-1.17]; P < .0001) and more physical comorbidities. CONCLUSIONS The present study is the first to demonstrate that higher adherence to AD is associated with a decrease of all-cause mortality in a large nationwide cohort of cancer patients. Our data add to the pressing need to encourage adherence to AD among cancer patients.
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Affiliation(s)
- Gal Shoval
- Chief Physician Office, Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel.,Child and Adolescent Division, Geha Mental Health Center, Petah Tiqva, Israel.,Department of Psychiatry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran D Balicer
- Chief Physician Office, Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel.,Public Health Department, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Becca Feldman
- Chief Physician Office, Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel
| | - Moshe Hoshen
- Chief Physician Office, Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel
| | - Gilad Eger
- Child and Adolescent Division, Geha Mental Health Center, Petah Tiqva, Israel.,Department of Psychiatry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Abraham Weizman
- Child and Adolescent Division, Geha Mental Health Center, Petah Tiqva, Israel.,Department of Psychiatry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, New York
| | - Gil Zalsman
- Child and Adolescent Division, Geha Mental Health Center, Petah Tiqva, Israel.,Department of Psychiatry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, New York.,Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Pavel Golubchik
- Child and Adolescent Division, Geha Mental Health Center, Petah Tiqva, Israel.,Department of Psychiatry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barak Gordon
- Medical Corps, Israel Defense Forces, Tel Aviv, Israel.,Department of Family Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Amir Krivoy
- Chief Physician Office, Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel.,Child and Adolescent Division, Geha Mental Health Center, Petah Tiqva, Israel.,Department of Psychiatry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Rayan-Gharra N, Shadmi E, Tadmor B, Flaks-Manov N, Balicer RD. Patients' ratings of the in-hospital discharge briefing and post-discharge primary care follow-up: The association with 30-day readmissions. Patient Educ Couns 2019; 102:1513-1519. [PMID: 30987768 DOI: 10.1016/j.pec.2019.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE We examined whether patients' ratings of their in-hospital discharge briefing and their post-discharge Primary Care Physicians' (PCP) review of the discharge summary are associated with 30-day readmissions. METHODS A prospective study of 594 internal-medicine patients at a tertiary medical-center in Israel. The in-hospital baseline questionnaire included sociodemographic characteristics, physical, mental, and functional health status. Patients were surveyed by phone about the discharge and post-discharge processes. Clinical data and health-service use was retrieved from a central data-warehouse. Multivariate regressions modeled the relationship between in-hospital baseline characteristics, discharge briefing, PCP visit indicator, the PCP discharge summary review, and 30-day readmissions. RESULTS The extent of the PCPs' review of the hospital discharge summary at the post-discharge visit was rated higher than the in-hospital discharge briefing (3.46 vs. 3.17, p = 0.001) and was associated with lower odds of readmission (OR=0.35, 95% CI 0.26-0.45). The model that included this assessment performed better than the in-hospital baseline, the in-hospital discharge-briefing, and the PCP visit models (C-statistic = 0.87, compared with: 0.70, 0.81, 0.81, respectively). CONCLUSIONS Providing extensive post-discharge explanations by PCPs serves as a significant protective factor against readmissions. PRACTICE IMPLICATIONS PCPs should be encouraged to thoroughly review the discharge summary letter with the patient.
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Affiliation(s)
- Nosaiba Rayan-Gharra
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel.
| | - Efrat Shadmi
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel; The Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel
| | | | | | - Ran D Balicer
- The Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel
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Shmueli L, Shmueli E, Pliskin JS, Balicer RD, Davidovitch N, Hekselman I, Greenfield G. Second opinion utilization by healthcare insurance type in a mixed private-public healthcare system: a population-based study. BMJ Open 2019; 9:e025673. [PMID: 31352409 PMCID: PMC6661653 DOI: 10.1136/bmjopen-2018-025673] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To evaluate the utilisation (overall and by specialty) and the characteristics of second-opinion seekers by insurance type (either health fund or supplementary insurance) in a mixed private-public healthcare. DESIGN An observational study. SETTING Secondary care visits provided by a large public health fund and a large supplementary health insurance in Israel. PARTICIPANTS The entire sample included 1 392 907 patients aged 21 years and above who visited at least one specialist over an 18 months period, either in the secondary care or privately via the supplementary insurance. OUTCOMES MEASURES An algorithm was developed to identify potential second-opinion instances in the dataset using visits and claims data. Multivariate logistic regression was used to identify characteristics of second-opinion seekers by the type of insurance they used. RESULTS 143 371 (13%) out of 1 080 892 patients who had supplementary insurance sought a single second opinion, mostly from orthopaedic surgeons. Relatively to patients who sought second opinion via the supplementary insurance, second-opinion seekers via the health fund tended to be females (OR=1.2, 95% CI 1.17 to 1.23), of age 40-59 years (OR=1.36, 95% CI 1.31 to 1.42) and with chronic conditions (OR=1.13, 95% CI 1.08 to 1.18). In contrast, second-opinion seekers via the supplementary insurance tended to be native-born and established immigrants (OR=0.79, 95% CI 0.76 to 0.84), in a high socioeconomic level (OR=0.39, 95% CI 0.37 to 0. 4) and living in central areas (OR=0.88, 95% CI 0.85 to 0.9). CONCLUSIONS Certain patient profiles tended to seek second opinions via the supplementary insurance more than others. People from the centre of the country and with a high socioeconomic status tended to do so, as medical specialists tend to reside in central urban areas. Further research is recommended to examine the availability of medical specialists by specialty and residence.
