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author:("shadi, errat")
1.  Multimorbidity and equity in health 
doi:10.1186/1475-9276-12-59
PMCID: PMC3846622  PMID: 23961952
2.  Targeting patients for multimorbid care management interventions: the case for equity in high-risk patient identification 
Targeting patients for multimorbid care management interventions requires accurate and comprehensive assessment of patients’ need in order to direct resources to those who need and can benefit from them the most. Multimorbid patient selection is complicated due to the lack of clear criteria - unlike disease management programs for which patients with a specific condition are identified. This ambiguity can potentially result in inequitable selection, as biases in selection may differentially affect patients from disadvantaged population groups. Patient selection could in principal be performed in three ways: physician referral, patient screening surveys, or by statistical prediction algorithms. This paper discusses equity issues related to each method. We conclude that each method may result in inequitable selection and bias, such as physicians’ attentiveness or familiarity, or prediction models’ reliance on prior resource use, potentially affected by socio-cultural and economic barriers. These biases should be acknowledged and dealt with. We recommend combining patient selection approaches to achieve high care sensitivity, efficiency and equity.
doi:10.1186/1475-9276-12-70
PMCID: PMC3847614  PMID: 23962231
Multimorbidity; Equity; High-risk patients; Care management
3.  Reducing Health Disparities: Strategy Planning and Implementation in Israel's Largest Health Care Organization 
Health Services Research  2011;46(4):1281-1299.
Objective
To describe an organization-wide disparity reduction strategy and to assess its success in quality improvement and reduction of gaps in health and health care.
Study Setting
Clalit Health Services, Israel's largest non-for-profit insurer and provider serving 3.8 million persons.
Study Design
Before and after design: quality assessment before and 12-month postinitiation of the strategic plan. A composite weighted score of seven quality indicators, measuring attainment of diabetes, blood pressure, and lipid control, lack of anemia in infants, and performance of mammography, occult blood tests, and influenza vaccinations.
Data Extraction Methods
Quality indicator scores, derived from Clalit's central data warehouse, based on data from electronic medical records.
Principal Findings
Low-performing clinics, of low-socioeconomic and minority populations, were targeted for intervention. Twelve months after the initiation of the project continuous improvement was observed coupled with a reduction of 40 percent of the gap between disadvantaged clinics, serving ∼10 percent of enrollees, and all other medium-large clinics.
Conclusion
The comprehensive strategy, following a quality improvement framework, with a top-down top-management incentives and monitoring, and a bottom-up locally tailored interventions, approach, is showing promising results of overall quality improvement coupled with disparity reduction in key health and health care indicators.
doi:10.1111/j.1475-6773.2011.01247.x
PMCID: PMC3165188  PMID: 21352224
Disparities; quality improvement; quality assessment; primary care
4.  Interventions for reducing readmissions – are we barking up the right tree? 
Readmission reduction is at the focus of health care systems worldwide in efforts to improve efficiency across care settings. Yet, setting targets for readmission reduction is complicated due to inconsistencies in evidence pointing to effective organization-wide interventions and because of inverse incentives (such as maintaining high occupancy rates). Nonetheless, readmission reduction is one of the few quality measures that, if implemented properly, can serve as a catalyst for system integration. Appropriate mechanisms should be applied to hospitals as well as ambulatory settings to ensure that accountability is assigned to all stakeholders.
doi:10.1186/2045-4015-2-2
PMCID: PMC3570430  PMID: 23343051
Readmission; Quality of care; Health services research
5.  Assessing socioeconomic health care utilization inequity in Israel: impact of alternative approaches to morbidity adjustment 
BMC Public Health  2011;11:609.
Background
The ability to accurately detect differential resource use between persons of different socioeconomic status relies on the accuracy of health-needs adjustment measures. This study tests different approaches to morbidity adjustment in explanation of health care utilization inequity.
Methods
A representative sample was selected of 10 percent (~270,000) adult enrolees of Clalit Health Services, Israel's largest health care organization. The Johns-Hopkins University Adjusted Clinical Groups® were used to assess each person's overall morbidity burden based on one year's (2009) diagnostic information. The odds of above average health care resource use (primary care visits, specialty visits, diagnostic tests, or hospitalizations) were tested using multivariate logistic regression models, separately adjusting for levels of health-need using data on age and gender, comorbidity (using the Charlson Comorbidity Index), or morbidity burden (using the Adjusted Clinical Groups). Model fit was assessed using tests of the Area Under the Receiver Operating Characteristics Curve and the Akaike Information Criteria.
