Achieving ethnic equality in the Israel trauma healthcare system: the case of the elderly population

Characteristics and Trends of Strabismus Surgeries at a Tertiary Hospital Over 2 Decades - What Can Be Learned for Years to Come?

PURPOSE

To analyze characteristics and trends of strabismus surgeries in an Israeli hospital over 2 decades.

METHODS

A descriptive, retrospective study including all strabismus surgeries (666) performed during 2000-2019 at an Israeli tertiary hospital. Electronic medical records (EMRs) were directly retrieved to produce an anonymized database.

RESULTS

No trends were evident for age, sex, or ethnicity (p = .294, 0.914 and p = .167, respectively). The mean number of horizontal muscles remained stable, while an increase was noted in the mean number of muscles operated on to repair vertical strabismus (p < .0001). Among acquired cases, a 2.67-fold increase was noted in the proportion of spontaneous strabismus and a decrease of traumatic causes to a third (p < .001). An increase was noted in the proportion of exotropia among horizontal strabismus corrections (p = .022), and esotropia correction techniques distribution changed (p = .004). Reoperations comprised a third of all cases during both decades (p = .198). Reoperations were more prevalent among younger and Jewish patients (p < .001 and p = .024, respectively). Techniques to correct esotropia and exotropia differed significantly between primary surgeries and reoperations (p < .00001 each).

CONCLUSIONS

The complexity of surgical techniques increased over time. Ethnic minorities were less prone to reoperations.

Trends in Pregabalin Use and Prescribing Patterns in the Adult Population: A 10-Year Pharmacoepidemiologic Study

BACKGROUND AND OBJECTIVE

Pregabalin is steadily gaining popularity worldwide, with epidemiological studies indicating an increase in labeled, off-labeled, and recreational uses. In Israel, pregabalin prescriptions are not regulated by the controlled substances legislations, prompting a need to examine its usage trends for potential policy adjustments. The objective of this study was to assess trends in pregabalin prescribing during a 10-year period, to characterize demographic and clinical characteristics of individuals prescribed pregabalin, and to identify risk factors associated with high-intensity pregabalin use.

METHODS

This retrospective, longitudinal study examined trends in pregabalin prescribing from 2010 to 2019 based on data extracted from the Clalit Health Services (CHS) electronic database. Annual pregabalin prescribing rate was calculated individually for each reporting year. A univariable analysis was conducted to compare the demographic and clinical characteristics of pregabalin users in 2019 with those in 2010. Multivariable regression analysis was performed to assess dose-related patterns by specific demographic and clinical characteristics.

RESULTS

Pregabalin prescription rate more than doubled over 10 years [odds ratio (OR) 2.3, p = 0.001], reaching 7.2 [95% confidence interval (CI) 7.18-7.28] prescriptions per 100 CHS members in 2019. The highest prescription rates were observed among the elderly population (13.2 and 24.1 prescriptions per 100 CHS members for those aged 55-74 and over 75 years old, respectively). Same-year administration of pregabalin with opioids, benzodiazepines, and Z-drugs was common; however, the percentage of patients using these drugs together declined in 2019 compared with 2010 (p < 0.001). Males, patients with low socioeconomic status, patients aged 35-54 years, and those who consumed opioids, benzodiazepines, and Z-drugs received higher pregabalin doses.

CONCLUSION

Pregabalin use has increased significantly in the Israeli adult-based CHS population, consistent with worldwide data. A growing use over time may indicate overprescription. More studies are needed on misuse patterns to identify populations most susceptible to high-dose and high-intensity pregabalin use.

The association of medical, social, and normative factors with the implementation of end-of-life care practices

BACKGROUND

End-of-life (EoL) care practices (EoLCP) are procedures carried out at the EoL and bear directly on this stage in the patient's life. Public support of these practices in Israel is far from uniform. Previous studies show that while ∼30% of participants support artificial respiration or feeding of terminally ill patients, 66% support analgesic treatment, even at the risk of shortening life. This study aimed to create a typology of six end-of-life care practices in Israel and assess the association of medical, social, and normative factors with the implementation of those practices. These practices included mechanical ventilation, artificial feeding, deep sedation, providing information to the patient and family caregivers, including family caregivers in EoL decision-making, and opting for death at home.

METHODS

This cross-sectional study was performed as an online survey of 605 adults aged 50 or more in Israel, of which ~ 50% (n = 297) reported supporting a dying terminally ill relative in the last 3 years. Participants were requested to provide their account of the EoL process of their relative dying from a terminal illness in several aspects, as well as the EoL care practices utilized by them.