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Affiliation(s)
- Liora Shmueli
- Department of Management, Bar Ilan University, Ramat Gan, Israel
| | - Erez Shmueli
- Department of Industrial Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Joseph S Pliskin
- Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ran D Balicer
- Epidemiology, Ben-Gurion University, Tel Aviv, Israel
- Clalit Research Institute, Tel Aviv, Israel
| | - Nadav Davidovitch
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Igal Hekselman
- Clalit Mushlam Health Insurance, Bnei Brak, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Geva Greenfield
- Department of Primary Care & Public Health, Imperial College London, London, UK
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Flaks-Manov N, Topaz M, Hoshen M, Balicer RD, Shadmi E. Identifying patients at highest-risk: the best timing to apply a readmission predictive model. BMC Med Inform Decis Mak 2019; 19:118. [PMID: 31242886 PMCID: PMC6595564 DOI: 10.1186/s12911-019-0836-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 06/06/2019] [Indexed: 11/21/2022] Open
Abstract
Background Most of readmission prediction models are implemented at the time of patient discharge. However, interventions which include an early in-hospital component are critical in reducing readmissions and improving patient outcomes. Thus, at-discharge high-risk identification may be too late for effective intervention. Nonetheless, the tradeoff between early versus at-discharge prediction and the optimal timing of the risk prediction model application remains to be determined. We examined a high-risk patient selection process with readmission prediction models using data available at two time points: at admission and at the time of hospital discharge. Methods An historical prospective study of hospitalized adults (≥65 years) discharged alive from internal medicine units in Clalit’s (the largest integrated payer-provider health fund in Israel) general hospitals in 2015. The outcome was all-cause 30-day emergency readmissions to any internal medicine ward at any hospital. We used the previously validated Preadmission Readmission Detection Model (PREADM) and developed a new model incorporating PREADM with hospital data (PREADM-H). We compared the percentage of overlap between the models and calculated the positive predictive value (PPV) for the subgroups identified by each model separately and by both models. Results The final cohort included 35,156 index hospital admissions. The PREADM-H model included 17 variables with a C-statistic of 0.68 (95% CI: 0.67–0.70) and PPV of 43.0% in the highest-risk categories. Of patients categorized by the PREADM-H in the highest-risk decile, 78% were classified similarly by the PREADM. The 22% (n = 229) classified by the PREADM-H at the highest decile, but not by the PREADM, had a PPV of 37%. Conversely, those classified by the PREADM into the highest decile but not by the PREADM-H (n = 218) had a PPV of 31%. Conclusions The timing of readmission risk prediction makes a difference in terms of the population identified at each prediction time point – at-admission or at-discharge. Our findings suggest that readmission risk identification should incorporate a two time-point approach in which preadmission data is used to identify high-risk patients as early as possible during the index admission and an “all-hospital” model is applied at discharge to identify those that incur risk during the hospital stay.
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Affiliation(s)
- Natalie Flaks-Manov
- Clalit Research Institute, Clalit Health Services, Shoham 2, Ramat Gan, Israel
| | - Maxim Topaz
- Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, 31905, Haifa, Israel
| | - Moshe Hoshen
- Clalit Research Institute, Clalit Health Services, Shoham 2, Ramat Gan, Israel
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Shoham 2, Ramat Gan, Israel.,Department of Epidemiology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Efrat Shadmi
- Clalit Research Institute, Clalit Health Services, Shoham 2, Ramat Gan, Israel. .,Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, 31905, Haifa, Israel.
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Rayan-Gharra N, Balicer RD, Tadmor B, Shadmi E. Association between cultural factors and readmissions: the mediating effect of hospital discharge practices and care-transition preparedness. BMJ Qual Saf 2019; 28:866-874. [PMID: 31113835 DOI: 10.1136/bmjqs-2019-009317] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVES The study examines whether hospital discharge practices and care-transition preparedness mediate the association between patients' cultural factors and readmissions. METHODS A prospective study of internal medicine patients (n=599) examining a culturally diverse cohort, at a tertiary medical centre in Israel. The in-hospital baseline questionnaire included sociodemographic, cultural factors (Multidimensional Health Locus of Control, family collectivism, health literacy and minority status) and physical, mental and functional health status. A follow-up telephone survey assessed hospital discharge practices: use of the teach-back method, providers' cultural competence, at-discharge language concordance and caregiver presence and care-transition preparedness using the care transition measure (CTM). Clinical and administrative data, including 30-day readmissions to any hospital, were retrieved from the healthcare organisation's data warehouse. Multiple mediation was tested using Hayes's PROCESS procedure, model 80. RESULTS A total of 101 patients (17%) were readmitted within 30 days. Multiple logistic regressions indicated that all cultural factors, except for minority status, were associated with 30-day readmission when no mediators were included (p<0.05). Multiple mediation analysis indicated significant indirect effects of the cultural factors on readmission through the hospital discharge practices and CTM. Finally, when the mediators were included, strong direct and indirect effects between minority status and readmission were found (B coefficient=-0.95; p=0.021). CONCLUSIONS The results show that the association between patients' cultural factors and 30-day readmission is mediated by the hospital discharge practices and care transition. Providing high-quality discharge planning tailored to patients' cultural characteristics is associated with better care-transition preparedness, which, in turn, is associated with reduced 30-day readmissions.
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Affiliation(s)
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Tel-Aviv, Israel
| | - Boaz Tadmor
- The Rabin Medical Center Research Authority, Clalit Health Services, Petah Tikva, Israel
| | - Efrat Shadmi
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
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Shmueli L, Davidovitch N, Pliskin JS, Hekselman I, Balicer RD, Greenfield G. Reasons, perceived outcomes and characteristics of second-opinion seekers: are there differences in private vs. public settings? BMC Health Serv Res 2019; 19:238. [PMID: 31014323 PMCID: PMC6480844 DOI: 10.1186/s12913-019-4067-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/05/2019] [Indexed: 01/29/2023] Open
Abstract
Background In most countries, patients can get a second opinion (SO) through public or private healthcare systems. There is lack of data on SO utilization in private vs. public settings. We aim to evaluate the characteristics of people seeking SOs in private vs. public settings, to evaluate their reasons for seeking a SO from a private physician and to compare the perceived outcomes of SOs given in a private system vs. a public system. Methods A cross-sectional national telephone survey, using representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, on the same medical concern. We modeled SO utilization in a public system vs. a private system by patient characteristics using a multivariate logistic regression model. Results 214 of 339 respondents who obtained a SO during the study period, did so in a private practice (63.1%). The main reason for seeking a SO from a private physician rather than a physician in the public system was the assumption that private physicians are more professional (45.7%). However, respondents who obtained a private SO were neither more satisfied from the SO (p = 0.45), nor felt improvement in their perceived clinical outcomes after the SO (p = 0.37). Low self-reported income group, immigrants (immigrated to Israel after 1989) and religious people tended to seek SOs from the public system more than others. Conclusions The main reason for seeking a SO from private physicians was the assumption that they are more professional. However, there were no differences in satisfaction from the SO nor perceived clinical improvement. As most of SOs are sought in the private system, patient misconceptions about the private market superiority may lead to ineffective resource usage and increase inequalities in access to SOs. Ways to improve public services should be considered to reduce health inequalities.
