Background: In view of increasing global and local trends in population ageing and the high healthcare utilization rates among the elderly, this study assesses the quality of primary care provided to the elderly population in Israel. It examines changes in quality over time, how quality varies across sub-groups of the elderly, and how quality in Israel compares with other countries. Data originate from the National Program for Quality Indicators in Community Healthcare (QICH), which operates in full collaboration with Israel’sfour HMOs. Methods: The study population included all elderly Israeli residents aged 65 years or older during 2002–2015 (N = 879,671 residents in 2015). Seven elderly-specific quality indicators from within the QICH framework were included: influenza and pneumococcal vaccinations, benzodiazepine overuse, long-acting benzodiazepine use, body weight documentation, weight loss and underweight. In addition, two non-age specific quality indicators relating to diabetes mellitus were included: the rate of HbA1C documentation and uncontrolled diabetes. Data were collected from patient electronic medical records (EMR) in accordance with each HMO, and aggregated by three variables: gender, age, and socio-economic position (SEP). Results: During the measurement period, vaccination rates significantly increased (Influenza: from 42.0% in 2002 to 63.2% in 2015; and pneumococcal vaccination: from 25.8% in 2005 to 77.0% in 2015). Body weight documentation (in 65–74 year old persons) increased from only 16.3% in 2003 to 80.9% in 2015. The rate of underweight (BMI < 23 kg/m ) and significant weight-loss (10% or more of their body weight) was only measured in 2015. The overall rate of benzodiazepine overuse remained steady from 2011 to 2015 at around 5%, while the rate of long-acting benzodiazepine use decreased from 3.8% in 2011 to 2.4% in 2015. The rate of HbA1c documentation for elderly diabetics was higher than for non-elderly diabetics in 2015 (92.2% vs 87.9%). The rate of uncontrolled diabetes was lower for the elderly than the non-elderly population in 2015 (6.9% vs. 15.7%). Gender disparities were observed across all measures, after age stratification, with worse indicator rates among females compared to males. SEP-disparities were not consistent across measures. In all indicators except benzodiazepine overuse, Israel showed a higher quality of care for the elderly in comparison with the international healthcare community. Conclusions: Overall, the quality of care received by elderly Israelis has improved substantially since measurements first began; yet, females receive lower quality care than males. Monitoring results of primary care quality indicators can contribute to population’s successful aging; both chronic conditions at earlier ages (e.g. diabetes), and short-term hazardous conditions such as the use of potentially harmful medications and weight loss should be evaluated. Keywords: Quality indicators, Community healthcare, Elderly health, Gender disparities, Vaccinations, Underweight, Benzodiazepine overuse * Correspondence: firstname.lastname@example.org Program directorate of the National Program for Quality Indicators in Community Healthcare in Israel, Hebrew University, POB 12272, 92210 Jerusalem, Israel Braun School of Public Health, Hebrew University, POB 12272, 92210 Jerusalem, Israel Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 2 of 15 Background utilizing quality indicators from within the framework of Worldwide population ageing, due to an increase in life the Israel National Program for Quality Indicators in expectancy and decrease in fertility rates, is occurring Community Healthcare (QICH) . rapidly . The World Health Organization (WHO) projects by 2050 the world’s older population (60 years Methods or above, WHO definition) will encompass 22% of the The Israeli National Health Insurance (NHI) law was total population . Correspondingly, 17% of the overall implemented in 1995 offering all Israeli residents a European population in 2014 was comprised of adults standardized basket of medical services through four 65 years or older with growth expected in the future . health maintenance organizations (HMOs, kupot cholim). By the year 2030, more than 20% of the US population Under this law, every resident has the right to choose their is expected to be 65 years and older . HMO, transfer from one HMO to another, and receive While modern health improvements help reduce ser- health services through their HMO . QICH works ious disabilities in the elderly, WHO reports an increase with the four HMOs and evaluates the quality of in multiple morbidities, burden of chronic diseases, and community-based medical care in Israel, provides this health-care utilization [1, 5]. Chronic disease affects 61% information to policy makers and the public, promotes of Europeans 65 years or older , and multiple morbid- health care monitoring and guideline-based care, and ities affect more than 60% of elderly adults worldwide improves population health. QICH monitors all Israeli . Two out of three older Americans suffered from citizens, including the entire Israeli elderly population. multiple chronic conditions in 2013 . Health care This study selected seven elderly-specific (65 years or utilization in high-income countries increases with age; older) quality indicators available from within the QICH in Canada, the elderly accounted for 40% of acute framework (Table 1). hospital stays in 2010 . In addition, healthcare ex- penditure peaked for adults 65–74 years in the United Population Kingdom, but decreased until the last year of life. This The study population included all elderly residents aged last year is the strongest driver of increasing healthcare 65 years or older during the years 2002–2015. The study expenditures worldwide [1, 10]. population grew from 591,877 residents in 2002 to Similar to the global ageing rate, Israel is experiencing 879,671 residents in 2015. a rapid rate of elderly population growth. The propor- tion of the elderly among the general population is ex- Data pected to increase to 15% by 2035 (11% in 2014). In Data for 2002–2015 were collected from patient elec- 2014, one in four households in Israel included someone tronic medical records (EMR) in accordance with the 65 years or older . Israeli immigration trends have four HMOs. Yearly data for residents who passed away, also contributed to both the relative and absolute in- elderly residents who switched HMOs (0.28%, 2014), crease in the number of older adults . and missing EMR data (0.7%, 