Results
Low socioeconomic status was associated with higher morbidity burden (1.5-fold difference). Adjusting for health needs using age and gender or the Charlson index, persons of low socioeconomic status had greater odds of above average resource use for all types of services examined (primary care and specialist visits, diagnostic tests, or hospitalizations). In contrast, after adjustment for overall morbidity burden (using Adjusted Clinical Groups), low socioeconomic status was no longer associated with greater odds of specialty care or diagnostic tests (OR: 0.95, CI: 0.94-0.99; and OR: 0.91, CI: 0.86-0.96, for specialty visits and diagnostic respectively). Tests of model fit showed that adjustment using the comprehensive morbidity burden measure provided a better fit than age and gender or the Charlson Index.
Conclusions
Identification of socioeconomic differences in health care utilization is an important step in disparity reduction efforts. Adjustment for health-needs using a comprehensive morbidity burden diagnoses-based measure, this study showed relative underutilization in use of specialist and diagnostic services, and thus allowed for identification of inequity in health resources use, which could not be detected with less comprehensive forms of health-needs adjustments.
doi:10.1186/1471-2458-11-609
PMCID: PMC3171367  PMID: 21801459
6.  A Pilot Test of the Effect of Guided Care on the Quality of Primary Care Experiences for Multimorbid Older Adults 
Objective
Improving health care of multimorbid older adults is a critical public health challenge. The objective of this study is to evaluate the effect of a pilot intervention to enhance the quality of primary care experiences for chronically ill older persons (Guided Care).
Design
Nonrandomized prospective clinical trial.
Patients/Participants
Older, chronically ill, community-dwelling patients (N = 150) of 4 General Internists in 1 urban community practice setting who were members of a capitated health plan and identified as being at high risk of heavy use of health services in the coming year by claims-based predictive modeling.
Interventions
Guided Care, an enhancement to primary care that incorporates the operative principles of chronic care innovations, was delivered by a specially trained, practice-based registered nurse working closely with 2 primary care physicians. Each patient received a geriatric assessment, a comprehensive care plan, evidence-based primary care with proactive follow-up of chronic conditions, coordination of the efforts of health professionals across all health care settings, and facilitated access to community resources.
Measurements and Main Results
Quality of primary care experiences (physician–patient communication, interpersonal treatment, knowledge of patient, integration of care, and trust in physician) was assessed using the Primary Care Assessment Survey (PCAS) at baseline and 6 months later. At baseline, the patients assigned to receive Guided Care were similar to those assigned to receive usual care in their demographics and disability levels, but they had higher risk scores and were less likely to be married. Thirty-one of the 75 subjects assigned to the Guided Care group received the intervention. At 6 months, intention-to-treat analyses adjusting for age, gender, and risk score suggest that Guided Care may improve the quality of physician–patient communication. In per-protocol analyses, receipt of Guided Care was associated with more favorable change than usual care from baseline to follow-up in all 5 PCAS domains, but only physician–patient communication showed a statistically significant improvement.
Conclusions
In this pilot study, Guided Care appeared to improve the quality of primary care experiences for high-risk, chronically ill older adults. A larger cluster-randomized controlled trial of Guided Care is underway.
doi:10.1007/s11606-008-0529-9
PMCID: PMC2324149  PMID: 18266045
aged; multimorbidity; chronic disease; nursing; quality of care
7.  Oncology patients' experience at the interface between hospital and community care: a mixed method investigation 
Introduction
Oncology patients often experience breakdowns in care when transitioning between care settings.
Aims and objectives
To examine the experience of oncology patients at the transition between hospital and community care and identify factors which affect fragmentation.
Methods
We used a complementary mixed method approach. Qualitative phase: semi-structured interviews and focus groups were conducted with patients and their caregivers, nurses, social workers, physicians and medical administrators. Quantitative phase: a survey was administered to 400 oncology patients of a large tertiary medical center in Northern Israel. Patients who were discharged from the hospital completed a validated questionnaire on their transition from the hospital to the community and on their perceptions of the quality of their primary care. The surveys were administered in Hebrew, Arabic, and Russian.
Results
From the preliminary analysis of the qualitative data four broad themes emerged: (1) responsibility for care, (2) administrative and bureaucratic burden, (3) informal routes of communication, and (4) cultural barriers. The regression analyses examined the effect of patient characteristics (gender, age, education, income, health status, and language group) and showed that patients' language accounted for most of the variance in quality scores. Russian speaking patients reported poorer quality of care and Arabic speaking patients reported better quality of care, than Hebrew speakers, in all primary care domains. Both Arabic and Russian speakers scored significantly higher on the Care Transition Measure than Hebrew speakers.
Conclusions
The differences between sub-groups found here suggest that avoidable variations in care exist. To enable a more streamlined process, cultural issues need to be addressed at the interface between care settings. Further research should examine the causes for such differences.
PMCID: PMC2430304
oncological care; quality of care; transition; hospital care; primary care; Israel

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