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Improving care for minorities by Improving care for minorities by health education in Israel.health education in Israel.

EquiP ConferenceEquiP Conference

Brussels 2004Brussels 2004

Margalit Goldfracht *, ** ; Diane Levin *; Ofra Peled *

Irit Poraz*; Dorit Weiss *; Nicky Liebermann *,

* Clalit Health Services Headquarters, Community Div., Israel

** Family Medicine Department, Technion, Haifa, Israel

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Main Contributors

• Mr. Raid Atrash• Dr. Zuhadi Agbaria• Dr. Muchamad Nagemi• Dr. Yunes Abu Rabia• Mrs. Siham Badarna• Mrs. Nuhah Zeidan

• Dr. Napaz Nobani• Dr. Huri Gharir• Dr. Zoabi Ghalaal• The members of the

steering committees in

the districts

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4

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"No one specific intervention, if used alone, led to "No one specific intervention, if used alone, led to major improvements in management of chronic major improvements in management of chronic diseases "diseases "

Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk Van JT, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. [Diabetes Care. 2001;24:1821-33

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Chronic Diseases Care ModelChronic Diseases Care Model

Bodenheimer T, Wagner EH, Grumbach K. JAMA. 2002;288:1775-9

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The elements of chronic care model:The elements of chronic care model: • Community resources and policiesCommunity resources and policies

• Health care organizationHealth care organization

• Self management supportSelf management support

• Delivery system designDelivery system design

• Decision supportDecision support

• Clinical information systemsClinical information systems

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Patients become principal caregiversPatients become principal caregivers

• Patients live with the disease many yearsPatients live with the disease many years

• Proactive approachProactive approach

• EmpowermentEmpowerment

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Clalit Health Services - BackgroundClalit Health Services - Background

• Israeli largest HMO: insures 57% of Israeli population, 3,700,000 members

• Insures mainly the 6th socio-economical lower deciles of the population

• 1200 clinics nationwide• 2,000 primary physicians• 2,000 nurses in primary care• 170,000 diabetes patients• 27 ,000 (16%) Arabic diabetes patients

• Israeli largest HMO: insures 57% of Israeli population, 3,700,000 members

• Insures mainly the 6th socio-economical lower deciles of the population

• 1200 clinics nationwide• 2,000 primary physicians• 2,000 nurses in primary care• 170,000 diabetes patients• 27 ,000 (16%) Arabic diabetes patients

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““Diabetes in the community” Diabetes in the community” program 1996 -2003program 1996 -2003

Multifaceted quality improvement program

Interventions:• Clinical guidelines 1995, 2000Structure• Multi-professional steering team at the main

management and districts• Representative of the “Diabetes in the Community” at

the executive and primary clinic level

Multifaceted quality improvement program

Interventions:• Clinical guidelines 1995, 2000Structure• Multi-professional steering team at the main

management and districts• Representative of the “Diabetes in the Community” at

the executive and primary clinic level

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Interventions: BInterventions: B

Work methods Manual (1996) and computerized (2000)

diabetes care map• Diabetes registry in every clinic - manual

(1996) and computerized (1998-2000)• Clinical Pathway - “Policy statement of the

Health Service Provider on the subject of diabetes (1998)”

Work methods Manual (1996) and computerized (2000)

diabetes care map• Diabetes registry in every clinic - manual

(1996) and computerized (1998-2000)• Clinical Pathway - “Policy statement of the

Health Service Provider on the subject of diabetes (1998)”

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Interventions CInterventions C

• Long term compulsory CME 1996,1997,1998,2000, 2001, 2002, 2003 (for all primary care providers)

• Patients’ empowerment: workshop for providers, health education kits, videos, workshops for patients

• Performance feedback:

• Long term compulsory CME 1996,1997,1998,2000, 2001, 2002, 2003 (for all primary care providers)

• Patients’ empowerment: workshop for providers, health education kits, videos, workshops for patients

• Performance feedback:

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Quality Circle

Goals, indicators

Data gathering

Problem analysis

Intervention planningImplementation of the intervention

Data gathering

Data comparison to the goals

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Data Gathering

• 1995-1999

Randomized sample of 2867 diabetes patients nation wide. Manual data gathering from medical records according to specific indicators

• 2001 and on Computerized data gathering of all the Diabetes

population of the HMO according to well defined indicators

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Diabetes patients’ follow up - Performance Diabetes patients’ follow up - Performance of HbA1c test at least once a yearof HbA1c test at least once a year

0%

10%

20%

30%

40%

50%

60%

70%

80%

1995 1997 1999 2000 2002

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Diabetes patients’ follow upDiabetes patients’ follow upDiabetes control according to HbA1cDiabetes control according to HbA1c

0%5%

10%15%20%25%30%35%40%45%

1995 1997 1999 2000 2001 2002

HbA1c>9 HbA1c<7

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Follow up and Diabetes Control 2001Follow up and Diabetes Control 2001

77%

23%

42%

70%

37%

26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

follow up HbA1c<7 HBA1c>9 arabic p

non arabicp

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Quality CircleQuality Circle

• Goal: to improve control of diabetes

among Arabic population of diabetes

patients

• Data gathering: The control of Arabic

diabetics was worse: 20% well controlled

versus 35% among non Arabs

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Problem Analysis-Diabetes ControlProblem Analysis-Diabetes Control

