Israeli Public Health Research Articles

Cost effectiveness of home care versus hospital care: a retrospective analysis

BackgroundIncreased utilization of health services due to population growth affects the allocation of national resources and budgets. Hence, it is important for national policy. Home hospitalization is one of the solutions for dealing with the growing demand for hospital beds and reducing the duration of hospitalization and its costs. It is gradually becoming part of the regular care in many health systems, yet, studies on the economic aspects of Community-Based Home Hospitalization (CBHH) implementation in Israel are few. The aim of this study is to examine costs of CBHH in comparison to costs of inpatient hospital care in the Israeli public health system.MethodsRetrospective data was collected using document research in databases. A review of the costs of patients in CBHH at Maccabi Healthcare Services (MHS) was conducted. A total of 3374 patients were included in this study: 1687 patients who were in CBHH, and 1687 age- and sex-matched patients who were hospitalized in an internal department (the control group). The study population included the patients admitted to CBHH from January 2018 to July 2020, and patients admitted to internal medicine departments during the same period.ResultsThe number of hospitalizations during the follow up period were statistically significantly lower in the CBHH group compared with the control group (M = 1.18, SD = 0.56 vs. M = 1.61, SD = 1.29, p < 0.001). In addition, the mean number of hospitalization days was also statistically significantly lower for 4.3 (SD = 4.5) for CBHH patients compared to the control group (M = 4.3 days, SD = 4.5 vs. M = 7.5 days, SD = 10.3, p < 0.001). Furthermore, the mean cost per day was statistically significantly higher for inpatient hospitalization compared to CBHH (M = 1829.1, SD = 87.5 vs. M = 783.2, SD = 178.3, p < 0.001). Older patients, patients with diabetes and patients hospitalized in hospitals had a higher number of hospitalization days.ConclusionsThe costs of CBHH seem to be lower than those of inpatient care. Managing CBHH is characterized by constantly measuring financial feasibility that would be an impetus for further development of this service.

Identifying the Gaps Between Public Health Training and Practice: A Workforce Competencies Comparative Analysis.

Objectives: The study aimed to generate insights on how best to enhance the compatibility between Public Health training program competencies and the implementation of competencies required by employers to address current and emerging public health needs. Methods: A survey adapted from the WHO-ASPHER Competency Framework for the Public Health Workforce was conducted online among Israeli public health managers from August to November 2021. The survey was formulated to mirror Essential Public Health Operations. Forty-nine managers participated (37.6% response rate) in an assessment of 44 public health competencies and the core organizational public health operations. Results: Analysis of Essential Public Health Operations revealed a notably high deficiency reported for Advocacy Communication and Social Mobilization for health competencies. Collaborations and Partnership and, Leadership and System Thinking were the most reported insufficient competencies, particularly in health departments and research institutes. Governmental offices reported Organizational Literacy and Adaptability competencies being deficient. Deficiencies were more impactful as the level of expertise increased. Conclusion: There is a clear need for public health professionals to acquire versatile and innovative competencies in response to the ever-changing health threats.

Trust in COVID-19 policy among public health professionals in Israel during the first wave of the pandemic: a cross-sectional study