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Affiliation(s)
- Liora Shmueli
- Department of Health Systems Management, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel
| | - Nadav Davidovitch
- Department of Health Systems Management, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel
| | - Joseph S Pliskin
- Department of Health Systems Management, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel.,Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel
| | - Igal Hekselman
- Clalit Mushlam Health Insurance Systems, Clalit Health Services, 1 Ben Gurion, 5120149, Bnei Brak, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, 101 Arlozorov, 62098, Tel-Aviv, Israel
| | - Geva Greenfield
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, The Reynolds Building, St. Dunstan's Road, London, W6 8RP, UK.
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Low M, Neuberger A, Hooton TM, Green MS, Raz R, Balicer RD, Almog R. Association between urinary community-acquired fluoroquinolone-resistant Escherichia coli and neighbourhood antibiotic consumption: a population-based case-control study. Lancet Infect Dis 2019; 19:419-428. [PMID: 30846277 DOI: 10.1016/s1473-3099(18)30676-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/29/2018] [Accepted: 10/28/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND It is unknown whether increased use of antibiotics in a community increases the risk of acquiring antibiotic resistance by individuals living in that community, regardless of prior individual antibiotic consumption and other risk factors for antibiotic resistance. METHODS We used a hierarchical multivariate logistic regression approach to evaluate the association between neighbourhood fluoroquinolone consumption and individual risk of colonisation or infection of the urinary tract with fluoroquinolone-resistant Escherichia coli. We did a population-based case-control study of adults (aged ≥22 years) living in 1733 predefined geographical statistical areas (neighbourhoods) in Israel. A multilevel study design was used to analyse data derived from electronic medical records of patients enrolled in the Clalit state-mandated health service. FINDINGS 300 105 events with E coli growth and 1 899 168 cultures with no growth were identified from medical records and included in the analysis. 45 427 (16·8%) of 270 190 women and 8835 (29·5%) of 29 915 men had fluoroquinolone-resistant E coli events. We found an independent association between residence in a neighbourhood with higher antibiotic consumption and an increased risk of bacteriuria caused by fluoroquinolone-resistant E coli. Odds ratios (ORs) for the quintiles with higher neighbourhood consumption (compared with the lowest quintile) were 1·15 (95% CI 1·06-1·24), 1·31 (1·20-1·43), 1·41 (1·29-1·54), and 1·51 (1·38-1·65) for women, and 1·17 (1·02-1·35), 1·24 (1·06-1·45), 1·35 (1·15-1·59), and 1·50 (1·26-1·77) for men. Results remained significant when the analysis was restricted to patients who had not consumed fluoroquinolones themselves. INTERPRETATION These data suggest that increased use of antibiotics in specific geographical areas is associated with an increased personal risk of acquiring antibiotic-resistant bacteria, independent of personal history of antibiotic consumption and other known risk factors for antimicrobial resistance. FUNDING None.
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Affiliation(s)
- Marcelo Low
- Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel; School of Public Health, University of Haifa, Haifa, Israel.
| | - Ami Neuberger
- Division of Infectious Diseases and Internal Medicine B, Rambam Healthcare Campus and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Thomas M Hooton
- Division of Infectious Disease and Miller School of Medicine, University of Miami, FL, USA
| | | | - Raul Raz
- Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Ran D Balicer
- Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel; Ben-Gurion University of the Negev, Beer-Sheba, Israel
| | - Ronit Almog
- Epidemiology Department and Biobank Rambam Healthcare Campus, University of Haifa, Haifa, Israel; School of Public Health, University of Haifa, Haifa, Israel
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Spitzer-Shohat S, Goldfracht M, Key C, Hoshen M, Balicer RD, Shadmi E. Primary care networks and team effectiveness: the case of a large-scale quality improvement disparity reduction program. J Interprof Care 2018; 33:472-480. [PMID: 30422722 DOI: 10.1080/13561820.2018.1538942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Documentation of primary care teams' involvement in disparity reduction efforts exists, yet little is known about how teams interact or perceive their effectiveness. We investigated how the social network and structural ties among primary-care-clinic team members relate to their perceived team effectiveness (TE), in a large-scale disparity reduction intervention in Israel's largest insurer and provider of services. A mixed-method design of Social Network Analysis and qualitative data collection was employed. 108 interviews with medical, nursing, and administrative teams of 26 clinics and their respective managerial units were performed and information on the organizational ties, analyzing density and centrality, collected. Pearson correlations examined association between network measures and perceived TE. Clinics with strong intra-clinic density and high clinic-subregional-management density were positively correlated with perceived TE. Clinic in-degree centrality was also positively associated with perceived TE. Qualitative analyses support these findings with teamwork emerging as a factor which can impede or facilitate teams' ability to design and implement disparity reduction interventions. The study demonstrates that in an organization-wide disparity reduction initiative, cohesive intra-network structure and close relations with mid-level management increase the likelihood that teams perceive themselves as possessing the skills and resources needed to lead and implement disparity reduction efforts. List of abbreviations Team Effectiveness (TE); Clalit Health Services (Clalit); Social Network Analysis (SNA); Quality Improvement (QI); National Health Care Collaborative (NHPC); Tampa Bay Community Cancer Network (TBCCN).