Patient

Medical team

Life HabitsCulture

Beliefs

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Medical teamMedical team

• Quality of the team membersAccording to the HMO policy• Language90% Arabic speaking• Culture90% Arabic culture• AccessibilityBetter than non Arabic population• Guidelines implementation Follow up better than non Arabic

population 77% versus 70%

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Life Habits -Physical ActivityLife Habits -Physical ActivityAges 25-65Ages 25-65

11.20%

8%

22.70% 23.70%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Men WomenArabsNon Arabs

Survey Ministry of Health (MABA”T) 99-01

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Life Habits – Obesity BMI>30 Life Habits – Obesity BMI>30 Ages 25-65Ages 25-65

22.50%

41.20%

18.50%22.40%

0.00%

5.00%

10.00%15.00%

20.00%

25.00%

30.00%

35.00%40.00%

45.00%

50.00%

Men Women ArabsNon ArabsSurvey Ministry of Health (MABA”T) 99-01

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Diabetes Prevalence - Self ReportDiabetes Prevalence - Self ReportAges 25-65Ages 25-65

5.7

13.5

4.9

9.4

0

2

4

6

8

10

12

14

16

Men Women ArabsNon Arabs

%

Survey Ministry of Health (MABA”T) 99-01

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CultureCulture

• Fat is beautiful• Fat is successful• Only poor people walk• Women should not walk outside family compound

unattended• Not eating as a guest is an offence to the host• Food is a center of festivities• Concept of chronic disease not clear

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BeliefsBeliefs

• Fat is healthy

• Woman with diabetes will not have children

• Man with diabetes is impotent

• People with diabetes are invalids

Diabetes= stigma

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Quality CircleQuality Circle

• Goal: to improve control of diabetes among

Arabic population of diabetes patients

• Data gathering: The control of Arabic diabetics

was worse: 20% well controlled versus 35%

among non Arabs

• Problem analysis: the main problems are

culture and beliefs of the Arabic population

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InterventionsInterventions

• Multidisciplinary team based on Arabic based on Arabic

professionalsprofessionals

• Brainstorming – reasons for the difference in – reasons for the difference in

outcomesoutcomes

• Brainstorming regarding the interventionBrainstorming regarding the intervention

• Intervention: A health fair in the clinic - A health fair in the clinic -

concentrating on healthy lifestyleconcentrating on healthy lifestyle

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Quality Circle

Goals, indicators

Data gathering

Problem analysis

Intervention planning

Implementation of the intervention

Data gathering

Data comparison to the goals

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Intervention PlanningIntervention Planning

Health fair - stands for

• Healthy dietHealthy diet

• Smoking preventionSmoking prevention

• Physical activityPhysical activity

• Foot care for diabeticsFoot care for diabetics

• Identification of metabolic syndrome (blood Identification of metabolic syndrome (blood

pressure testing, BMI, glucose tests)pressure testing, BMI, glucose tests)

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Intervention PlanningIntervention Planning

• Lecture about diabetes by physician from the clinicLecture about diabetes by physician from the clinic

• A personal story of diabetes patient from the clinicA personal story of diabetes patient from the clinic

• The lecture was prepared by one of the Arabic The lecture was prepared by one of the Arabic

professionals in Arabic and distributed to the clinicsprofessionals in Arabic and distributed to the clinics

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Evaluation of the interventionEvaluation of the intervention Attendance: the health happenings were attended by 6,

6674 people in 92 clinics. 30% identified themselves as diabetics.Methods: We have chosen a randomized cohort for evaluation of 300 people. All the participants were contacted by interviewer in Arabic and interviewed over the phone according to questionnaire

HbA1c: We have identified this cohort in our computer data set. We have identified 157 diabetes patients who performed HbA1c test in 2001(before interventions) and 2002-2003(after interventions)

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ResultsResults

• 6674 people attended the health fairs, 15% 6674 people attended the health fairs, 15%

of all the diabetics.of all the diabetics.

• Demography: 37% males, 56% under age 50Demography: 37% males, 56% under age 50

• 30% identified themselves as diabetics, 20% 30% identified themselves as diabetics, 20%

arrived with a diabetes relative, 50% came arrived with a diabetes relative, 50% came

due to general interestdue to general interest

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Diabetes Control According to Diabetes Control According to HbA1c Levels 2001-2002HbA1c Levels 2001-2002

23%

40%37%

27%

46%

27%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

HbA1c<7 7<Hb1C<9 HbA1C>9

20012003

N=157

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Contents recollectionContents recollection

IssueIssue Percentage of Percentage of recollectionrecollection

DietDiet 100%100%

Physical activityPhysical activity 99%99%

Treatment by medicationsTreatment by medications 96%96%

Smoking preventionSmoking prevention 96%96%

Foot careFoot care 98%98%

Follow upFollow up 96%96%

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Change in life habits Change in life habits – self reported– self reported

Life habitLife habit Change according Change according to instructions to instructions

DietDiet 40%40%

Physical activityPhysical activity 15%15%

SmokingSmoking 73%73%

Foot careFoot care 25%25%

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Control of diabetes within Arabic population Control of diabetes within Arabic population 2001-2003 according to HbA1c2001-2003 according to HbA1c

23%

42%

26%

35%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

HbA1c<7 HBA1c>9

20012003

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Conclusions

• There is a special need within Arabic population for knowledge concerning healthy life style specially among diabetes patients

• There is need for major campaign among Arabic population to change beliefs and culture to adopt healthier life style

• Health education employed within quality improvement is an effective method to change outcomes of management of chronic disease

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