RESULTS

The accounts of the 297 interviewees who supported a dying relative reveal a varied EoL typology. The utilization of end-of-life care practices was associated with the socio-normative beliefs of family caregivers but not with their socioeconomic status. Strong correlations were found between family caregiver support for three key practices (mechanical ventilation, artificial feeding, and family involvement in EoL) and the actual utilization of these practices in the care of dying patients.

CONCLUSIONS

The findings portray an important image of equity in the utilization of EoLCP in Israel, as the use of these practices was not associated with socioeconomic status. At the same time, the study found substantial diversity in family caregivers' preferences regarding EoL care practices use not related to socioeconomic status. We believe that differences in preferences that do not lead to problems with equity or other important societal values should be respected. Accordingly, policymakers and health system leaders should resist calls for legislation that would impose uniform EoL practices for all Israelis. Instead, they should take concrete steps to preserve and enhance the widespread current practice of practitioners to adapt EoL care to the varied needs and preferences of Israeli families and cultural, social, and religious subgroups. These steps should include providing frameworks and tools for family caregivers to support their loved ones close to their deaths, such as educational programs, seminars, supportive care before and during the end of life of their loved ones, etc.

Socio-demographic characteristics and their relation to medical service consumption among elderly in Israel during the COVID-19 lockdown in 2020 as compared to the corresponding period in 2019

PURPOSE

The COVID-19 pandemic has led to the isolation of the population in Israel, including the elderly. The present study aimed to compare the consumption of medical services among adults over the age of 65 in Israel at the time of the first COVID-19 lockdown relative to the corresponding period the year before.

METHODS

We conducted a retrospective longitudinal observational quantitative research based on the Natali Healthcare Solutions Israel database of subscribers. Company subscribers over the age of 65 (N = 103,955) were included in the sample (64.5% women) in two time periods, before the COVID-19 outbreak-P1, in 2019, and during the first COVID-19 lockdown- P2 in 2020. Logistic regression was applied to examine service consumption for study variables.

RESULTS

The average number of referrals to services was lower during the COVID-19 lockdown period (M = 0.3658, SD = 0.781) compared to the corresponding period in the previous year (M = 0.5402, SD = 0.935). The average number of ambulance orders, doctor home visits and service refusals were higher when compared to the same period in the previous year. During both time periods, women (P1- M = 0.5631, SD = 0.951; P2- M = 0.3846, SD = 0.800) required significantly more (p < .000) services than men (P1- M = 0.5114, SD = 0.910; P2- M = 0.3417, SD = 0.753). Older, widowed people, living in non-Jewish/mixed localities, or in average or below average socioeconomic status localities required relatively more services to those with opposite socio-demographic traits (p < .000).

SUMMARY AND CONCLUSIONS

In a large sample of elderly in Israel, findings indicate a decrease in referrals to medical care during the first COVID-19 lockdown period, yet an increase in ambulance orders, doctor visits and service refusals. Socio-demographic characteristics showed a similar effect in both time periods. The period of the first COVID-19 lockdown was characterized by a higher incidence of medical service refusals as compared to the equivalent period in the previous year.

Does Ethnic Diversity Impact on Risk Perceptions, Preparedness, and Management of Heat Waves?

Detrimental health impacts of heatwaves, including excess mortality, are increasing worldwide. To assess risk perceptions, protective knowledge and behaviors concerning heatwaves in Israel, a study was initiated, comparing attitudes of majority (Jewish) and minority (Arab) populations. A quantitative survey was disseminated through an internet panel, to a representative sample of 556 individuals (79% Jews; 21% Arabs). Overall, 74% consider heatwaves a problem, 93% believe that heatwaves' frequencies will increase, 27% are very concerned about the effects of heatwaves. Higher levels of awareness to heatwaves were found among Jewish compared to Arab respondents; 90 vs. 77% (respectively) could name heatwaves' symptoms (p < 0.001); 81 vs. 56% (respectively) reported knowing how to protect themselves (p < 0.001); 74 vs. 47% (respectively) reported knowing what to do when someone suffers from heat stroke (p < 0.001). Arab compared to Jewish respondents presented higher levels of concern about heatwaves' effects (3.22 vs. 3.09 respectively; t −2.25, p = 0.03), while knowledge of protective measures was higher among Jews compared to Arabs (3.67 vs. 3.56 t = 2.13 p = 0.04). A crucial component of enhancing preparedness to heatwaves is empowerment of minority as well as majority groups, to strengthen their capacity to implement protective behavior and elevate their self-belief in their individual ability and fortitude.

Predictors of respiratory cancer-related mortality for Jews and Arabs in Israel

Background

Respiratory cancers, including lung, tracheal and bronchus cancers, are a leading cause of cancer-related mortality in Israel; however, incidence can differ among demographic groups. Despite the importance of sociodemographic characteristics and the interactions between them to incidence and mortality, this topic is understudied. This study analyzes sociodemographic disparities by sex and ethnicity among Jews and Arabs to understand cancer outcome differences stratified by SES, marital status, and number of children as potential contextual factors.