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Affiliation(s)
- S Spitzer-Shohat
- Department of Population Health, Azrieli Faculty of Medicine, Bar-Ilan University , Safed , Israel.,Center for Health and the Social Sciences, University of Chicago , IL , USA
| | - M Goldfracht
- Clalit Community Division, Clalit Health Services , Tel Aviv , Israel
| | - C Key
- Clalit Community Division, Clalit Health Services , Tel Aviv , Israel
| | - M Hoshen
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services , Tel Aviv , Israel
| | - R D Balicer
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services , Tel Aviv , Israel.,Epidemiology Department, Faculty of Health Sciences, Ben-Gurion University , Beer-Sheva , Israel
| | - E Shadmi
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services , Tel Aviv , Israel.,Faculty of Social Welfare and Health Sciences, University of Haifa , Beer-Sheva , Israel
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Dankner R, Boker LK, Boffetta P, Balicer RD, Murad H, Berlin A, Olmer L, Agai N, Freedman LS. A historical cohort study on glycemic-control and cancer-risk among patients with diabetes. Cancer Epidemiol 2018; 57:104-109. [PMID: 30388485 DOI: 10.1016/j.canep.2018.10.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 10/17/2018] [Accepted: 10/20/2018] [Indexed: 12/28/2022]
Abstract
AIMS This population-based historical cohort study examined whether poor glycemic-control (i.e., high glucose and HbA1c blood levels) in patients with diabetes is associated with cancer-risk. METHODS From a large healthcare database, patients aged 21-89 years, diagnosed with diabetes before January 2002 (prevalent) or during 2002-2010 (incident), were followed for cancer during 2004-2012 (excluding cancers diagnosed within the first 2 years since diabetes diagnosis). Risks of selected cancers (all-sites, colon, breast, lung, prostate, pancreas and liver) were estimated according to glycemic-control in a Cox regression model with time-dependent covariates, adjusted for age, sex, ethnic origin, socioeconomic status, smoking and parity. Missing glucose or HbA1c values were imputed. RESULTS Among 440,000 patients included in our analysis, cancer was detected more than 2 years after diabetes diagnosis in 26,887 patients (6%) during the follow-up period. Associations of poor glycemic-control with all-sites cancer and most specific cancers were either null or only weak (hazard ratios (HRs) for a 1% HbA1c or a 30 mg/dl glucose increase between 0.94 and 1.09). Exceptions were pancreatic cancer, for which there was a strong positive association (HRs: 1.26-1.51), and prostate cancer, for which there was a moderate negative association (HRs: 0.85-0.96). CONCLUSION Overall, poor glycemic-control appears to be only weakly associated with cancer-risk, if at all. A substantial part of the positive association with pancreatic cancer is attributable to reverse causation, with the cancer causing poorer glycemic-control prior to its diagnosis. The negative association with prostate cancer may be related to lower PSA levels in those with poor control.
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Affiliation(s)
- R Dankner
- Unit for Cardiovascular Epidemiology, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Department of Epidemiology and Preventive Medicine, School of Public Health, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel; Patient Oriented Research, The Feinstein Institute for Medical Research, Manhasset, North Shore, New York, United States.
| | - L Keinan Boker
- The Israel Center for Disease Control, Israel Ministry of Health, Israel; School of Public Health, Faculty of Social Welfare and Health Sciences, Haifa University, Haifa, Israel
| | - P Boffetta
- Tisch Cancer Institute and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York NY, United States
| | - R D Balicer
- Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel; Public Health Department, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - H Murad
- Unit for Biostatistics, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel
| | - A Berlin
- Unit for Cardiovascular Epidemiology, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel; Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel
| | - L Olmer
- Unit for Biostatistics, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel
| | - N Agai
- Unit for Cardiovascular Epidemiology, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel
| | - L S Freedman
- Sackler Faculty of Medicine, Department of Epidemiology and Preventive Medicine, School of Public Health, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel; Unit for Biostatistics, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel
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Steinman MA, Low M, Balicer RD, Shadmi E. Impact of a nurse-based intervention on medication outcomes in vulnerable older adults. BMC Geriatr 2018; 18:207. [PMID: 30189846 PMCID: PMC6127952 DOI: 10.1186/s12877-018-0905-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 08/29/2018] [Indexed: 12/13/2022] Open
Abstract
Background Medication-related problems are common in older adults with multiple chronic conditions. We evaluated the impact of a nurse-based primary care intervention, based on the Guided Care model of care, on patient-centered aspects of medication use. Methods Controlled clinical trial of the Comprehensive Care for Multimorbid Adults Project (CC-MAP), conducted among 1218 participants in 7 intervention clinics and 6 control (usual care) clinics. Inclusion criteria included age 45–94, presence of ≥3 chronic conditions, and Adjusted Clinical Groups (ACG) score > 0.19. The co-primary outcomes were number of changes to the medication regimen between baseline and 9 month followup, and number of changes to symptom-focused medications, markers of attentiveness to medication-related issues. Results Mean age in the intervention group was 72 years, 59% were women, and participants used a mean of 6.6 medications at baseline. The control group was slightly older (73 years) and used more medications (mean 7.1). Between baseline and 9 months, intervention subjects had more changes to their medication regimen than control subjects (mean 4.04 vs. 3.62 medication changes; adjusted difference 0.55, p = 0.001). Similarly, intervention subjects had more changes to their symptomatic medications (mean 1.38 vs. 1.26 changes, adjusted difference 0.20, p = 0.003). The total number of medications in use remained stable between baseline and follow-up in both groups (p > 0.18). Conclusion This nurse-based, primary care intervention resulted in substantially more changes to patients’ medication regimens than usual care, without increasing the total number of medications used. This enhanced rate of change likely reflects greater attentiveness to the medication-related needs of patients. Trial registration This trial is registered at https://clinicaltrials.gov, trial number NCT01811173. Electronic supplementary material The online version of this article (10.1186/s12877-018-0905-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael A Steinman
- University of California, 3333 California St, San Francisco, CA, 94118, USA. .,San Francisco VA Health Care System, 4150 Clement St, Box 181G, San Francisco, CA, 94121, USA. .,Clalit Research Institute, Tel Aviv, Israel. .,University of Haifa, Haifa, Israel.