BackgroundThe COVID-19 pandemic has highlighted the important role of professionals in designing and communicating effective policies. The purpose of this study was to evaluate the level of trust in the COVID-19 national public health policy among public health professionals in Israel and its correlates during the first wave of the pandemic.MethodsA purposive sampling of public health professionals in Israel, through professional and academic public health networks (N = 112). The survey was distributed online during May 2020. Level of trust was measured by the mean of 18 related statements using a 5-point Likert scale, where 1 means not at all and 5 means to a very high extent, and grouped as low and high trust by median (2.75).ResultsA moderate level of trust in policy was found among professionals (Mean: 2.84, 95% Cl: [2.70, 2.98]). The level of trust among public health physicians was somewhat lower than among researchers and other health professionals (Mean: 2.66 vs. 2.81 and 2.96, respectively, p = 0.286), with a higher proportion expressing low trust (70% vs. 51% and 38%, respectively, p < 0.05). Participants with a low compared to high level of trust in policy were less supportive of the use of Israel Security Agency tools for contact tracing (Mean = 2.21 vs. 3.17, p < 0.01), and reported lower levels of trust in the Ministry of Health (Mean = 2.52 vs. 3.91, p < 0.01). A strong positive correlation was found between the level of trust in policy and the level of trust in the Ministry of Health (rs = 0.782, p < 0.01). Most professionals (77%) rated their involvement in decision making as low or not at all, and they reported a lower level of trust in policy than those with high involvement (Mean = 2.76 vs. 3.12, p < 0.05). Regarding trust in the ability of agencies to deal with the COVID-19 crisis, respondents reported high levels of trust in the Association of Public Health Physicians (80%) and in hospitals (79%), but very low levels of trust in the Minister of Health (5%).ConclusionsThis study shows that Israeli public health professionals exhibited moderate levels of trust in COVID-19 national public health policy and varied levels of trust in government agencies during the first wave of COVID-19. The level of trust in policy was lower among most of the participants who were not involved in decision making. The level of trust found is worrisome and should be monitored, because it may harm cooperation, professional response, and public trust. Professionals’ trust in policy-making during early stages of emergencies is important, and preemptive measures should be considered, such as involving professionals in the decision-making process, maintaining transparency of the process, and basing policy on scientific and epidemiological evidence.

Trends in Non-invasive Prenatal Screening and Invasive Testing in Denmark (2000-2019) and Israel (2011-2019).

Introduction: Following the wide distribution of non-invasive prenatal genetic screening (NIPS), numerous studies have reported a decline in total invasive tests in the recent years, up to 50–70% in some countries. However, in Denmark and Israel we have not experienced these declines. The objective of our study was to evaluate the trends in NIPS and chromosomal microarray analysis (CMA) use in Denmark and Israel.Methods: This retrospective study was performed by data acquisition from the Danish Cytogenetics Central Registry throughout the years 2000–2019, and Israeli Public Health Services, Ministry of Health computerized database (from 2011).Results: Of the 1,243,956 live births registered in Denmark over the years 2000–2019, a relatively steady level of invasive testing around 6% was noted since 2004, as opposed to 13.0% in Israel based on 1,594,962 live births between 2011 and 2019. The average uptake of NIPS was 1.1 ± 0.5% in Denmark vs. 4.3% in Israel (2013–2019). Relatively steady rates of invasive testing were noted in both countries, compared to a slight decline in NIPS in the recent years.Discussion: The recent decrease in the rates of invasive testing in the NIPS era was not observed in Denmark or in Israel. These results imply that Danish and Israeli women and/or health providers might favor the high resolution and yield of CMA testing over the non-invasiveness of NIPS. We explore and discuss this phenomenon, based on five central factors.

The measles outbreak in Israel in 2018-19: lessons for COVID-19 pandemic

ABSTRACT During 2018–2019 Israel saw some 4300 measles cases in a country-wide epidemic. Increased measles incidence rates and considerable disease burden have been observed in under-vaccinated communities, predominantly Jewish ultraorthodox. The measles epidemic, despite proper public health handling, revealed susceptible population subgroups as well as gaps and lacking resources in the Israeli public health systems. In the COVID-19 pandemic in Israel, as of December 2020, the number of COVID-19 cases reported nationally was over 300,000 with approximately 3000 fatalities. Notably, minority groups such as the ultraorthodox Jewish community and the Arab community in Israel has been profoundly affected by the COVID-19 pandemic. We believe it is still possible to implement the key lessons from the measles outbreak in Israel that could aid in the COVID-19 response in Israel and elsewhere. These conceptions should include a social-based approach, investment in public health human resources and infrastructure, tackling root causes of inequalities, emphasis on trust and solidarity, proactive communication, need for political will, and proper use of epidemiological data as a basis for decision-making. In parallel to proper use of COVID-19 vaccines, when available, a ‘social vaccine’ is crucial as well as preparedness and response according to public health principles.