2015) were not included in Chronic disease affected approximately 70% of elderly the dataset. The source of relevant study information in- Israelis in 2009 . A study conducted by the second cluded physician visits, nursing notes, pharmacy claims, largest health maintenance organization in Israel medical appointments, and immunization records. To (Maccabi Health Services), found that over 90% of study ensure confidentiality, data from each HMO were anon- participants 75 years or older suffered from multiple ymized, aggregated, and merged into a national dataset chronic conditions . Following global healthcare to calculate population-wide rates. utilization trends, the elderly population (65 years or Data were aggregated by three variables: gender, age older) was hospitalized 3.2 times more than the general groups, and socio-economic position (SEP). SEP was de- population (2013)  and made on average 11.2 primary fined by co-payment exemption when receiving health care physician visits per year (versus an overall average services, classified as either low SEP (exempt group, of only three per year for the general population) . representing 39% of the elderly population in 2015) or Aging affects both mental and physical health, pro- middle and high SEP (non-exempt group). In the moting the study of the quality of care among the elderly documentation period, exemption was granted based on in Israel. Past elderly studies have focused on primary national insurance allowances such as income support, care (e.g. the chronic care model or home-based primary handicap allowance, large family allowance, etc. In a care) [14, 15], elderly disease states , or elderly care pilot study, the above SEP indicator was validated against processes within the health system . This research an area-based SEP variable. Using census information on aims to add new knowledge to the field. This study numerous indicators (including income, education and sought to examine the quality of primary care provided unemployment) the Israeli Central Bureau of Statistics to elderly Israelis over a 14-year measurement period routinely calculate and allocate a socioeconomic score to Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 3 of 15 Table 1 QICH elderly-specific quality indicators Quality indicator Denominator Numerator Comments Influenza Vaccination All residents aged 65 years and older Number of residents (out of the �“ Seasonal” refers to the winter during the measurement year denominator) who received a season during the height of the seasonal influenza vaccination during influenza virus, September 1st of the measurement year the former year to February 28th of current year � Information derived from pharmacy claims and nursing notes Pneumococcal Vaccination All residents aged 65–74 years Number of residents (out of the � Information derived from pharmacy during the measurement year denominator) who received the claims and nursing notes pneumococcal vaccination either � The 65–74 year age group was once after age 65 or in the last selected due to data availability 5 years being limited to the past 10 years Body Weight and Height All residents aged 65–84 years Number of residents (out of the � Information derived from medical Documentation during the measurement year denominator) with documented appointment documentation body weight during the measurement year and at least one height documentation between 65 and 84 years of age Underweight Number of residents aged 65 or Number of residents (out of the � Information derived from medical older during the measurement year denominator) with most recent appointment documentation with body weight and height documented BMI < 23 kg/m documentation (see above) Weight loss All residents aged 65 years or older Number of residents (out of the � Information derived from medical during the measurement year denominator) experiencing a decline appointment documentation of 10% or more in their body weight within 2 years Benzodiazepine Overuse All residents aged 65 years and older Number of residents (out of the � Overused benzodiazepines defined during the measurement year denominator) with benzodiazepine by purchased benzodiazepines or overuse during the measurement related drugs ≥ 365 DDD/year year in the measurement year (DDD = Defined Daily Dose) � Information derived from pharmacy claims Benzodiazepine Long-Acting All residents aged 65 years and older Number of residents (out of the � Long-acting benzodiazepine use Use during the measurement year denominator) with at least one defined by the purchase of one or purchase of long-acting more long-acting benzodiazepines benzodiazepines during the or related drugs measurement year � Information derived from pharmacy claims each geographical statistical area (GSA). In the pilot study, evidence to support the indicator, (3) quantifiability, (4) subjects received the score allocated to their GSA (based availability and accessibility of electronic data from the on their address as recorded in the HMO) . Validation EMRs, and (5) ability to implement within the healthcare showed a strong association between these two variables; setting. Indicators meeting these criteria undergo a consen- 52% of lower quartile GSA-based SEP had an exemption sus decision for incorporation into the QICH framework from co-payments and 24% of those in the higher quartile and then definitions are unified across HMOs. The QICH were exempted. quality indicator development process is similar to the rec- ommendations provided by the US Institute of Medicine Quality indicators . Seven elderly-specific (65 years and older) indicators, The QICH indicators undergo a three-step evaluation sys- which underwent this incorporation process into the QICH tem before implementation. The program’sdirectorate con- framework, were selected for this study. Detailed definitions sults evidence, guidelines, international measures, and of the indicators are given in Table 1; influenza and professional recommendations. Then, an internal HMO as- pneumococcal vaccinations, benzodiazepine overuse, long- sessment is conducted, followed by hearings with stake- acting benzodiazepine use, body weight documentation, holders (e.g. Health Councils, Health Associations, and weight loss and underweight. The quality indicators in- clinical experts) directed by the steering committee. Five cluded indicated either measurements (i.e. weight, height main selection criteria are utilized to evaluate the indica- and level of HbA1C) from which quality indicators were tors: (1) importance and relevance to the