| | - Marcelo Low
- Clalit Research Institute, Tel Aviv, Israel.,University of Haifa, Haifa, Israel
| | | | - Efrat Shadmi
- Clalit Research Institute, Tel Aviv, Israel.,University of Haifa, Haifa, Israel
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Ellen ME, Shach R, Balicer RD. Helping patients help themselves: Supporting the healthcare journey. Patient Educ Couns 2018; 101:1708-1711. [PMID: 29691111 DOI: 10.1016/j.pec.2018.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/25/2018] [Accepted: 04/11/2018] [Indexed: 06/08/2023]
Abstract
Patients often feel lost when navigating the health care system, and poor care coordination leads to negative patient outcomes, consumes resources and makes diseases more difficult to treat. Patients and citizens have become eager to take health care decision making into their own hands. To this end, solutions have been proposed which assist patients by providing them with more information and enabling them to take a more active role in their care. These include enlisting a patient navigator, consumer engagement, process mapping, decision aids, and clinical pathways. However, as the global penetration of mobile devices approaches 100%, it is timely to update and optimize health system support technologies and information dissemination pathways. There is much room for improvement and health systems are beginning to echo other industries in asking "what do consumers want?" in their applications. We believe that now is the time to address emergent gaps and supplement the irreplaceable human elements of patient navigation with a mobile or computer application. It would be able to automate parts of the process, and consolidate important information, to serve as a broad-reaching, real-time companion for healthcare consumers and their families to accompany them on their journey from diagnosis to follow up.
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Affiliation(s)
- Moriah E Ellen
- Senior Lecturer, Department of Health Systems Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben Gurion University of the Negev, P.O.B. 653, Beer-Sheva, 8410501, Israel; McMaster Health Forum, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L6, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor, 155 College St, Toronto, ON, M5T 3M6, Canada.
| | - Ruth Shach
- Senior Lecturer, Department of Health Systems Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben Gurion University of the Negev, P.O.B. 653, Beer-Sheva, 8410501, Israel; Brown School, Washington University in St Louis, 1 Brookings Dr, St. Louis, MO, 63130, United States
| | - Ran D Balicer
- McMaster Health Forum, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L6, Canada; Clalit Research Institute at Clalit Health Services, 101 Arlozorov Street, Tel Aviv, 6209804, Israel
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Srulovici E, Feldman B, Reges O, Hoshen M, Balicer RD, Rotem M, Shadmi E, Key C, Curtis B, He X, Rubin G, Strizek A, Leventer-Roberts M. Which patients with Type 2 diabetes will have greater compliance to participation in the Diabetes Conversation Map™ program? A retrospective cohort study. Diabetes Res Clin Pract 2018; 143:337-347. [PMID: 30081107 DOI: 10.1016/j.diabres.2018.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 07/08/2018] [Accepted: 07/30/2018] [Indexed: 11/19/2022]
Abstract
AIM To investigate the characteristics of participants in the Diabetes Conversation Map™ (Map™) program who had higher vs. lower compliance to the program, to determine if program tailoring and monitoring is needed among these groups. METHODS This was a retrospective cohort study of 8990 patients enrolled in the Map™ program (low compliance [attending 0-1 sessions, n = 2759] and high compliance [attending ≥2 sessions, n = 6231]). Socio-demographic, clinical, health behaviors, and healthcare utilization characteristics were extracted. Multivariable stepwise logistic regression was used as the analysis strategy. RESULTS Those who were of higher socio-economic status (OR = 1.567, 95%CI:1.317-1.865), who lived in urban area (OR = 1.501, 95%CI:1.254-1.798), with greater frequency of primary care visits (OR = 1.012, 95%CI:1.002-1.021), with medium (OR = 1.176, 95%CI:1.013-1.365) or high oral medication adherence (OR = 1.198, 95%CI:1.059-1.356), and with a greater frequency of blood glucose tests (OR = 1.102, 95%CI:1.033-1.175) had greater odds of being in the high compliance group. Conversely, those aged 35-44 (OR = 0.538, 95%CI:0.402-0.721) and 45-54 years (OR = 0.763, 95%CI:0.622-0.937), with longer Type 2 diabetes duration (OR = 0.980, 95%CI:0.967-0.993), with higher blood glucose levels (OR = 0.999, 95%CI:0.998-1.000), and current (OR = 0.659, 95%CI:0.569-0.762) or former smokers (OR = 0.831, 95%CI:0.737-0.938) had reduced odds for being in the higher compliance group. CONCLUSIONS Instructors in advance can target sub-groups to increase their attendance rates, and consequently improve their outcomes.
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Affiliation(s)
- Einav Srulovici
- Department of Nursing, University of Haifa, Haifa, Israel; Clalit Research Institute, Clalit Healthcare Services, Tel Aviv, Israel.
| | - Becca Feldman
- Clalit Research Institute, Clalit Healthcare Services, Tel Aviv, Israel
| | - Orna Reges
- Clalit Research Institute, Clalit Healthcare Services, Tel Aviv, Israel
| | - Moshe Hoshen
- Clalit Research Institute, Clalit Healthcare Services, Tel Aviv, Israel
| | - Ran D Balicer
- Clalit Research Institute, Clalit Healthcare Services, Tel Aviv, Israel
| | - Mina Rotem
- Community Nursing Division, Clalit Healthcare Services, Tel Aviv, Israel
| | - Efrat Shadmi
- Department of Nursing, University of Haifa, Haifa, Israel
| | - Calanit Key
- Community Nursing Division, Clalit Healthcare Services, Tel Aviv, Israel
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Rayan-Gharra N, Tadmor B, Balicer RD, Shadmi E. Multicultural Transitions: Caregiver Presence and Language-Concordance at Discharge. Int J Integr Care 2018; 18:9. [PMID: 30220892 PMCID: PMC6137623 DOI: 10.5334/ijic.3965] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 07/23/2018] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Patients with low health literacy (HL) and minority patients encounter many challenges during hospital to community transitions. We assessed care transitions of minority patients with various HL levels and tested whether presence of caregivers and provision of language-concordant care are associated with better care transitions. METHODS A prospective cohort study of 598 internal medicine patients, Hebrew, Russian, or Arabic native speakers, at a tertiary medical center in central Israel, from 2013 to 2014.HL was assessed at baseline with the Brief Health Literacy Screen. A follow-up telephone survey was used to administer the Care Transition Measure [CTM] and to assess, caregiver presence and patient-provider language-concordance at discharge. RESULTS Patients with low HL and without language-concordance or caregiver presence had the lowest CTM scores (33.1, range 0-100). When language-concordance and caregivers were available, CTM scores did not differ between the medium-high and low HL groups (68.7 and 66.9, respectively, p = 0.118). The adjusted analysis, showed that language-concordance and caregiver presence during discharge moderate the relationship between HL and patients' care transition experience (p < 0.001). CONCLUSIONS Language-concordance care and caregiver presence are associated with higher patients' ratings of the transitional-care experience among patients with low HL levels and among minorities.
