The COVID-19 pandemic posed many dilemmas for policymakers, which sometimes resulted in unprecedented decision-making

BACKGROUND

The COVID-19 pandemic evolved through five phases, beginning with 'the great threat', then moving through 'the emergence of variants', 'vaccines euphoria', and 'the disillusionment', and culminating in 'a disease we can live with'. Each phase required a different governance response. With the progress of the pandemic, data were collected, evidence was created, and health technology was developed and disseminated. Policymaking shifted from protecting the population by limiting infections with non-pharmaceutical interventions to controlling the pandemic by prevention of severe disease with vaccines and drugs for those infected. Once the vaccine became available, the state started devolving the responsibility for the individual's health and behavior.

MAIN BODY

Each phase of the pandemic posed new and unique dilemmas for policymakers, which resulted in unprecedented decision-making. Restrictions to individual's rights such as a lockdown or the 'Green Pass policy' were unimaginable before the pandemic. One of the most striking decisions that the Ministry of Health made was approving the third (booster) vaccine dose in Israel, before it was approved by the FDA or any other country. It was possible to make an informed, evidence-based decision due to the availability of reliable and timely data. Transparent communication with the public probably promoted adherence to the booster dose recommendation. The boosters made an important contribution to public health, even though their uptake was less than the uptake for the initial doses. The decision to approve the booster illustrates seven key lessons from the pandemic: health technology is key; leadership is crucial (both political and professional); a single body should coordinate the actions of all stakeholders involved in the response, and these should collaborate closely; policymakers need to engage the public and win their trust and compliance; data are essential to build a suitable response; and nations and international organizations should collaborate in preparing for and responding to pandemics, because viruses travel without borders.

CONCLUSION

The COVID-19 pandemic posed many dilemmas for policymakers. The lessons learned from the actions taken to deal with them should be incorporated into preparedness for future challenges.

The Israeli Experience with the "Green Pass" Policy Highlights Issues to Be Considered by Policymakers in Other Countries

In the first half of 2021, Israel had been ahead of other countries concerning the speed of its rollout and coverage of COVID-19 vaccinations. During that time, Israel had implemented a vaccine certificate policy, the "Green Pass Policy" (GPP), to reduce virus spread and to allow the safe relaxation of COVID-19 restrictions in a time of great uncertainty. Based on an analysis of GPP regulations and public statements compiled from the Israeli Ministry of Health website, we describe the design and implementation of the GPP. We also look back and discuss lessons learned for countries that are considering a GPP policy, given the current upsurge of the Delta variant as of summer 2021. To reduce equity concerns when introducing a GPP, all population groups should be eligible for the vaccine (contingent on approval from the manufacturer) and have access to it. Alternatively, health authorities can grant temporary certificates based on a negative test. We also highlight the fact that in practice, there will be gaps between the GPP regulations and implementation. While some places might require a GPP without legal need, others will not implement it despite a legal obligation. The GPP regulations should have standardised epidemiological criteria, be implemented gradually, remain flexible, and change according to the epidemiological risks.

The effects of continuous glucose monitoring system on patient outcomes and associated costs in a real-world setting

AIMS

Continuous glucose monitoring system (CGMS) technologies may alert unaware hypoglycaemia or near hypoglycaemia events. However, costs are a significant concern in general CGMS use. This study describes the real-world effects of both clinical outcomes and associated costs in a major Health Maintenance Organization, 1 year following preauthorization of CGMS for each patient.

METHODS

Cohort study. Type 1 diabetes patients who were preauthorized CGMS were identified, and their medical records during the year before preauthorization were compared to the following year. Data were collected for glucose control, medical services utilization and related costs.

RESULTS

We identified 524 eligible patients, 57% males. Adherence to CGMS use was improved by age. The proportion of patients reaching HbA_1c  < 7.5% (58 mmol/mol) increased in the high-adherence group and decreased in the low-adherence group. There were no significant changes in outpatient medical services utilization. However, there was a decrease in emergency room visit rates (30%-19%, p < 0.01) and hospitalization rates (22%-12%, p < 0.01) with the highest decrease among the high-adherence group. Hospitalization duration also decreased. However, the total costs per patient were higher as CGMS adherence increased.

CONCLUSION

Continuous glucose monitoring system technologies have the potential of both improving blood glucose control and reducing inpatient utilization. However, CGMS technologies costs may put a significant burden on healthcare systems.

