Michal Shani

Aims: To compare changes in body mass index (BMI) categories after sustained versus minimal glucagon‐like peptide‐1 receptor agonist (GLP‐1 RA) exposure in older adults with obesity and without diabetes. A secondary aim was to compare changes in glycated haemoglobin (HbA1c) categories among those with paired HbA1c measurements. Materials and Methods: Retrospective cohort study within Clalit Health Services, Israel. Adults aged ≥ 65 years without diabetes, with baseline BMI ≥ 30 kg/m ² and paired BMI measurements, were classified as minimal (1–2 dispensations) or sustained (≥ 3) exposure. The primary outcome was BMI category improvement. Secondary outcomes were relative BMI change, HbA1c category change in the paired‐HbA1c subset, and incident diagnosed diabetes. BMI improvement was modelled by logistic regression adjusted for age, sex, socioeconomic status and comorbidity. Results: Of 13 387 patients (69% female), 11 121 (83%) had sustained and 2266 (17%) minimal exposure. BMI category improved in 55% of the sustained versus 30% of the minimal group ( p < 0.001; median change −8% vs. −2%). Among 7392 with paired HbA1c, HbA1c improved in 34% versus 20% (sustained vs. minimal; p < 0.001), and 65% versus 37% of those with prediabetes became normoglycaemic. Diabetes diagnosis was less frequent with sustained exposure (2.5% vs. 5.3%; p < 0.001). Adjusted for measured confounders, sustained exposure was associated with BMI improvement (OR: 2.77, 95% CI: 2.51–3.06). Conclusions: Among older adults with obesity and without diabetes, sustained versus minimal GLP‐1 RA exposure was associated with greater improvement in BMI and HbA1c categories and a lower incidence of diabetes. These findings describe observed changes after treatment initiation, not a proven causal treatment effect.

Background: Obesity is a chronic disease with rising prevalence. Guidelines suggest medications for obesity management if lifestyle interventions do not lead to substantial weight loss. Randomized control trials have shown the efficacy of anti-obesity medications in inducing weight loss, but real-world data are lacking. Therefore, our study aims to evaluate anti-obesity medications’ effectiveness in reducing weight and improving cardiometabolic parameters and to assess their persistence in a real-world setting. Methods: A historical cohort study using routinely collected data from Clalit Health Services (CHS). We retrieved data on all CHS members aged ≥20 years who initiated anti-obesity medication (orlistat, liraglutide 3 mg, and lorcaserin) between 2018 and 2020. We assessed average weight loss and the percentage of patients that had lost ≥5% and ≥10% of their body weight at 3, 6, and 9 months and compared the effectiveness of these 3 medications. Results: We included 5,306 CHS members in our study; most (77.8%) were female, aged 40–59 years (52.4%). Treatment with liraglutide 3 mg and lorcaserin was associated with subsequent weight reduction. The average weight loss at 6 months was 5.6 kg (4.95–6.25, 95% confidence interval [CI]) with liraglutide 3 mg and 1.7 kg (1.2–2.2, 95% CI) with lorcaserin. There was no evidence that treatment with orlistat was associated with subsequent weight loss (−0.18 kg [−0.8 to 0.4, 95% CI]). At 6 months, 38% of the patients with orlistat, 43% with lorcaserin, and 51% with liraglutide 3 mg persisted with their treatments (P < 0.001). Conclusion: Liraglutide 3 mg was the primary medication associated with clinically significant weight loss and had the highest persistence rate in our real-world study.

Background: Readmission after hospitalization for acute COPD exacerbation (AE-COPD) has been proposed as a healthcare quality indicator (QI) in Israel. We studied patients hospitalized for AE-COPD, towards determining whether AE-COPD readmission is an appropriate national QI in order to improve COPD patient care. Methods: Data were retrieved for all Clalit Health Service (CHS) members age 40–90 years hospitalized in CHS hospitals during 2016 with a diagnosis of acute COPD exacerbation. Information retrieved included demographics, medical history, Charleson comorbidity score, readmissions within 90 days, chronic medication use and family physician and pulmonologist visits. Patients readmitted within 90 days were compared to those who were not readmitted. Patients were also analyzed according to whether they were hospitalized during the year before the index hospitalization. Results: In 2016 there were 70,601 members with a recorded diagnosis of COPD in CHS. Of these, 1,203 patients (1.7%) were hospitalized in a CHS hospital with a diagnosis of acute COPD exacerbation during 2016. Average age was 70.6 years, 63% were men. 78% were active smokers. 61% of the patients were readmitted to internal medicine wards within 90 days of the index hospitalization. Patients who were readmitted were more likely to have been hospitalized during the year before the index hospitalization (Odds ratio (OR) 2.5, Confidence Interval ((CI)(1.85, 3.38)) and had a higher Charlson comorbidity score (OR 1.07 (CI 1.01, 1.11)). Healthcare utilization by patients who were readmitted, both before and after admission, was generally greater. One yr mortality was 15.1% and 9.2% in those readmitted and not readmitted, respectively (p = 0.003). Conclusions: Readmitted COPD patients appear to be the sickest group of COPD patients with advanced disease and poor prognosis, and it may not be possible to prevent readmissions. This questions the utility of COPD readmissions as a healthcare quality indicator.