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Affiliation(s)
- Nosaiba Rayan-Gharra
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, IL
| | | | - Ran D. Balicer
- The Clalit Research Institute, Clalit Health Services, Tel Aviv, IL
| | - Efrat Shadmi
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, IL
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Eisen A, Porter A, Hoshen M, Balicer RD, Reges O, Rabi Y, Leibowitz M, Iakobishvili Z, Hasdai D. The association between eGFR in the normal or mildly impaired range and incident cadiovascular disease: Age and sex analysis. Eur J Intern Med 2018; 54:70-75. [PMID: 29773416 DOI: 10.1016/j.ejim.2018.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 04/12/2018] [Accepted: 05/09/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Worse renal function, even in the normal or mildly impaired range, is associated with incident cardiovascular disease (CVD). Whether this association exists in both sexes across all ages is not known. METHODS A population based cohort of individuals >22 years with no prior CVD and with an eGFR 60-130 ml/min/1.73 m2. eGFR was calculated using the CKD-EPI formula. Incident CVD was defined as either myocardial infarction, unstable angina pectoris, coronary revascularization, or cerebrovascular event. Incident CVD was examined separately in men and women in 3 age-groups (young, 22-40 years; middle-aged, 41-60 years; and elderly, ≥61 years), during a median follow-up of 96.0 months. RESULTS Among 1,341,400 individuals (57% women, mean age 49.2 ± 16.6 years), men had more incident CVD as compared to women (34,968 vs. 23,515 total incident CVD) in all age-groups (0.6% vs. 0.2% in young; 6.2% vs. 2.0% in middle-aged; 13.4% vs. 8.4% in elderly, respectively). After adjustment for CVD risk factors, an increment of 10 units in eGFR was independently associated with a decrease of 5.4%, 3.4% and 5.4% in incident CVD in young, middle-aged and elderly men (p < 0.001 for each) and a decrease of 6.3%, 3.4% and 6.8% in the same age-groups in women (p < 0.001 for each). There was no significant age-sex interaction in the association between eGFR and incident CVD. CONCLUSION Although incident CVD differs in men and women, as well as in different age-groups, a higher eGFR even in the normal or mildly impaired range is associated with lesser incident CVD in men and women of all ages.
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Affiliation(s)
- Alon Eisen
- Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Avital Porter
- Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Hoshen
- Clalit Health Research Institute, Tel Aviv, Israel
| | | | - Orna Reges
- Clalit Health Research Institute, Tel Aviv, Israel
| | - Yardena Rabi
- Clalit Health Research Institute, Tel Aviv, Israel
| | | | - Zaza Iakobishvili
- Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Hasdai
- Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Balicer RD, Luengo-Oroz M, Cohen-Stavi C, Loyola E, Mantingh F, Romanoff L, Galea G. Using big data for non-communicable disease surveillance. Lancet Diabetes Endocrinol 2018; 6:595-598. [PMID: 29146206 DOI: 10.1016/s2213-8587(17)30372-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/01/2017] [Accepted: 10/01/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Ran D Balicer
- Clalit Research Institute, WHO Collaborating Centre for NCD Research Prevention and Control, Chief Physician's Office, Clalit Health Services, Tel Aviv 62098, Israel; Epidemiology Department, Ben Gurion University of the Negev, Be'er Sheva, Israel.
| | | | - Chandra Cohen-Stavi
- Clalit Research Institute, WHO Collaborating Centre for NCD Research Prevention and Control, Chief Physician's Office, Clalit Health Services, Tel Aviv 62098, Israel
| | - Enrique Loyola
- WHO European Office for the Prevention and Control of Non-Communicable Diseases (NCD Office), Moscow, Russia
| | - Frederiek Mantingh
- Division of Non-Communicable Diseases and Promoting Health through the Life-Course, WHO Regional Office for Europe, Copenhagen, Denmark
| | | | - Gauden Galea
- Division of Non-Communicable Diseases and Promoting Health through the Life-Course, WHO Regional Office for Europe, Copenhagen, Denmark
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Abelson S, Collord G, Ng SWK, Weissbrod O, Mendelson Cohen N, Niemeyer E, Barda N, Zuzarte PC, Heisler L, Sundaravadanam Y, Luben R, Hayat S, Wang TT, Zhao Z, Cirlan I, Pugh TJ, Soave D, Ng K, Latimer C, Hardy C, Raine K, Jones D, Hoult D, Britten A, McPherson JD, Johansson M, Mbabaali F, Eagles J, Miller JK, Pasternack D, Timms L, Krzyzanowski P, Awadalla P, Costa R, Segal E, Bratman SV, Beer P, Behjati S, Martincorena I, Wang JCY, Bowles KM, Quirós JR, Karakatsani A, La Vecchia C, Trichopoulou A, Salamanca-Fernández E, Huerta JM, Barricarte A, Travis RC, Tumino R, Masala G, Boeing H, Panico S, Kaaks R, Krämer A, Sieri S, Riboli E, Vineis P, Foll M, McKay J, Polidoro S, Sala N, Khaw KT, Vermeulen R, Campbell PJ, Papaemmanuil E, Minden MD, Tanay A, Balicer RD, Wareham NJ, Gerstung M, Dick JE, Brennan P, Vassiliou GS, Shlush LI. Prediction of acute myeloid leukaemia risk in healthy individuals. Nature 2018; 559:400-404. [PMID: 29988082 PMCID: PMC6485381 DOI: 10.1038/s41586-018-0317-6] [Citation(s) in RCA: 506] [Impact Index Per Article: 84.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 05/03/2018] [Indexed: 02/07/2023]
Abstract
The incidence of acute myeloid leukaemia (AML) increases with age and mortality exceeds 90% when diagnosed after age 65. Most cases arise without any detectable early symptoms and patients usually present with the acute complications of bone marrow failure1. The onset of such de novo AML cases is typically preceded by the accumulation of somatic mutations in preleukaemic haematopoietic stem and progenitor cells (HSPCs) that undergo clonal expansion2,3. However, recurrent AML mutations also accumulate in HSPCs during ageing of healthy individuals who do not develop AML, a phenomenon referred to as age-related clonal haematopoiesis (ARCH)4-8. Here we use deep sequencing to analyse genes that are recurrently mutated in AML to distinguish between individuals who have a high risk of developing AML and those with benign ARCH. We analysed peripheral blood cells from 95 individuals that were obtained on average 6.3 years before AML diagnosis (pre-AML group), together with 414 unselected age- and gender-matched individuals (control group). Pre-AML cases were distinct from controls and had more mutations per sample, higher variant allele frequencies, indicating greater clonal expansion, and showed enrichment of mutations in specific genes. Genetic parameters were used to derive a model that accurately predicted AML-free survival; this model was validated in an independent cohort of 29 pre-AML cases and 262 controls. Because AML is rare, we also developed an AML predictive model using a large electronic health record database that identified individuals at greater risk. Collectively our findings provide proof-of-concept that it is possible to discriminate ARCH from pre-AML many years before malignant transformation. This could in future enable earlier detection and monitoring, and may help to inform intervention.