Methods

This retrospective cohort study analyzed respiratory cancer-related mortality rates among Israelis born between 1940 and 1960 over 21-years. The follow up period was between January 1, 1996 and 12.31.2016. Mortality rates for Jews and Arabs were calculated. Using a Cox Regression, a multivariate model was constructed to determine the association between ethnicity and respiratory cancer mortality. The study population was then divided into four groups, by sex and ethnicity, to determine the association between marital status, number of children, and SES with respiratory cancer mortality for each subgroup.

Results

The overall mortality rate was 0.6%. Arabs had higher mortality rates compared to Jews, even after adjusting for demographic factors including age, sex and SES (Adjusted Hazard Ratio (AHR) = 1.442, 99% confidence intervals (CI) = 1.354,1.546). Among men, a higher mortality rate was found among Arabs (AHR = 1.383, 99%CI = 1.295,1.477), while among women, Arabs had lower mortality rates (AHR = 0.469, 99%CI = 0.398,0.552). Significant mortality rate differences were observed by ethnicity and sex for each sociodemographic variable.

Conclusions

This study highlights the importance and implications of understanding differences in respiratory cancer mortality between Jews and Arabs, a minority group in Israel, and is relevant for minority groups in general. There is a need to tailor interventions for these groups, based on differing underlying causes and contextual factors for these cancers. Cancer outcomes among these groups should also be studied separately, by sex, to better understand them.

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This retrospective multivariable cohort study analyzed respiratory cancer mortality.

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Data was collected for 26 years for 196,974 Arabs and 1,470,676 Jews in Israel.

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A higher mortality rate was found among Arab men compared to Jewish men.

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A lower mortality rate was found among Arab women compared to Jewish women.

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Implications for predictive factors found for respiratory cancer-related mortality.

Opportunities for diversifying and enriching our article mix

As 2020 comes to a close, the Israel Journal of Health Policy Research (IJHPR) will soon be starting its tenth year of publication. This editorial compares data from 2012 (the journal's first year of publication) and 2019 (the journal's most recent full year of publication), regarding the journal's mix of article types, topics, data sources and methods, with further drill-downs regarding 2019.The analysis revealed several encouraging findings, including a broad and changing mix of topics covered. However, the analysis also revealed several findings that are less encouraging, including the limited number of articles which assessed national policy changes, examined changes over time, and/or made secondary use of large-scale survey data. These findings apparently reflect, to some extent, the mix of studies being carried out by Israeli health services researchers.As the senior editors of the IJHPR we are interested in working with funders, academic institutions, the owners and principal users of relevant administrative databases, and individual scholars to further understand the factors influencing the mix of research being carried out, and subsequently published, by Israel's health services research community. This deeper understanding could then be used to develop a joint plan to diversify and enrich health services research and health policy analysis in Israel. The plan should include a policy of ensuring improved access to data, to properly support information-based research.

Ethnic inequality within the elderly population in utilizing healthcare services

The accessibility of minority ethnic groups to healthcare services is challenging in many societies, most especially among the elderly population. Elderly individuals from minority groups have been found to have lower levels of utilizing healthcare services, including preventive care, intensive hospital care, advanced technological procedures and rehabilitation. Universal health coverage is incapable of addressing all of healthcare's access inequities and there is a need to assess the overall outcomes, including mortality rates over time, functionality of discharged patients, quality of life and/or unplanned readmissions that may indicate low quality hospital discharge processes. There is a need to investigate the impact of perceived trust/distrust in the healthcare system of elderly patients from minority ethnicities on their willingness to consume medical services.To ensure equity in service provision, there is a need to examine whether medical providers, even unconsciously, prioritize vital services, such as rehabilitation services to populations that share similar social backgrounds. An essential measure is enhancement of health literacy at all levels, from the individual to policy-makers and strategic adoption of health literacy programs that encompass all ethnicities, considering their respective needs, norms and expectations.Ethnic equality in accessing medical services is crucial in view of the numerous migrants and asylum-seekers who look for refuge in varied societies globally. Such populations are perceived as faring worse in healthcare quality of care, and this highlights the need to adapt the healthcare systems to the varied health behaviors, contextual factors, language barriers, lower health literacy levels and limited access to timely care. Improving equity and access to medical care is dependent on enhanced health literacy; policies that consider diverse needs of majority and minority groups; and advanced research. Concurrent implementation of these measures will be well aligned with the global strive to promote the Sustainable Development Goals (SDGs).