Risk sharing or risk shifting? On the development of patient access schemes in the process of updating the national list of health services in Israel

Background: Agreements between payers and pharmaceutical/medical device companies are widely implemented to address financial and clinical uncertainties. We analyzed the main characteristics of these agreements in Israel from 2011-2018.Research design and methods: We reviewed all agreements implemented during the study period. Information regarding the type of agreement, therapeutic indications, its time frame and the total budget involved are presented.Results: A total of 56 agreements were signed since 2011, of which 53 (95%) were financial-based and 50 (89%) referred to pharmaceuticals. The annual number of agreements increased from one in 2011 to 21 in 2018. The main therapeutic areas covered were: oncology (41%), hepatitis C (16%), neurology (11%), respiratory (9%), and cardiovascular (7%). The proportion of the annual budget allocated subject to these agreements increased accordingly from 3% in 2011 to 73% in 2018. The majority (63%) of the agreements were signed for 5 years, 9% were shorter-term and 20% have no time-limit. In 14 (44%) of the financial-based agreements implemented through 2017, the actual utilization exceeded the pre-specified threshold and the companies reimbursed the health-plans accordingly.Conclusions: The number of agreements and the allocated budget subject to these agreements increased substantially in recent years. Most agreements are financial-based that, in many cases, shifted the short-term financial risk from health-plans to the industry.

Abstract 073: Maximizing Sacubitril/Valsartan Clinical Benefit Under Budget Constraints

Background: The angiotensin receptor-neprilysin inhibitor sacubitril/valsartan has been shown in the PARADIGM-HF trial to be superior to enalapril in reducing the risks of cardiovascular (CV) deaths and hospitalizations in heart failure (HF) patients. Although several studies suggested that sacubitril/valsartan is a cost-effective therapy, budget constraints may limit its use. Our objective was to characterize HF sub-populations in which cost per CV death/hospitalization prevented are excessively high in order to assist in treatment prioritization decisions.

Methods: Outcome data were retrieved from the published PARADIGM-HF trial reports. Costs were calculated based on current United States prices of sacubitril/valsartan.

Results: In the PARADIGM-HF trial, treatment of 4,187 patients with sacubitril/valsartan resulted in prevention of 203 CV deaths or HF hospitalizations (135 CV deaths) during a total of 9,396 patient-years. The estimated additional cost of sacubitril/valsartan during the trial’s follow-up period would have reached $42,089,220. Therefore, the cost of preventing one HF hospitalization or CV death would have been $207,336 and the cost of preventing one CV death would have been $311,772. This figure is significantly higher in sub-groups that presented a lower risk-reduction, as in patients with an ejection fraction >35% ($674,831) and in patients without prior use of HF medical therapy ($2,024,494).

Conclusions: In healthcare settings under budget constraints, payers can maximize clinical outcomes in HF patients, by prioritizing sacubitril/valsartan therapy to sub-populations that have demonstrated higher benefit in the PARADIGM-HF trial. Advocating the reduction of sacubitril/valsartan prices could enable wider populations to benefit from this promising therapy.

The association between adherence to cardiovascular medications and healthcare utilization

BACKGROUND

Poor adherence to medications for cardiovascular disease (CVD) is associated with adverse health outcomes, but little is known about its association with healthcare utilization (HCU).

OBJECTIVE

To examine whether adherence is associated with a long-term decrease in HCU.

METHODS

This is a retrospective cohort study of 1582 patients with CVD who enrolled in Maccabi Healthcare Services in Israel, initiating CVD medication therapy in 2006. Adherence was assessed by the proportion of days covered (PDC) with medications. Patients were defined as: non-adherent (PDC <0.4), partially adherent (0.4 ≤ PDC < 0.8), and fully adherent (PDC ≥0.8). HCU was estimated for 4 years following treatment initiation. Multivariable GEE models were used to analyze predictors of HCU. Model I included total adherence during the entire follow-up period as well as the interaction between this measure and the follow-up year. Model II included previous and current year's adherence as well as previous year's HCU cost. Both models were adjusted for potential confounders including: patient's age, gender, socioeconomic status, ownership of voluntary supplementary health insurance, and comorbidities.

RESULTS

The median age of patients was 63 (69 % males). Fifty-four percent of patients (n = 860) were defined as adherent, 24 % as partially adherent and 22 % as non-adherent. Model I: the annual HCU costs of adherent patients decreased by 10 % following treatment initiation [rate ratio (RR) = 0.90, 95 % confidence interval (CI) 0.86-0.94, P < 0.001]. This decrease stemmed predominantly from reduction in hospitalization costs. No significant changes in annual costs following treatment initiation were observed among partially adherent (RR = 1.00, 95 % CI 0.90-1.10, P = 0.935) and non-adherent (RR = 0.98, 95 % CI 0.87-1.10, P = 0.681) patients. Model II: no temporal association was found between adherence and HCU.

CONCLUSIONS

Adherence to CVD medications is relatively low. Adherence is associated with long-term decrease in healthcare expenditure. Exploring reasons for the high non-adherence and ways to improve adherence may optimize utilization of health systems' scarce resources.

Determinants of Cost-Related Nonadherence to Medications among Chronically Ill Patients in Maccabi Healthcare Services, Israel

BACKGROUND

The effectiveness of value-based insurance design is based on nonadherence, which derives solely from patients' economic constraints.

OBJECTIVE

Our objective was to examine the extent of cost-related nonadherence to chronic medications and to analyze its potential determinants.