מגפת שיתוק הילדים: אירוע מעצב מדיניות, 1956-1949

The polio epidemic broke out in Israel in July 1949, soon after the establishment of the State and during a period of mass immigration. The fledgling Ministry of Health was in the stage of creating the medical system and infrastructure and was still in the process of formulating policy. The new State of Israel now faced a complex, multifaceted challenge, at a time when it was vigorously seeking acceptance and recognition of its standing in the UN and the World Health Organization (WHO). The healthcare system battled the epidemic for over four years. In view of the severity of the situation and the lack of alternative solutions, the heads of the healthcare system adopted their own independent policy. Demonstrating professional courage, they undertook the manufacture of vaccines and initiated a mass vaccination campaign. Israel’s handling of the epidemic boosted the country’s standing and reputation among medical professionals worldwide and in the WHO. In addition to laboratories for producing vaccines, Israel developed treatment, rehabilitation and monitoring systems. The impressive response of the Israeli public health authorities to the epidemic established its position among the leading countries worldwide in the field of preventive medicine.

Association between trust in the public healthcare system and selecting a surgeon in public hospitals in Israel: a cross-sectional population study

BackgroundThe Israeli public health system has seen a steady decline in public trust and confidence, which has resulted in an increased rate of individuals holding private and commercial health insurance policies that allow more choice of various services (especially choose the surgeon’s). This study evaluated the attitudes and beliefs of Israeli adults regarding public trust, equitability and choice within the public health system.MethodsA cross-sectional telephone survey conducted among a representative random sample of Israeli adults (> 25 years). Participants responded to a 27-item questionnaire. Multivariate regression analyses were performed to determine the contribution of various socio-demographic variables to the perceptions of trust and equitability in the health system and the ability to choose a surgeon, As well as a possible links among these parameters.ResultsOf 865 adults that responded to the survey, most were women (51.8%), Jewish (68.6%), and married (73.0%). Trust in the public health system, the perception of the system’s equitability and the public’s perception of the importance of selecting a surgeon were inter-related. The results emphasize a possible association between three meaningful factors: the trust in the public health system, the perception of the system’s equitability and the public’s perception regarding the importance of selecting a surgeon.ConclusionsPublic trust in the public health system is a fundamental condition for maintaining an efficient and equitable health system in Israel. The survey suggests that uncertainty regarding the identity of the surgeon who will perform a procedure in a public hospital may be linked to a sense of insecurity and distrust of the public in the public health system. This study did not examine the causal relationship between the various factors, but the study data suggests a possible link between lower trust in the system and a lower perception of its equitability, and a subsequent associated increase in the public’s desire to select a surgeon. This study suggests to recognize public trust as a central and significant tool to strengthen public health system. One of the ways to strengthen the public’s confidence in the public health system could be to provide the patient with reliable information regarding parameters such as the identity of the senior surgeon in the operating room or the surgeon’s suitability for the patient’s medical condition.

Management of Community-Based Home Hospitalization (CBHH) in Israeli Public Health System

Management of Community-Based Home Hospitalization (CBHH) in Israeli Public Health System

Experts' Views on the Gaps in Public Health Emergency Preparedness in Israel: A Qualitative Case Study.

Despite the significant improvement in all components of preparedness in the past decade, there are still gaps between the guidelines and the reality on the ground. The purpose of this study is to explore how Israeli public health and emergency medicine experts perceive the demands for health organization emergency preparedness and the actual practice. Qualitative phenomenological research. We interviewed 22 Israeli public health and emergency medicine experts face-to-face and conducted a content analysis. The findings revealed barriers in the following areas: preparation and readiness of hospitals, preparedness and readiness in the community, connection between the community and the hospital, inter-agency coordination and interface, interdisciplinary integration, preparedness resources, postcrisis evaluation, assimilating smart technologies, information accessibility, and communication. To reduce the gap between theory and practice, retrospective research and evaluation must be included to learn in depth what strategies and resources should be used during a health crisis. Likewise, profiles should be constructed and the community should be segmented in order to design resilience programs and accommodate information to subpopulations.

Participative management: the effect of the exposure to and attitude of employees and managers towards participation in the management decision-making process – a case study of a public organisation in Israel

ABSTRACT This article examines the assertion that in some situations employees do not support a participative management style applied by their managers. The effect of exposure to participation on employees’ attitudes was examined in an Israeli public health organisation, through participation in improvement teams. It was found that employee participation, even if successful, did not imply adoption of positive attitudes towards participation. It was further found that managers hold more positive attitudes towards participation than employees. Finally, ethnic origin was found to have a strong effect on attitudes towards participation.