field, (2) sufficient later calculated, purchasing of benzodiazepines, or Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 4 of 15 procedures (i.e. vaccinations). Despite the fact that the in- disability, and death [32, 33]. According to the US HMO formation on body weight existed in the EMRs of HMOs Medicare coverage and eligibility guidelines, elderly patients from 2003, the indicators of underweight and weight-loss should receive a body weight measurement at every yearly were only calculated from 2013, the year the quality indica- “wellness” visit . Weight loss was defined under QICH tors steering committee has decided to incorporate them in framework as the calculated difference between two con- the quality indicators program. The comprehensive geriat- secutive measurements, whereas for the definition of under- ric assessment indicator was not included in QICH due to weight we used the cutoff value of Body Mass Index (BMI, lack of evidence supporting some components of this as- which is person’s weight in kilograms divided by the square sessment and the variability of use among clinicians. of height in meters) lower than 23. Influenza and pneumococcal vaccinations aim to prevent Overuse of benzodiazepines and any use of long-acting influenza and pneumococcal infections in the elderly; these benzodiazepines are important elderly population measures. diseases are major causes of morbidity and mortality in this Benzodiazepines are a veteran class of medications with a population. In an influenza season, approximately 90% of primary usage for sleep and anti-anxiety, also causing confu- influenza-related deaths occur in the elderly [22, 23]. Dur- sion, memory loss, loss of focus and balance leading to falls, ing the 2014–2015 Israeli influenza season, the rate of clinic dependency and withdrawal symptoms, motor vehicle acci- visits for those 65 years and older with an influenza-like ill- dents, and hip fractures in the elderly population [35–37]. ness (ILI) was higher than the previous two influenza sea- The slower metabolic rate of the elderly population causes sons, despite a higher rate of influenza vaccinations . benzodiazepines to build-up in the bloodstream leading to a The incidence rate of invasive pneumococcal disease (IPD) prolonged exertion of the medication effect , and result- in Israel between 2009 and 2010 for those aged 65–74 years ing in elderly specific morbidity. Benzodiazepine prescribing was 20 per 100,000 people; incidence rate increased as age is contra-indicated among the elderly for insomnia, increased. The case-fatality rate was 25% among 65– agitation, or delirium and this indicator was created in ac- 74 years-old, and 35% among those 85 years-old and older cordance with the OECD measures [38–40]. The benzodi- . Additionally, half of all IPD cases occurred in those azepine indicators are relevant today since studies have 65 years or older in the United States in 2013 . This found that benzodiazepine prescribing and usage in the eld- study sought to include the pneumococcal vaccinations in- erly remains high, despite guideline recommendations for dicator, despite weak supporting evidence, due to its public decrease or stoppage of use. A review performed on the health importance and inclusion in elderly primary care usage of benzodiazepines in the United Kingdom, United guidelines of most countries. Inclusion of these indicators States, and Europe, found that as age increased overall was supported by the Israeli Ministry of Health and benzodiazepine consumption increased, with higher usage the US Centers for Disease Control and Prevention  rates in women compared to men . A recent US study recommendation for a seasonal influenza vaccination once found that 8.7% of the study participants aged 65–80 years a year for adults 65 years or older, and a pneumococcal vac- used benzodiazepines and 23.8% of that cohort had long- cination once after age 65. Further, herd immunity through acting benzodiazepine use . A2007Australianstudy re- vaccinated children is less effective than directly vaccinating ported 15.7% of elderly Australian study participants had at elderly adults . least one benzodiazepine prescription . Body weight documentation and detection of underweight Additionally, we examined the performance on two key and weight loss in the elderly are important steps to pre- quality indicators in the field of diabetes treatment in 2015, venting morbidity and mortality. Documenting body weight which are not age-specific in order to establish whether per- is essential to preventative care, as is providing information formance on these measures differs between the elderly and on patients’ weight status compared to the recommended the non-elderly. For these measures, we also examined the healthy weight status, nutritional needs, medication dosing, change in performance rate during a five-year period, 2011– and implied specific health problems . Underweight in 2015: documentation rate of hemoglobin A1c (HbA1c) the elderly has been associated with excess mortality, versus levels for individuals with diabetes mellitus, and the rate of those with a normal weight . Instability in elderly weight uncontrolled diabetes mellitus (defined as HbA1c greater has also been associated with all-cause mortality , and than 9%). monitoring elderly weight changes over time assists in un- derstanding elderly health quality. Moreover, dynamic body Analysis weight measures (i.e. weight changes), compared to static Annual trends were examined for each indicator for the en- body weight measures (e.g. body mass index), better pre- tire measurement period. Data for 2015 were stratified by dicts mortality among the elderly . Weight loss has been gender, age, and socio-economic position (SEP), and differ- associated with elderly health conditions, such as frailty. ences in each indicator’s performance rate by these socio- Frailty is associated with increased odds for falls, hospitali- demographic variables were assessed using a z-typed test. zations, longer hospital stays, delayed surgery recovery, To adjust for multiple comparisons (20 tests were Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 5 of 15 conducted) and the large sample, a p-value below 0.0005 Overall rates of pneumococcal vaccination increased since was considered statistically significant. the first measurement in 2005 (25.8% to 77.0% in 2015, Fig. 1). Vaccination rates increased dramatically from 36.5% in Quality of the data 2007 to 70.9% in 2008 due to excessive immunization efforts The definitions of the included indicators