Background: To study the relationship between adherence to chronic medications and adherence to preventive medicine recommendations among persons with diabetes mellitus and hypertension. Methods: Data were collected from the Clalit database included all members of Clalit aged 50 to 74 years, diagnosed with diabetes mellitus or hypertension before 2016 and treated with at least 1 medication (statins hypotensive or antidiabetic drugs) during 2017. We analyzed all the monthly prescriptions that were filled during 2017. We determined personal adherence rates by calculating each individual's average adherence rate to all the prescribed medications. Adherence rates were stratified by quintiles. We checked whether each person included followed the Israeli recommendations for influenza vaccine, colon cancer screening, and mammography. Results: Of 268,792 persons, 81.1% had hypertension, and 59.5% had diabetes; 40.6% had diabetes and hypertension. The mean age was 63.7 years; 50.6% were men. The mean number of medications used was 2.2 ± 1.1. An adherence rate of ≤20% was found in 4.2%, and >80% in 42.5%. Overall, 59.6% had received an influenza vaccine, 68.0% had undergone colon cancer screening, and 75.2% of the women had undergone mammography. Increased adherence to medications was associated with increased adherence to preventive recommendations. For persons in the study cohort, adjusted odds ratios comparing the highest to the lowest quintile of medication adherence were 1.52 (1.46–1.59) for influenza vaccine, 1.59 (1.53–1.66) for colon cancer screen, and 1.35 (1.27–1.44) for mammography. Discussion: A positive association was observed between adherence to chronic medications and adherence to preventive medicine among persons with hypertension and diabetes.

Background: Use of medical cannabis (MC) in Israel has increased since its regulatory approval in 2016. Currently, more than 1% of Israeli adults are treated with MC; this requires primary care physicians (PCPs) to be familiar with this treatment option. Objectives: We assessed the attitudes and knowledge of Israeli PCPs toward MC and evaluated their willingness to prescribe it for different medical conditions. Methods: A cross-sectional survey which was distributed to PCPs in Israel. Physicians were asked about their opinions, knowledge, and willingness to prescribe MC. Results: Two hundred and one PCPs answered the questionnaire. Their average age was 47 years (±11.2), 71% were specialists. 51% of the respondents thought that MC is an effective treatment. 63% replied that they had little knowledge and 75% indicated that they would like to deepen it. 61% of the respondents were willing to initiate an MC treatment for a dying patient, while less than 50% were willing to initiate MC treatment for various other conditions. Most respondents indicated that they were willing to renew a prescription for any approved medical condition. Willingness to prescribe MC increased for physicians who agreed that MC was effective (odds ratio [OR] 21.9, 95% confidence interval [CI] 2.40–200.85), for physicians who strongly agreed with the statement that they had sufficient knowledge (OR 5.0, 95% CI 1.58–15.83) and for residents compared with specialists (OR 4.0, 95% CI 1.52–10.73). Conclusions: Our survey revealed PCPs’ differing opinions and insufficient knowledge regarding treatment with MC. These findings suggest that continuing medical education regarding MC is needed.

Background: Oral anticoagulants (OAC) reduce the risk for stroke and death from all causes in patients with non-valvular atrial fibrillation (NVAF) Objective: To explore adherence rates of OAC among patients with NVAF in tong-term use in a real-world setting and to examine patient characteristics associated with good adherence. Methods: We conducted a population-based cohort study with members of Clalit Health Services, Israel. All patients aged >= 30 years with a diagnosis of NVAF before 2016 who were treated with OAC were included. We included patients who fitted at least one prescription per year in the three consecutive years 2016-2018. We analyzed all prescriptions that were filled for the medications from 1 January 2017 to 31 December 2017. We considered purchasing of at least nine monthly prescriptions during 2017 as good medication adherence. Results: We identified 26,029 patients with NVAF who were treated with OAC; 10,284 (39.5%) were treated with apixaban, 6321 (24.3%) with warfarin, 6290 (24.1%) with rivaroxaban, and 3134 (12.0%) with dabigatran. Rates of good medication adherence were 88.9% for rivaroxaban, 84.9% for apixaban, 83.6% for dabigatran, and 55.8% for warfarin (P < 0.0001). Advanced age was associated with higher adherence rates (P < 0.001). Socioeconomic status was not associated with medication adherence. Good adherence with OAC was associated with tower low density lipoprotein (LDL) cholesterol and glucose levels. Conclusions: Adherence rates to OAC in chronic use among patients with chronic NAVF are high. Investing in OAC adherence may have a wider health impact than expected.