The Israeli public health response to wild poliovirus importation

In 2013, a silent wild poliovirus type 1 importation and sustained transmission event occurred in southern Israel. With the aim of preventing clinical poliomyelitis and ensuring virus re-elimination, the public health response to the importation event included intensification of clinical and environmental surveillance activities, enhancement of vaccine coverage, and supplemental immunisation with a bivalent oral polio vaccine against wild poliovirus types 1 and 3. A national campaign launched in August, 2013, resulted in vaccination of 943,587 children younger than 10 years (79% of the eligible target population). Expanded environmental surveillance (roughly 80% population coverage) documented a gradual disappearance of wild poliovirus type 1 in the country from September, 2013, to April, 2014. No paralytic poliomyelitis case was detected. A prompt extensive and coordinated national public health response, implemented on the basis of evidence-based decision making, successfully contained this serious importation and sustained transmission event of wild poliovirus to Israel. On April 28, 2015, WHO officially declared Israel as a polio-free country.

Is socioeconomic status associated with utilization of health care services in a single-payer universal health care system?

ObjectivesTo assess an association of Socio-economic status with utilization of health care services between years 2002 and 2008 in Israel.MethodsWe retrospectively analyzed the utilization of health care services in a cohort of 100,000 members, 21 years and older, of a Clalit Health Services. The research compared utilization according to the neighborhood SES status; and clinic’s location as another SES proxy. Data included: Charlson Score morbidity factor, utilization of health care services (visits to primary physicians and specialists, purchase of pharmaceuticals, number of hospitalization days, visits to ED, utilization of laboratory tests and imaging). The analysis was performed using Generalized Linear Model (GLM) technique.ResultsPeople with lower SES visited more the ED and primary physicians and were hospitalized for longer periods. People with higher SES visited more specialists, bought more prescription drugs and used more medical imaging. The associations between SES and most of the services we analyzed did not change between 2002 and 2008. However, the gap between lower and higher SES levels in ED visits and the use of prescription drugs slightly increased over time, while the gap in visits to specialists decreased.ConclusionsThe research shows that even in a universal health care system SES is associated with utilization of health care services. In order to improve equity in utilization of services the Israeli public health should reduce economic barriers and in parallel invest in making information accessible to improve “navigation skills” for all.

Priorities in the Israeli health care system

The Israeli health care system is looked upon by some people as one of the most advanced health care systems in the world in terms of access, quality, costs and coverage. The Israel health care system has four key components: (1) universal coverage; (2) 'cradle to grave' coverage; (3) coverage of both basic services and catastrophic care; and (4) coverage of medications. Patients pay a (relatively) small copayment to see specialists and to purchase medication; and, primary care is free. However, during 2011 the Israeli Medical Association (IMA) spent 5 months on a strike, justifying it as trying to 'save' the Israeli public health. This paper describes some aspects of the Israeli Health Care System, the criteria for setting priorities for the expenditures on health care and values underlying these criteria. The paper observes that the new agreement between the IMA and the government has given timely priority to problematic areas of specialization (in which there is an acute shortage of physicians) and to hospitals in the periphery of the country. Yet weak points in the health system in Israel remain. Particularly, the extent to which national health care expenditures are being financed privately--which is rising--and the parallel decline in the role of government financing.

How Long Should Women Persevere with IVF?

The Israeli public health insurance system covers an (almost) unlimited number of IVF cycles. In a global context, this is a policy which is looked upon as a northern star. However, many women may continue IVF treatment when the probability of a successful pregnancy is 'zero'. This paper argues that the implication of a policy of unlimited rounds of IVF from the perspective of the 'culture of perseverance' that develops in IVF clinics has not yet been fully assessed. A systematic long term assessment of the health and welfare of women after IVF in Israel--especially after prolonged treatment with IVF--is necessary. In a global context, an evidence-based policy on ART may improve both the allocation of resources and the duty of care, not only in Israel, but also in other countries.