METHODS

We conducted a telephone survey among a representative sample of Maccabi Healthcare Services chronically ill patients aged 55 years or older (n = 522). We developed a 12-month recall questionnaire that included demographic and socioeconomic characteristics, out-of-pocket expenditure on prescribed medication, physician's provision of explanation regarding prescribed therapy, adherence, and reasons for nonadherence. Respondents were defined as nonadherent if they reported that they did not purchase prescribed medications in the previous year because of their cost. We applied the multivariable logistic regression model to examine predictors of nonadherence.

RESULTS

Median (interquartile range) age of the study sample was 69 (13) years (53% males). One hundred sixty-five patients (31.6%) reported not purchasing prescribed medications mainly because of medications' adverse effects and/or cost. Fifty respondents (9.6%) reported cost-related nonadherence. The multivariable logistic regression model revealed that cost-related nonadherence was associated with respondent's income lower than 4600 New Israeli shekel (odds ratio [OR] = 10.86; 95% confidence interval [CI] 1.45-81.12), unemployment (OR = 4.32; 95% CI 1.47-12.66), lack of physician explanation about the prescribed medication (OR = 2.38; 95% CI 1.18-4.78), and age (OR = 0.95; 95% CI 0.91-0.99).

CONCLUSIONS

Cost-related nonadherence to chronic pharmaceuticals is self-reported among nearly 10% of the chronically ill patients and is strongly affected by low socioeconomic status, even under universal health insurance coverage and with relatively low co-payments as applied in Israel. Lack of information provided by physicians regarding the therapy is associated with a higher likelihood of cost-related nonadherence.

[Can linking co-payment for drugs to evidence on treatment value improve health outcomes and contain healthcare costs?]

Co-payment strategies are frequently used by health insurers as a measure of containing healthcare costs. However, co-payments may reduce the use of essential drugs in chronically-ill patients. Recently, value-based insurance designs, where co-payments rates are determined by the value of the treatment, have been introduced in the United States. This review summarizes the results of recent studies in the United States, suggesting that reducing co-payments for highly valued treatments and raising co-payments for less effective treatments can lead to better compliance and better outcomes, with the potential of reducing long-term costs. Further research is needed to examine the feasibility of this approach and the long-term impact on quality of care and treatment costs in other healthcare systems, including Israel.

[Mandibular Langerhans cell histiocytosis]

INTRODUCTION

Langerhan's cell histiocytosis is defined as an abnormal proliferation of Langerhans cells in various organs and tissues (bone, skin, lymph nodes...). Among facial locations, mandibular involvement is the most frequent and occurs in young people less than 20 years. The aim of this report is to review the characteristic features of this disease, the current means of diagnosis and treatment through two case reports.

CASES

Two male patients aged 10 and 55 years respectively presented with single mandibular location of Langerhans cell histiocytosis. The diagnosis was confirmed by histological examination of the biopsy specimen. The first patient underwent surgical resection of the tumor. No recurrence was observed. In the second patient, the postoperative course was marked by the appearance of an inflammatory phenomenon in the adjacent skin and mucosa, successfully treated by intralesional corticosteroid therapy.

DISCUSSION

Langerhan's cell histiocytosis is a rare disease. The mandibular location has variable clinical expressions which can vary from dental mobility to tumor development in the gingiva. The radiological appearance is also variable; histological proof is required for diagnosis. Treatment depends on the number and locations of the lesions. In case of a single location, the treatment options may vary from a "wait and see" attitude to a non aggressive surgery, with a possible local corticosteroid therapy or radiothe-rapy. For multiples locations, chemotherapy is indicated.

C4d: a marker for hepatic transplant rejection

BACKGROUND

Acute rejection is still a common complication of hepatic transplantation. The diagnosis, based on the histological examination of the graft, may be difficult to confirm in the setting of combined hepatitis C virus infection. The presence of C4d in the portal capillaries could facilitate differentiation between acute rejection and relapsed hepatitis C. The deposit of C4d provides evidence of activation of humoral immunity. To attempt to confirm this hypothesis, we searched for the presence of C4d in posttransplant hepatic biopsies.

METHODS

Thirty-six biopsies from 34 patients were analyzed retrospectively. The samples had been requested for one of the following reasons: suspected rejection, relapsed hepatitis C infection, or systematic check-up 1 year after the transplant.

RESULTS

C4d expression was common in biopsies classified as acute rejection (33%) and chronic rejection (100%). C4d was never detected in the event of recurrent hepatitis C infection without rejection.

CONCLUSION

These results, which are comparable to recently published data, give credence to the theory that C4d could be used as a marker for rejection following hepatic transplantation.

[Cardiac multifocal hydatid cyst]

Hydatid cysts in the heart are rare, with an unpredictable outcome and numerous complications, requiring rapid surgical management. We report the case of a 19 year old female patient, who underwent surgery with extra corporeal circulation for a hydatid cyst of the interventricular septum of the heart, complicated by secondary pulmonary echinococcus infection, confirmed on CT and MRI. Resection of the cyst was performed via a right auriculotomy. The post operative period was favourable; the other pulmonary sites were treated medically. We emphasise the methods of diagnosis and management.