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Affiliation(s)
- Sagi Abelson
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
| | - Grace Collord
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Stanley W K Ng
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Omer Weissbrod
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel
| | - Netta Mendelson Cohen
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel
| | - Elisabeth Niemeyer
- Department of Immunology, Weizmann Institute of Science, Rehovot, Israel
| | - Noam Barda
- Clalit Research Institute, Tel Aviv, Israel
| | | | | | | | - Robert Luben
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Shabina Hayat
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Ting Ting Wang
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Zhen Zhao
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
| | - Iulia Cirlan
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
| | - Trevor J Pugh
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - David Soave
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Karen Ng
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Calli Latimer
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK
| | - Claire Hardy
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK
| | - Keiran Raine
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK
| | - David Jones
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK
| | - Diana Hoult
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Abigail Britten
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | | | - Mattias Johansson
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | | | - Jenna Eagles
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | | | | | - Lee Timms
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | | | - Philip Awadalla
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Rui Costa
- European Molecular Biology Laboratory, European Bioinformatics Institute EMBL-EBI, Wellcome Genome Campus, Hinxton, UK
| | - Eran Segal
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel
| | - Scott V Bratman
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Philip Beer
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK
| | - Sam Behjati
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Inigo Martincorena
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK
| | - Jean C Y Wang
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Medical Oncology and Hematology, University Health Network, Toronto, Ontario, Canada
| | - Kristian M Bowles
- Department of Molecular Haematology, Norwich Medical School, The University of East Anglia, Norwich, UK
- Department of Haematology, Norfolk and Norwich University Hospitals NHS Trust, Norwich, UK
| | | | - Anna Karakatsani
- Hellenic Health Foundation, Athens, Greece
- 2nd Pulmonary Medicine Department, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University Hospital, Haidari, Athens, Greece
| | - Carlo La Vecchia
- Hellenic Health Foundation, Athens, Greece
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | | | - Elena Salamanca-Fernández
- Escuela Andaluza de Salud Pública, Instituto de Investigación Biosanitaria ibs.GRANADA, Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain
- CIBER Epidemiology and Public Health CIBERESP, Madrid, Spain
| | - José M Huerta
- CIBER Epidemiology and Public Health CIBERESP, Madrid, Spain
- Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, Murcia, Spain
| | - Aurelio Barricarte
- CIBER Epidemiology and Public Health CIBERESP, Madrid, Spain
- Navarra Public Health Institute, Pamplona, Spain
- Navarra Institute for Health Research, Pamplona, Spain
| | - Ruth C Travis
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rosario Tumino
- Cancer Registry and Histopathology Department, Civic-M. P. Arezzo Hospital, Azienda Sanitaria Provinciale, Ragusa, Italy
| | - Giovanna Masala
- Cancer Risk Factors and Life-Style Epidemiology Unit, Cancer Research and Prevention Institute - ISPO, Florence, Italy
| | - Heiner Boeing
- Department of Epidemiology, German Institute of Human Nutrition (DIfE), Potsdam-Rehbrücke, Germany
| | - Salvatore Panico
- Dipartimento Di Medicina Clinica E Chirurgia, Federico II University, Naples, Italy
| | - Rudolf Kaaks
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Alwin Krämer
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Sabina Sieri
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Elio Riboli
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Paolo Vineis
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Matthieu Foll
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - James McKay
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | | | - Núria Sala
- Unit of Nutrition and Cancer, Cancer Epidemiology Research Program and Translational Research Laboratory, Catalan Institute of Oncology, ICO-IDIBELL, Barcelona, Spain
| | | | - Roel Vermeulen
- Division of Environmental Epidemiology and Veterinary Public Health, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
| | - Peter J Campbell
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | - Elli Papaemmanuil
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK
- Center for Molecular Oncology and Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark D Minden
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Medical Oncology and Hematology, University Health Network, Toronto, Ontario, Canada
| | - Amos Tanay
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel
| | | | | | - Moritz Gerstung
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK.
- European Molecular Biology Laboratory, European Bioinformatics Institute EMBL-EBI, Wellcome Genome Campus, Hinxton, UK.
| | - John E Dick
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada.
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada.
| | - Paul Brennan
- International Agency for Research on Cancer, World Health Organization, Lyon, France.
| | - George S Vassiliou
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK.
- Department of Haematology, University of Cambridge, Cambridge, UK.
- Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, University of Cambridge, Cambridge, UK.
| | - Liran I Shlush
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada.