Bedouin-Arab women's access to antenatal care at the interface of physical and structural barriers: A pilot study

Since 2000, the Israeli Public Health Services have established eight Maternal-and-Child-Health (MCH) stations in unrecognised Bedouin-Arab villages in South Israel in order to reduce barriers to healthcare. The goals of this pilot study were: (1) to explore the new MCH stations’ impact on antenatal care (ANC) accessibility; and (2) to compare access to ANC between women from villages with MCH stations and women from villages without MCH stations. The study combined quantitative and qualitative methods including structured interviews with 174 MCH service users, review of 158 ANC records and 16 in-depth interviews with Bedouin-Arab women. The establishment of MCH stations in unrecognised villages has improved physical access to ANC and secondarily diminished other barriers related to financial and sociocultural dimensions of women's access to healthcare, thus enhancing women's options for independent healthcare-seeking; yet, limited opening hours, staff shortages and communication problems hamper ANC delivery at the new MCH stations. This pilot study indicates that the MCH stations’ establishment in unrecognised villages was a successful intervention, which improved women's access to ANC. Even though current service delivery challenges need to be overcome to achieve the intervention's full potential, its replication should be considered in further villages.

A cluster of deaths following influenza vaccination, Israel, 2006

When four deaths occurred in one week among influenza vaccine recipients, the Israeli Health Ministry suspended its 2006 influenza vaccination campaign pending investigation of the causes of death. Medical histories of the deceased vaccinees, quality control reports, and laboratory test results were examined. Prior vaccine use that season and a risk assessment of the vaccinated population were also considered. All four decedents had been treated for cardiac and other chronic diseases, and none had experienced post-injection symptoms suggesting adverse reaction to influenza vaccine. Quality control and laboratory reports confirmed vaccine batch safety, and no adverse effects had been reported among any other vaccine recipients. Investigators found no causal connection between the deaths and the vaccine, and the Health Ministry resumed the campaign. Israeli public health officials viewed the investigation as vital to maintaining broad confidence in the public health system, and in future vaccination campaigns.

Outbreak of Life-Threatening Thiamine Deficiency in Infants in Israel Caused by a Defective Soy-Based Formula

Objective. Between October and No- vember 2003, several infants with encephalopathy were hospitalized in pediatric intensive care units in Israel. Two died of cardiomyopathy. Analysis of the accumu- lated data showed that all had been fed the same brand of soy-based formula (Remedia Super Soya 1), specifi- cally manufactured for the Israeli market. The source was identified on November 6, 2003, when a 5.5-month-old infant was admitted to Sourasky Medical Center with upbeat nystagmus, ophthalmoplegia, and vomiting. Wer- nicke's encephalopathy was suspected, and treatment with supplementary thiamine was started. His condition improved within hours. Detailed history revealed that the infant was being fed the same formula, raising sus- picions that it was deficient in thiamine. The formula was tested by the Israeli public health authorities, and the thiamine level was found to be undetectable ( 25% indicates severe deficiency. Blood lactate levels (normal: 0.5-2 mmol/L) were measured in 6 infants, cerebrospinal fluid lactate in 2 (normal: 0.5-2 mmol/L), and blood pyruvate in 4 (nor- mal: 0.03-0.08 mmol/L). The diagnostic criteria for thia- mine deficiency were abnormal transketolase activity and/or unexplained lactic acidosis. Treatment consisted of intramuscular thiamine 50 mg/day for 14 days com- bined with a switch to another infant formula. Results. Early symptoms were nonspecific and in- cluded mainly vomiting (n 8), lethargy (n 7), irrita- bility (n 5), abdominal distension (n 4), diarrhea (n 4), respiratory symptoms (n 4), developmental delay (n 3), and failure to thrive (n 2). Infection was found in all cases. Six infants were admitted with fever. One pa- tient had clinical dysentery and group C Salmonella sep- sis; the others had mild infection: acute gastroenteritis (n 2); upper respiratory infection (n 2); and broncho- pneumonia, acute bronchitis, and viral infection (n 1 each). Two infants were treated with antibiotics. Three infants had neurologic symptoms of ophthalmoplegia with bilateral abduction deficit with or without upbeat nystagmus. All 3 had blood lactic acidosis, and 2 had high cerebrospinal fluid lactate levels. Patient 1, our in- dex case, was hospitalized for upbeat nystagmus and ophthalmoplegia, in addition to daily vomiting episodes since 4 months of age and weight loss of 0.5 kg. Findings on brain computed tomography were normal. Blood lac- tate levels were high, and TPPE was 37.8%. Brain mag- netic resonance imaging (MRI) revealed no abnormali- ties. Patient 2, who presented at 5 months with lethargy, vomiting, grunting, and abdominal tenderness, was found to have intussusception on abdominal ultrasound and underwent 2 attempts at reduction with air enema several hours apart. However, the lethargy failed to re- solve and ophthalmoplegia appeared the next day, lead- ing to suspicions of Wernicke's encephalopathy. Labora- tory tests showed severe thiamine deficiency (TPPE 31.2%). In patients 1 and 2, treatment led to complete resolution of symptoms. The third infant, a 5-month-old girl, was admitted on October 10, 2003, well before the outbreak was recognized, with vomiting, fever, and oph- thalmoplegia. Her condition deteriorated to seizures, ap- nea, and coma. Brain MRI showed a bilateral symmetri- cal hyperintense signal in the basal ganglia, mamillary bodies, and periaqueductal gray matter. Suspecting a metabolic disease, vitamins were added to the intrave- nous solution, including thiamine 250 mg twice a day. Clinical improvement was noted 1 day later. TPPE assay performed after treatment with thiamine was started was still abnormal (17.6%). Her formula was substituted after 4 weeks, after the announcement about the thiamine deficiency. Although the MRI findings improved 5 weeks later, the infant had sequelae of ophthalmoplegia