remained un- of the HMOs. In 2015, females were vaccinated at a lower changed during the measurement period, as well as the data rate than males (75.3% vs 79.0%, p < 0.00001); individuals of extraction methods, allowing a reliable examination of time- low SEP were vaccinated more compared to the individuals trends. Additionally, the methods created for data collection of the middle and high SEP (81.2% vs 77.0%, p < 0.00001) includes an extensive evaluation program intended to (Table 2). Males of low SEP were vaccinated at the highest minimize the chance of various errors, including differences rate, while females of high and middle SEP were vaccinated between health plans in documentation and coding of their at the lowest rate (84.0% vs. 75.3%, Appendix). insured population’s characteristics. Data extraction under- Body weight documentation was first measured in 2003 goes a three-level audit, including: 1) extensive internal (16.3%, only for the 65–74 age group). By 2015, the rate quality assurance tests conducted by the HMOs, 2) QICH reached 80.9% in those aged 65–84 years (Fig. 2). In 2015, audit and cross-examination of the reported data, and 3) a males and females had similar rates of documentation thorough external audit. This method has certainly led to (Table 2). Higher documentation rates were seen among fewer errors, although unable to eliminate them entirely. those with low SEP (83.1%) compared to the middle and high SEP population (79.8%, p < 0.00001, Table 2). Docu- International comparisons mentation rate was lower for those aged 65–74 (79.7%) Results were also compared to similar data from compared to the older age group (83.1% among those 75– Organization for Economic Cooperation and Development 84 years-old, p < 0.00001, Table 2). (OECD) and other developed countries. Definitions of the Underweight and weight-loss were calculated for the rate of Pneumococcal and Influenza immunization were first time during the period 2013–2015 and showed sta- comparable across countries. The definitions of the rate of bility over this period. benzodiazepine overuse, and long-term benzodiazepine Therateof underweight (BMI<23kg/m )among the use were similar, yet whereas in most OECD countries pre- elderly Israeli population in 2015 was 12.9%. The prevalence scriptions of benzodiazepines were counted, the Israeli data of underweight was higher in female compared to male (13. allowed a more accurate evaluation using pharmacy claims 8% vs 11.7%, respectively, p < 0.00001, Table 2). This gender- of benzodiazepines . The rate of body weight docu- difference was mostly pronounced within the younger age mentation was not reported in the countries considered group (65–74 years-old), with an absolute difference of and the definition of the rate of underweight or weight- nearly 3% in the prevalence of underweight between female loss in the elderly, varied between QICH and other devel- and male; while less than 1% difference between genders oped countries. While across OECD countries the preva- was found in the older age groups (0.4% in 75–84 years- lence of underweight, was defined as BMI < 18.5 kg/m , olds, and 0.8% in 85 years-old or older, data not shown). In- QICH directorate, following consultation with Israeli dividuals of low SEP were less likely to be classified as experts, choose to take a public health perspective and underweight, compared to those of middle-high SEP (12.2% identify individuals at risk of underweight and thus used vs 13.3%, respectively, p < 0.00001, Table 2). The prevalence BMI ≤ 23 kg/m . of underweight significantly increased with increasing age (from 11.3% among those 65–74 years-old, and up to 20.6% Results among those aged 85 or older, p< 0.00001, Table 2), a trend Since the first measurement in 2002, overall influenza vac- observed regardless of gender and SEP (Appendix). cination rates increased from 42.0% to 63.2% in 2015 (Fig. 1). The rate of elderly persons who experienced a significant In 2015, vaccination rate was lowest for those in the 65– weight-loss (10% or more of their body weight) within 2 74 years age group (59.5%) and highest for those aged 75– years, was 6.1% in 2015. The rate was higher among females 84 years (68.0%), p < 0.00001 (Table 2). Females were vacci- compared to males (6.7% vs 5.5%, p < 0.00001, Table 2), with nated less than males (61.4% vs 65.6%, p < 0.00001) in all a consistent absolute difference between genders (of approxi- age groups (females aged 65–74 years were the least vacci- mately 1%) across age and SEP groups (Appendix). Individ- nated (58.0%), Appendix). The absolutedifferenceof uals of low SEP had higher rates of weight-loss compared to immunization rate between males and females increased individuals of middle-high SEP (7.0% vs 5.6%, p < 0.00001, with age (from 3.2% for those aged 65–74 years to 7.9% for Table 2). Similar to underweight, the rates also increased those 85 years or older, data not shown). SEP groups with increasing age from 5.0% among those 65–74 years- showed similar vaccination rates; however, the males of low old, andupto9.2%among thoseaged85orolder (Table 2). SEP were vaccinated the most, while females of low SEP Overall rate of benzodiazepine overuse remained steady were vaccinated the least (67.6% vs. 60.6%, Appendix). from 2011, the first year of measurement, to 2015 at around Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 6 of 15 Fig. 1 Influenza and pneumococcal vaccinations among Israelis aged 65 years or older, rates by year, 2002–2015. Pneumococcal vaccination was defined as those who received the vaccination once in the last 6 years through 2007, since 2008 it is defined by the current definition 5% (Fig. 3). In 2015, the 85 years or older population over- to non-elders (15.7%). This measure has significantly im- used benzodiazepines at the highest rate (11.5%, compared proved since measurements began in 2002 (data not to only 3.0% among those 65–74 years old, p < 0.00001, shown). Between 2011 and 2015, the rates of uncon- Table 2) and females overused benzodiazepines at a higher trolled diabetes dropped by 14.5% (relative change, from rate than males (6.2% vs 4.0%, respectively, p < 0.00001, 18.4% in 2011 to 15.7% in 2016) among those aged 18– Table 2). The low SEP population overused benzodiazepines 64, and by 20.7% among those 65 years and above (from at a much higher rate compared to the middle-high SEP 8.7% in 2011 to 6.9% in 2015), showing a remarkably population (7.0% compared to 4.1%, p < 0.00001, Table 2). higher rate of improvement among elders. The rate of long-acting