Lessons From Analyzing the Medical Costs of Civilian Terror Victims: Planning Resources Allocation for a New Era of Confrontations.

Policy Points: Across the globe, the threat from terrorist attacks is rising, which requires a careful assessment of long-term medical support. We found 3 major sources of costs: hospital expenditures, mental health services dedicated to acute stress reactions, and ambulatory follow-up. During the first year, most of the costs were related to hospitalization and support for stress relief. During the second year, ambulatory and rehabilitation costs continued to grow. Public health specialists should consider these major components of costs and their evolution over time to properly advise the medical and social authorities on allocating resources for the medical and nonmedical support of civilian casualties resulting from war or terror. CONTEXT: Across the globe, the threat from terrorist attacks is rising, which requires a careful assessment of long-term medical support. Based on an 18-month follow-up of the Israeli civilian population following the 2014 war in Gaza, we describe and analyze the medical costs associated with rocket attacks and review the demography of the victims who filed claims for disability compensation. We then propose practical lessons to help health care authorities prepare for future confrontations. METHOD: Using the National Insurance Institute of Israel's (NII) database, we conducted descriptive and comparative analyses using statistical tests (Fisher's Exact Test, chi-square test, and students' t-tests). The costs were updated until March 30, 2016, and are presented in US dollars. We included only civilian expenses in our analysis. FINDINGS: We identified 5,189 victims, 3,236 of whom presented with acute stress reactions during the conflict. Eighteen months after the conflict, the victims' total medical costs reached $4.4 million. The NII reimbursed $2,541,053 for associated medical costs and $1,921,792 for associated mental health costs. A total of 709 victims filed claims with the NII for further support, including rehabilitation, medical devices, and disability pensions. CONCLUSION: We found 3 major sources of costs: hospital expenditures, mental health services dedicated to acute stress reactions, and ambulatory follow-up. During the first year, most of the costs were related to hospitalization and support for stress relief. During the second year, ambulatory and rehabilitation costs continued to grow. Public health specialists should consider these major components of costs and their evolution over time to properly advise the medical and social authorities on allocating resources for the medical and nonmedical support of civilian casualties resulting from war or terror.

Naturalistic Study of Posttraumatic Stress Disorder Among Israeli Civilians Exposed to Wartime Attacks.

OBJECTIVE: Civilians who survive wartime attacks commonly experience substantial psychological distress, including acute stress reactions (ASRs) and posttraumatic stress disorder (PTSD). The authors sought to determine the level of Israeli civilian exposure to wartime attacks, prevalence of posttraumatic stress disorder (PTSD) and physical injuries, and associated medical costs over a 7-year period. METHODS: Data from the National Insurance Institute of Israel on civilian survivors of wartime attacks in the 2009-2015 period were retrospectively examined. RESULTS: Overall, 11,476 civilians were affected by 243 wartime attacks during the study period. Of these individuals, 7,561 (65.9%) received early intervention (EI) psychological treatment for ASRs, 1,332 (11.6%) were subsequently adjudicated as having a disability (all causes), and 519 (4.5%) were adjudicated as disabled by PTSD through the end of 2016. Individuals who received immediate ASR treatment were less likely to be disabled by PTSD (p=0.001). Among those without physical injuries, the EI was associated with decreased PTSD disability (2.6% of those receiving the EI developed PTSD, whereas 7.2% of those who did not receive the EI developed PTSD); however, for those with physical injuries, the PTSD rate was higher among those who received the EI (30.4%) than among those who did not receive the EI (5.2%). Individuals having a disability other than PTSD incurred higher medical costs ($7,153 in 2016 U.S. dollars) than individuals with PTSD ($1,960). CONCLUSIONS: An approach of providing case management, medical care, behavioral health screening, and EI for ASRs in the wake of wartime attacks on civilians minimized long-term PTSD-related disability.

The long-term consequences of 35 years of terror attacks against civilians in Israel: Medical and nonmedical costs, disability.

BACKGROUND: Terrorism is a major threat, which requires operative preparedness, principally for the emergency struc-tures. Similarly, its rising impact on the healthcare system should interest the researchers in health affairs and policy. The number and the nature of disabilities due to terror is insufficiently addressed in the civilian population. In this article, we described the type and number of disabilities in Israel due to war and terror attacks since 1980. METHODS: Descriptive analyses of the National Insurance Institute of Israel (NII) Civilian Victim of Terror database which embraces medical and social information including the number and severity of disabilities and their nonmedical costs (disability pensions) since 1980; the related medical costs (based on hospital and ambulatory invoices) and their principal International Classification of Diseases (ICD 9) diagnoses and comparison to the data coming from the START database (National Consortium for the Study of Terrorism and Responses to Terrorism) Results: There was a surge in the number of disabilities following the years of the second Intifada 2000-2006. Al-though the number of wounded decreased after the end of the Second Intifada, the number of disabled stayed high due to their ongoing care. The costs of disability pensions grew in parallel to the number of disabled and approached 140 M US$ for 2016. CONCLUSIONS: The different waves of terror attacks have an awful legacy as 4,000 disabled whom are supported to-day by the State of Israel. Because of the unique way Israel is tracking and following the -victims, including the number of disabled and their attendant social and medical costs we can assess the broad impact of terrorism in Israel. It is interest-ing to note that when a country supports the victims of terror with an efficient system and dedicated means and re-sources, the social (nonmedical) costs are far more significant than the medical costs.

Terrorism reports: The tip of the iceberg.

IMPORTANCE: Medical impact of terror is a public health issue as the threat is growing all over the world. OBJECTIVE: Our objective was to compare the number of injured and incidents in the three different databases and reports [Global Terrorism Database (GTD), Israeli Security Agency (ISA) and National Insurance Institute (NII)] in Israel. DESIGN: Retrospective study. SETTING: Analyses of three different databases (GTD, ISA and NII) and basic comparison. MAIN OUTCOME(S) AND MEASURE(S): The victims reimbursed for medical expenses are the largest population. The number of injured as described by GTD and ISA database are less important. The 2010-2013 years are marked by more incidents recognized in Israel vs GTD assessment (except in 2014). CONCLUSIONS AND RELEVANCE: The number of victims being reimbursed for medical and mental health services is radically different from the GTD and the ISA reports. Public Health specialists should be advised of this phenomenon to deliver their right approach (including mental health) to growing threat and develop new definition of victim of terror.

Social support for terror-related victims: The Israeli system.

Since its foundation, the State of Israel has been affected by terror violence toward its civilian population. For more than 45 years, the Israeli legislation has built a legal insurance allowing citizens casualties of such violence to benefit from specific coverage and support. The objective of this article is to describe the history, legal framework, and organization of social support for terror victims in Israel.