From socialist principles to motorcycle maintenance: the origin and development of the salaried physician model in the Israeli Public Health Services, 1918 to 1998.

For more than 70 years, physicians in the Israeli health care system have been employed on a fixed salary rather than on a fee-for-service basis. The present report is a brief review of the origin and development of this unique salaried physician model and its effect on the terms of physicians' employment. Archival documents were reviewed. The salaried physician model was introduced to ensure egalitarian health care for patients rather than equal payment for physicians. It was accepted by physicians because it guaranteed their employment and income. However, over the years, the salaried physician model has evolved into a complex wage scale, with multiple fringe benefits that bypass formal agreements in order to reward individual physicians. In addition, the salaried physician model has encouraged illegal private practice, which is viewed today as one of the major problems of the Israeli Public Health Services.

COUNTERPOINT:Integrating CQI in Health Organizations: Perspectives

Control of health care expenditures has become a major issue for most nations, especially for industrialized countries. All of them try to optimise the quality of the health care delivered and to reduce costs, while integrating all the new technologies developed. As of today, this challenge has not been met by any health care administration. Consequently, mechanisms of regulation are changed frequently and patients do not always understand the logic associated with these policy changes. To preserve their confidence in the health care system, patients require from health care professionals proofs of efficiency and assurance of quality. Modern methods of quality management aim to respond to these needs. In this issue. Professor Stem highlights the new difficulties encountered by Israeli public health care organizations. Hospitals are facing a competitive environment based on economic constraints and the need for a client-oriented strategy. This is not significantly different from the current situation in France: public hospitals (under the global budget principle) have to compete with private hospitals which are numerous (more than 70% of all French hospitals) but usually small (they represent less than 30% of the total number of beds). Moreover, it appears that nowadays some public hospitals also have to compete against each other. This competition has often led to a better response to patients' needs by the provision of more technical and specialized services, but at the same time, it has become difficult for health care administrations to control quality of care. However, the hospital environment in France will change following implementation of the recent health care reform elaborated by the current Government. Among other changes, accreditation of hospitals will be required. This new requirement could be a handicap for the development of CQI

The appropriateness of performing coronary angiography in two major teaching hospitals in Israel.

To assess the appropriateness of using coronary angiography in two major medical centers in Israel. (a) Development of dichotomous appropriateness rating by concensus of an expert panel for possible indications to use coronary angiography; (b) applying the panel's rating to clinical data gathered from interviews and records of 499 patients who underwent coronary angiography. Angiographies were performed inappropriately in 58% of patients: in 56% neither prognostic stratification was performed, nor was comprehensive medical therapy prior to angiography undertaken. Referral to catheterization from an acute care hospital, compared to ambulatory referral, correlated independently with an inappropriate angiogram. In the Israeli public health system there is still a high rate of inappropriate coronary angiography, most of the cases being due to error in management before performing angiographies.