benzodiazepine use decreased since first measured in 2011, from 3.8% to 2.4% in 2015 Discussion (Fig. 2). In 2015, females used long-acting benzodiazepine Overall, elderly quality of care improved since measure- at a higher rate compared to males (2.8% vs 2.0%, p <0. ments first began. Yet, quality of healthcare is lacking 00001, Table 2). Use was slightly more frequent among in- among certain socio-demographic groups within the dividuals of low SEP vs. those of middle-high SEP (2.7% vs. framework of the Israeli elderly population. Influenza vac- 2.3%, p < 0.00001), and higher among individuals aged 75 cination rates increased in the last 12 years, yet elderly or older compared to the youngest age group (2.7% vs 2. women experienced the lowest quality of care. Similarly, 2%, p < 0.00001, Table 2). overall rates of pneumococcal vaccinations increased sub- Additionally, we examined two quality indicators, which stantially in the last 8 years; however, females again re- are not age specific in order to establish whether these ceived lower quality of care. Interestingly, individuals of measures differ between the elderly and the non-elderly. In low SEP received pneumococcal vaccinations at a higher 2015, N = 234,349 individuals aged 18–64 years, and N = rate compared to the middle and high SEP population. 253,823 individuals aged 65 years or above were diabetics. The rate of body weight documentation increased in an 11-year measurement period. It should be noted that dur- Documentation rate of hemoglobin A1c (HbA1c) levels ing this period, improvement in EMR took place, hence for individuals with diabetes mellitus facilitating digital documentation, and contributing to the In 2015, the rate of HbA1c documentation (at least once increase in height and weight documentation. during the measurement year), was higher among the elders In contrast to the other indicators, females and males (92.2%) compared to the non-elders (87.9%). In addition, had very similar rates of documentation. Underweight when looking back at the five previous years (2011 to 2015), and significant weight-loss were more frequent among the rates were steady among the elders (91.6% in 2011) and females than among males, and substantially increased among non-elders alike (88.0% in 2011). with increasing age. Rates of benzodiazepine overuse remained steady in a Rate of uncontrolled diabetes mellitus (HbA1c greater three-year measurement period, while rates of long- than 9%) acting benzodiazepine use decreased. Females and those In 2015, the rate of uncontrolled diabetes (defined as 85 years or older overused benzodiazepines at the high- HbA1c > 9% in the last measurement during the year) est rate and females had the highest rate of long-acting was 2.3 times lower among the elders (6.9%) compared benzodiazepine use. Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 7 of 15 Table 2 Quality indicator performance rates by gender, socioeconomic position, and age, 2015 Denominator Numerator Rate Influenza vaccination Total 879,671 556,355 63.25% Gender* Male 385,492 252,918 65.61% Female 494,179 303,437 61.40% SEP Low 340,395 215,794 63.40% Middle & High 539,276 340,561 63.15% Age* 65–74 488,997 290,925 59.49% 75–84 283,209 192,595 68.00% 85 or above 107,465 72,835 67.78% Pneumococcal vaccination Total 449,274 346,032 77.02% Gender* Male 208,638 164,901 79.04% Female 240,636 181,131 75.27% SEP* Low 136,138 110,501 81.17% Middle & High 313,136 235,531 75.22% Age 65–74 449,274 346,032 77.02% 75–84 NA NA NA 85 or above NA NA NA Benzodiazepine overuse Total 879,671 45,858 5.21% Gender* Male 385,492 15,402 4.00% Female 494,179 30,456 6.16% SEP* Low 340,395 23,841 7.00% Middle & High 539,276 22,017 4.08% Age* 65–74 488,997 14,567 2.98% 75–84 283,209 18,946 6.69% 85 or above 107,465 12,345 11.49% Long-term benzodiazepine Total 879,671 21,469 2.44% Gender* Male 385,492 7801 2.02% Female 494,179 13,668 2.77% SEP* Low 340,395 9039 2.66% Middle & High 539,276 12,430 2.30% Age* 65–74 488,997 10,949 2.24% 75–84 283,209 7668 2.71% 85 or above 107,465 2852 2.65% BMI documentation Total 770,565 623,731 80.94% Gender* Male 345,894 281,149 81.28% Female 424,671 342,582 80.67% SEP* Low 266,803 221,828 83.14% Middle & High 503,762 401,903 79.78% Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 8 of 15 Table 2 Quality indicator performance rates by gender, socioeconomic position, and age, 2015 (Continued) Denominator Numerator Rate Age* 65–74 485,473 386,987 79.71% 75–84 284,963 236,744 83.08% 85 or above NA NA NA Underweight Total 703,827 90,632 12.88% Gender* Male 312,365 36,537 11.70% Female 391,462 54,095 13.82% SEP* Low 257,456 31,455 12.22% Middle & High 446,371 59,177 13.26% Age* 65–74 386,936 43,546 11.25% 75–84 237,614 30,753 12.94% 85 or above 79,277 16,333 20.60% Weight loss Total 613,408 37,673 6.14% Gender* Male 272,010 14,968 5.50% Female 341,398 22,705 6.65% SEP* Low 222,945 15,613 7.00% Middle & High 390,463 22,060 5.65% Age* 65–74 320,649 16,165 5.04% 75–84 221,014 14,915 6.75% 85 or above 71,745 6593 9.19% All rates are calculated as crude rates *p < 0.00001 Two key quality indicators in the field of diabetes care (8% of population, 2014) . Lastly, while the rate of eld- showed better performance among the elderly compared to erly growth is increasing, the proportion of the elderly in the non-elderly population in 2015. Also, when comparing the total population is smaller compared to other developed changes by age group along a five-year timeline, changes in countries, due to the high Israeli fertility rate (highest rates for the elderly group were either similar to or better among all OECD nations, 3.08 births/woman, 2014) [3, 44]. than the non-elderly group (stability in HbA1c test perform- ance, steeper decrease in the rate of uncontrolled diabetes). International comparison Altogether, the diabetes control indicators show that the Influenza vaccination rates increased since the first quality of care delivered to the elderly in Israel is compar- measurement in 2002, reaching a rate of 63.4% in 2014. able to that given to the younger population or even better. Influenza vaccination rates were also measured in 33 The Israeli elderly population has some distinct charac- Organization for Economic Co-operation and Develop- teristics compared to the international elderly population. ment (OECD) countries. The average rate of influenza vac- Israel’shighlifeexpectancyisamain contributortothe cination among these countries was 48.0% in 2013. In the growing elderly population. In 2014, life expectancy at birth same year, Israel’s rate was