- Department of Immunology, Weizmann Institute of Science, Rehovot, Israel.
- Division of Hematology, Rambam Healthcare Campus, Haifa, Israel.
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Low M, Almog R, Balicer RD, Liberman N, Raz R, Peretz A, Nitzan O. Infectious disease burden and antibiotic prescribing in primary care in Israel. Ann Clin Microbiol Antimicrob 2018; 17:26. [PMID: 29885657 PMCID: PMC5994243 DOI: 10.1186/s12941-018-0278-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotics are frequently prescribed at many of the visits to primary care clinics, often for conditions for which they provide no benefit, including viral respiratory tract infections. OBJECTIVES The aim was to evaluate primary care visits due to infectious diseases, and to estimate antibiotic prescribing and antibiotic dispensing by pharmacies. METHODS Diagnosis of infectious disease, antibiotic prescribing and dispensing data at the individual patient level were extracted for 2015 from Clalit Health Services' electronic medical records and linked to determine the condition for which the antimicrobial was prescribed. RESULTS There were 6.6 million visits due to infections, representing 22% of all primary care visits. The most common events were upper respiratory tract infections (38%) and pharyngitis (10%). Highest prescription rates were for urinary tract infections (80%), otitis media (64%), pharyngitis (71%), sinusitis (63%), and lower respiratory tract infections (76%). The highest rates of undispensed prescriptions were for acute gastroenteritis, urinary tract infections, and pharyngitis (24, 23, and 16%, respectively). CONCLUSIONS Infectious diseases constitute a heavy burden on primary care, with overprescribing of antibiotics. Intervention to reduce unwarranted antibiotic use is needed. In pediatric care, interventions should focus on better controlling antibiotic consumption and encouraging adherence to guidelines for upper respiratory tract infections, pharyngitis, and otitis media. In adults interventions should aim to monitor antibiotic prescribing for upper respiratory tract infections and improve adherence to guidelines for urinary tract infections.
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Affiliation(s)
- Marcelo Low
- Clalit Research Institute & Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel. .,School of Public Health, University of Haifa, Haifa, Israel.
| | - Ronit Almog
- School of Public Health, University of Haifa, Haifa, Israel.,Rambam Medical Center, Haifa, Israel
| | - Ran D Balicer
- Clalit Research Institute & Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel.,Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Nicky Liberman
- Clalit Health Services, Community Medicine Division, Tel-Aviv, Israel
| | - Raul Raz
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Avi Peretz
- Clinical Microbiology Laboratory, The Baruch Padeh Medical Center Poriya, Tiberias, Israel.,The Faculty of Medicine in the Galilee, Bar Ilan University, Zefat, Israel
| | - Orna Nitzan
- The Faculty of Medicine in the Galilee, Bar Ilan University, Zefat, Israel.,Infectious Disease Unit, Poriya Medical Center, Tiberias, Israel
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50
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Friedman MY, Leventer-Roberts M, Rosenblum J, Zigman N, Goren I, Mourad V, Lederman N, Cohen N, Matz E, Dushnitzky DZ, Borovsky N, Hoshen MB, Focht G, Avitzour M, Shachar Y, Chowers Y, Eliakim R, Ben-Horin S, Odes S, Schwartz D, Dotan I, Israeli E, Levi Z, Benchimol EI, Balicer RD, Turner D. Development and validation of novel algorithms to identify patients with inflammatory bowel diseases in Israel: an epi-IIRN group study. Clin Epidemiol 2018; 10:671-681. [PMID: 29922093 PMCID: PMC5995295 DOI: 10.2147/clep.s151339] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background Before embarking on administrative research, validated case ascertainment algorithms must be developed. We aimed at developing algorithms for identifying inflammatory bowel disease (IBD) patients, date of disease onset, and IBD type (Crohn's disease [CD] vs ulcerative colitis [UC]) in the databases of the four Israeli Health Maintenance Organizations (HMOs) covering 98% of the population. Methods Algorithms were developed on 5,131 IBD patients and 2,072 controls, following independent chart review (60% CD and 39% UC). We reviewed 942 different combinations of clinical parameters aided by mathematical modeling. The algorithms were validated on an independent cohort of 160,000 random subjects. Results The combination of the following variables achieved the highest diagnostic accuracy: IBD-related codes, alone if more than five to six codes or combined with purchases of IBD-related medications (at least three purchases or ≥3 months from the first to last purchase) (sensitivity 89%, specificity 99%, positive predictive value [PPV] 92%, negative predictive value [NPV] 99%). A look-back period of 2-5 years (depending on the HMO) without IBD-related codes or medications best determined the date of diagnosis (sensitivity 83%, specificity 68%, PPV 82%, NPV 70%). IBD type was determined by the majority of CD/UC codes of the three recent contacts or the most recent when less than three contacts were recorded (sensitivity 92%, specificity 97%, PPV 97%, NPV 92%). Applying these algorithms, a total of 38,291 IBD patients were residing in Israel, corresponding to a prevalence rate of 459/100,000 (0.46%). Conclusion The application of the validated algorithms to Israel's administrative databases will now create a large and accurate ongoing population-based cohort of IBD patients for future administrative studies.
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Affiliation(s)
- Mira Y Friedman
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.,Braun School of Public and Community Medicine, The Hebrew University - Hadassah Medical Center, Jerusalem, Israel
| | | | | | - Nir Zigman
- Maccabi Healthcare Services, Tel Aviv, Israel
| | - Iris Goren
- Maccabi Healthcare Services, Tel Aviv, Israel
| | | | | | | | - Eran Matz
- Leumit Health Services, Tel Aviv, Israel
| | | | | | - Moshe B Hoshen
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv, Israel
| | - Gili Focht
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Malka Avitzour
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yael Shachar
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Rami Eliakim
- Department of Gastroenterology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shmuel Odes
- Department of Gastroenterology and Hepatology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Doron Schwartz
- Department of Gastroenterology and Hepatology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Eran Israeli
- Institute of Gastroenterology and Liver Diseases, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Zohar Levi
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Eric I Benchimol
- CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Department of Pediatrics and School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada
| | - Ran D Balicer
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv, Israel
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
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