similar to the rates in Ireland in Israel was 80.2 years for males, ranking in the top five (59.2%) and Canada (64.1%). The United Kingdom and countries with the highest life expectancy, and 84.1 for United States both reached higher rates of vaccination than females . In addition, Israel has a very low rate of Israel (75.5% and 66.5%, respectively); however, many institutionalization among the elderly population, only 3% European countries such as Germany, France, and Sweden of adults aged 65 or older live in long-term care institutions fell below Israel’s national vaccination rate at 58.6%, 51.9%, . Correspondingly, the 97% of the population who live and 45.8%, respectively . A recent study examining in- within the community experience a high rate of social sup- fluenza vaccination rates and demographics in Austria and port, allowing the elderly the ability to succeed in this envir- Croatia found that in the 2010–2011 measurement year onment. Furthermore, the composition of the elderly Israeli vaccination rates were highest among the 65 years and population sees diversity through immigrants (only 28% of older age group in these countries (31.1% and 45.7%, re- the older population were born in Israel), Jews, and Arabs spectively) . Rates of pneumococcal vaccination among Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 9 of 15 Fig. 2 a Body weight documentation, rates by year, 2003-2015; b Underweight and weight-loss, rates by year, 2013-2015; All rates are calculated as crude rates; Body weight was measured for elderly 65-74 years until 2010; in 2011 body weight was measured for those 65 to 84 years-old Israelis aged 65–74 years increased since measurements adults 65 years and older via the Healthcare Effectiveness first began in 2005, and reached a rate of 76.3% in 2014. Data and Information Set (HEDIS) survey. In 2013, 70.2% International comparison was difficult for this indicator as of HMO Medicare patients in the United States had previ- quality indicator measurements of pneumococcal vaccina- ously received a pneumococcal vaccination . Addition- tions on a population-wide level are limited; yet the United ally, Australia measured the rate of adult pneumococcal States measures the rate of pneumococcal vaccination in vaccinations via the Adult Vaccination Survey, showing Fig. 3 Benzodiazepine usage among Israelis aged 65 years or older, rates by year, 2011–2015 Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 10 of 15 that 54.4% of Australians aged 65 years or older had previ- Furthermore, the rate of long-acting benzodiazepine use ously received the pneumococcal vaccination . High in Israel was 3.1%, with the highest rate of use in Korea levels of vaccination among the elderly population pro- (20.5%) and the lowest rate in Finland (0.5%). This com- motes health maintenance by reducing influenza and parison ranks Israel in the bottom five countries utilizing pneumococcal illness, decreasing strains on the healthcare long-acting benzodiazepines, indicating fair quality of system, and providing herd immunity to those who cannot care for this indicator. While overall rates of benzodi- be vaccinated. While specific populations in Israel are re- azepine use have decreased in Israel, they are still high ceiving lower quality care than the majority, the overall rate and of concern for the elderly population. A high rate of in Israel indicates that more Israelis are receiving higher benzodiazepine use among the elderly indicates a health quality care in terms of vaccinations as compared to the risk for this population. Identifying this risk will help to international healthcare community. develop practitioner-focused continuing education on The rate of body weight documentation in Israel reached benzodiazepine prescribing for elderly patients. a rate of 80.9% in 2015. International comparison is difficult Women received poorer quality of care in all five process for this measure, as most countries do not measure the rate indicators presented, and showed a worse picture in the of body weight documentation among elderly populations. two intermediate health indicators. Women were vacci- However, understanding where documentation is lacking nated less than males for both influenza and pneumococcal can lead to the development of protocols to increase rates disease. These lower vaccination rates could be due to an in these populations, promoting better quality of care increased negative attitude towards vaccinations and their among the elderly population. Similarly, comparing the risks among women or differences in physician recommen- rates of underweight and significant weight-loss to rates in dations between genders; however, additional evaluation is the elderly population in other countries is limited, as it required . Additionally, women overused benzodiaze- seems that these national measures, referring to the general pines at a higher rate and used long-acting benzodiaze- elderly population, are unique. However, the prevalence of pines more than their male counterparts; results which are underweight, as defined by BMI < 18.5 kg/m,was consistent with prior research . This is partially described in large international meta-analysis including explained by an increase in insomnia among older women 19,538 older nursing home residents. The lowest rates were and the lack of public health concern by physicians regard- described in cohorts from Italy (4%, n = 181 participants), ing the continuous use of benzodiazepines among older Germany (5%, n = 200) and Sweden (6%, n = 172), though adults for the treatment of insomnia  or the difference an underweight rate of 10% among n = 1339 study partici- in how health professionals differentially diagnose and treat pants in the USA, and 21% in China (n = 525), and up to men versus women who present with similar symptoms 30% underweight among older nursing home residents in . Notably, the health status of the Israeli elderly was Japan (n = 8179) [32, 36]. recently compared to that of the elderly in 16 European Benzodiazepine overuse remained steady in a five-year countries, showing that the Israeli elderly population is measurement period, around 5%. Rates of long-acting characterized with poorer health status yet a more modest benzodiazepine use decreased, achieving a rate of 2.4% gender gap, compared to their European counterparts . in 2015. Israel measured benzodiazepine use via patient As noted in the methods section, SEP was defined in this purchasing. However, many countries, including the study according to exemption from medical co-payments. OECD countries, measure benzodiazepine usage via rate The high proportion of low SEP residents according to this of prescribing by the healthcare practitioner, making definition among the elderly (39%, compared to 11% in the direct comparisons somewhat difficult. Among the general population) is explained by the different, more countries that measure benzodiazepine use through extenuating criteria applied for elders . patient medication usage, Sweden measured 11.4% of The low SEP population overused benzodiazepines the population aged 80 years or older consumed at least at a higher rate compared to the middle and high one contraindicated drug during the measurement SEP population. This result might be influenced by period in 2011 (benzodiazepines are included in the the understanding that socio-economic position can contraindicated drug category) . In addition, an frame and affect patient expectations and healthcare OECD 2013 study  measured the rates of overuse and providers attitudes towards their patients . In con- long-acting benzodiazepine use among nine OECD trast, the low SEP population received a higher rate countries, including Israel. The results showed the rate of pneumococcal vaccinations as compared to the of benzodiazepine overuse in Israel to be 5.1%, with the high and middle SEP population. This result is pos- highest rate of overuse in Ireland (6.3%) and the lowest sibly explained by the fact that the exempt (low SEP) rate in the Netherlands (0.7%). Among the countries elderly population has a high rate of primary care studied, Israel is in the top three countries to overuse visit attendance , therefore providing increased benzodiazepines, indicating poor quality of care. opportunities for vaccination. Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 11 of 15 Strengths and limitations Policy implications Israel’s comprehensive health insurance system allows for Health needs of the elderly population in Israel should quality indicator development on the national level. The be met in various dimensions. The increase in the num- national health insurance provided to all eligible Israeli citi- ber of persons above the age of 65 beyond that of the zens facilitates collection of data from practically the entire general population makes these needs more significant Israeli population, thus providing an understanding of the and calls for thorough planning. There is a broad con- quality of care for all Israelis, not simply those who have sensus that contrary to the expected, aging should be ac- insurance. Israel’s comprehensive healthcare infrastructure companied by good general health and control of includes the use of EMRs, which allows for data collection chronic conditions, as well as being functional and from both current and past medical histories of patients. enjoying good quality of life (successful aging). These EMRs have been utilized for over a decade  cre- The QICH program have been addressing these goals ating a strong database of patient information. in two ways: focusing on long and short term preven- However, this study does not come without limitations. tion. The long-term preventive indictors encompass is- First, this is an observational study suffering from the sues such as smoking prevalence, diabetes prevalence known limitations of such a design. In addition, the inter- control and treatment of its complications and primary national comparisons were limited in their ability to make and secondary prevention of ischemic heart disease. direct or exact comparisons due to the diverse nature of These indicators, when applied at an earlier age, may re- health care systems, as well as, different definitions of spe- sult in a healthier population in the long run. The short- cific health concepts . Notably, while this study evalu- term preventive indicators encompass subjects such as the ates the level of quality of care provided in the community use of potentially harmful medications and the detection of setting to the elderly, it does not easily allow prediction of weight loss, which may shed light on the health status of the future changes in the health status of the elderly popu- elderly persons. lation. Further research should be conducted to determine In order to improve the quality of care delivered in the the extent to which changes in the quality of care affect community we suggest exploring additional indicators. For changes in the health status. Lastly, the socio-demographic example, indicators that aim to eliminate hazardous life styles stratification was limited, as it did not stratify the data based and ensure healthy habits between the ages of 35 to 65 on ethnic origin, minority classification, income level, etc. should be adopted. In addition, indicators that detect frailty and counteract its bad outcomes like monitoring the risk of falls, depression and medication reviews may further protect Scope and future development the elderly from being dependent. Also, in light of near future Our study reflects the quality indicators that are cur- global planning of moving much of the health care from hos- rently measured in the elderly population in Israel and a pitals to the community, indicators that monitor the quality question arises to what extent the existing set of quality of such transition and home care should be developed and measures represent a wider scope of quality of care for implemented. Finally, end of life care and preparing towards the elderly. Examining quality indicators measured in endoflifeshouldalsobeimprovedbyplacing thequality various countries, it is evident that such indicators stem indicators that may take the present status to a better place. from comprehensive geriatric assessment tools that in- tend to capture health risks and situations that impinge on quality of life. For example, an American set of mea- Conclusions sures include screening for visual problems, depression, Overall, healthcare quality of the Israeli elderly population elder abuse and urinary incontinence. In addition, some has improved substantially since measurements first began; of the HMOs in Israel provide a comprehensive assess- yet, it seems that females receive lower quality care than ment to elderly persons considered to be at risk. males. The overall high rates of influenza and pneumococ- It would be, however, inappropriate to adopt many of cal vaccinations can decrease the burden of influenza and these measures, as some of them cannot be quantified to a pneumococcal pneumonia on the healthcare system. In level that make them reliable and valid measures, and addition, high rates of body weight documentation will others were not shown to be clinically significant. Our pro- prompt early detection of deterioration and intervention. gram, however, is expanding as we intend to include in the Higher rates of benzodiazepine usage indicate a need for near future additional measures including screening for ab- continued healthcare practitioner-focused education re- dominal aortic aneurysm, detection of osteoporosis and garding benzodiazepine prescribing in the elderly. In com- prevention of a second bone fracture, and end of life issues parison to the international healthcare community, Israel like the placement of advanced directives. We feel that the has higher quality care for the elderly in all indicators, ex- existing and near future measures suitably reflect the qual- cept for benzodiazepine overuse. Altogether, the diabetes ity of care of Israel’s elderly population. control indicators show that the quality of care delivered to Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 12 of 15 Appendix Table 3 Quality indicator performance rates stratified by gender and socioeconomic position, 2015 Influenza vaccination Male Female Total SEP Age Numerator Denominator Rate Numerator Denominator Rate Numerator Denominator Rate Low SEP 65–74 45,214 70,197 64.41% 54,684 94,383 57.94% 99,898 164,580 60.70% 75–84 35,469 50,525 70.20% 47,185 75,635 62.39% 82,654 126,160 65.52% 85 or above 12,234 16,742 73.07% 21,008 32,913 63.83% 33,242 49,655 66.95% total 92,917 137,464 67.59% 122,877 202,931 60.55% 215,794 340,395 63.40% Middle & high SEP 65–74 93,556 156,522 59.77% 97,471 167,895 58.05% 191,027 324,417 58.88% 75–84 50,355 69,352 72.61% 59,586 87,697 67.95% 109,941 157,049 70.00% 85 or above 16,090 22,154 72.63% 23,503 35,656 65.92% 39,593 57,810 68.49% total 160,001 248,028 64.51% 180,560 291,248 62.00% 340,561 539,276 63.15% Total 252,918 385,492 65.61% 303,437 494,179 61.40% 556,355 879,671 63.25% Pneumococcal vaccination Male Female Total SEP Age Numerator Denominator Rate Numerator Denominator Rate Numerator Denominator Rate Low SEP 65–74 49,631 59,066 84.03% 60,870 77,072 78.98% 110,501 136,138 81.17% 75–84 NA NA NA NA NA NA NA NA NA 85 or above NA NA NA NA NA NA NA NA NA total 49,631 59,066 84.03% 60,870 77,072 78.98% 110,501 136,138 81.17% Middle & high SEP 65–74 164,901 208,638 79.04% 181,131 240,636 75.27% 346,032 449,274 77.02% 75–84 NA NA NA NA NA NA NA NA NA 85 or above NA NA NA NA NA NA NA NA NA total 164,901 208,638 79.04% 181,131 240,636 75.27% 346,032 449,274 77.02% Total 214,532 267,704 80.14% 242,001 317,708 76.17% 456,533 585,412 77.98% Benzodiazepine overuse Male Female Total SEP Age Numerator Denominator Rate Numerator Denominator Rate Numerator Denominator Rate Low SEP 65–74 2698 70,197 3.84% 4350 94,383 4.61% 7048 164,580 4.28% 75–84 3435 50,525 6.80% 6775 75,635 8.96% 10,210 126,160 8.09% 85 or above 2021 16,742 12.07% 4562 32,913 13.86% 6583 49,655 13.26% total 8154 137,464 5.93% 15,687 202,931 7.73% 23,841 340,395 7.00% Middle & high SEP 65–74 2639 156,522 1.69% 4880 167,895 2.91% 7519 324,417 2.32% 75–84 2888 69,352 4.16% 5848 87,697 6.67% 8736 157,049 5.56% 85 or above 1721 22,154 7.77% 4041 35,656 11.33% 5762 57,810 9.97% total 7248 248,028 2.92% 14,769 291,248 5.07% 22,017 539,276 4.08% Total 15,402 385,492 4.00% 30,456 494,179 6.16% 45,858 879,671 5.21% Long-term benzodiazepine Male Female Total SEP Age Numerator Denominator Rate Numerator Denominator Rate Numerator Denominator Rate Low SEP 65–74 1675 70,197 2.39% 2567 94,383 2.72% 4242 164,580 2.58% 75–84 1180 50,525 2.34% 2297 75,635 3.04% 3477 126,160 2.76% Podell et al. Israel Journal of Health Policy Research (2018) 7:21 Page 13 of 15 Table 3 Quality indicator performance rates stratified by gender and socioeconomic position, 2015 (Continued) 85 or above 424 16,742 2.53% 896 32,913 2.72% 1320 49,655 2.66% total 3279 137,464 2.39% 5760 202,931 2.84% 9039 340,395 2.66% Middle & high SEP 65–74 2544 156,522 1.63% 4163 167,895 2.48% 6707 324,417 2.07% 75–84 1478 69,352 2.13% 2713 87,697 3.09% 4191 157,049 2.67% 85 or above 500 22,154 2.26% 1032 35,656 2.89% 1532 57,810 2.65% total 4522 248,028 1.82% 7908 291,248 2.72% 12,430 539,276 2.30% Total 7801 385,492 2.02% 13,668 494,179 2.77% 21,469 879,671 2.44% BMI documentation Male Female Total SEP Age Numerator Denominator Rate Numerator Denominator Rate Numerator Denominator Rate Low SEP 65–74 53,898 64,758 83.23% 70,201 85,632 81.98% 124,099 150,390 82.52% 75–84 40,220 46,809 85.92% 57,509 69,604 82.62% 97,729 116,413 83.95% 85 or above NA NA NA NA NA NA NA NA NA total 94,118 111,567 84.36% 127,710 155,236 82.27% 221,828 266,803 83.14% Middle & high SEP 65–74 125,290 160,318 78.15% 137,598 174,765 78.73% 262,888 335,083 78.45% 75–84 61,741 74,009 83.42% 77,274 94,670 81.62% 139,015 168,679 82.41% 85 or above NA NA NA NA NA NA NA NA NA total 187,031 234,327 79.82% 214,872 269,435 79.75% 401,903 503,762 79.78% Total 281,149 345,894 81.28% 342,582 424,671 80.67% 623,731 770,565 80.94% Underweight Male Female Total SEP Age Numerator Denominator Rate Numerator Denominator Rate Numerator Denominator Rate Low SEP 65–74 6122 53,898 11.36% 6816 70,201 9.71% 12,938 124,099 10.43% 75–84 5127 40,220 12.75% 6426 57,509 11.17% 11,553 97,729 11.82% 85 or above 2511 13,178 19.05% 4453 22,450 19.84% 6964 35,628 19.55% total 13,760 107,296 12.82% 17,695 150,160 11.78% 31,455 257,456 12.22% Middle & high SEP 65–74 11,220 125,261 8.96% 19,388 137,576 14.09% 30,608 262,837 11.65% 75–84 7874 62,120 12.68% 11,326 77,765 14.56% 19,200 139,885 13.73% 85 or above 3683 17,688 20.82% 5686 25,961 21.90% 9369 43,649 21.46% total 22,777 205,069 11.11% 36,400 241,302 15.08% 59,177 446,371 13.26% Total 36,537 312,365 11.70% 54,095 391,462 13.82% 90,632 703,827 12.88% Weight loss Male Female Total SEP Age Numerator Denominator Rate Numerator Denominator Rate Numerator Denominator Rate Low SEP 65–74 2694 44,749 6.02% 3637 57,831 6.29% 6331 102,580 6.17% 75–84 2417 36,760 6.58% 4038 52,070 7.75% 6455 88,830 7.27% 85 or above 923 11,934 7.73% 1904 19,601 9.71% 2827 31,535 8.96% total 6034 93,443 6.46% 9579 129,502 7.40% 15,613 222,945 7.00% Middle & high SEP 65–74 4128 103,165 4.00% 5706 114,904 4.97% 9834 218,069 4.51% 75–84 3398 58,820 5.78% 5062 73,364 6.90% 8460 132,184 6.40% 85 or above 1408 16,582 8.49% 2358 23,628 9.98% 3766 40,210 9.37% total 8934 178,567 5.00% 13,126 211,896 6.19% 22,060 390,463 5.65% Total 14,968 272,010 5.50% 22,705 341,398 6.65% 37,673 613,408 6.14% Podell et al. 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