The Direct and Indirect Costs of Treating the Victims of the 2016 Nice Terror Attacks in a Single Pediatric Hospital.

OBJECTIVE: To analyze the cost of the terror attack in Nice in a single pediatric institution. METHODS: We carried out descriptive analyses of the data coming from the Lenval University Children's Hospital of Nice database after the July 14, 2016 terror attack. The medical cost for each patient was estimated from the invoice that the hospital sent to public insurance. The indirect costs were calculated from the hospital's accounting, as the items that were previously absent or the difference between costs in 2016 versus the previous year. RESULTS: The costs total 1.56 million USD, corresponding to 2% of Lenval Hospital's 2016 annual budget. Direct medical costs represented 9% of the total cost. The indirect costs were related to human resources (overtime, sick leave), revenue shortfall, and security and psychiatric reinforcement. CONCLUSION: Indirect costs had a greater impact than did direct medical costs. Examining the level and variety of direct and indirect costs will lead to a better understanding of the consequences of terror acts and to improved preparation for future attacks.

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 medical costs of terror: A review of the literature.

CONTEXT: The threat of terrorism is intensifying with a recent rise in the number of death and injuries. Nevertheless, few articles deal with the short and long-term medical costs of treating and assisting the civilian victims of terror. The objective of this article is to review the literature and describe the medical costs of supporting victims of terrorism. METHOD: The authors reviewed the literature on the medical costs following terror attacks in the PubMed/Medline and Google Web sites. Relevant scientific articles, textbooks, and global reports were included in the research. RESULTS: There was a scarcity of data related to the medical costs of terror. The authors review the few articles that describe the hospital and outpatient expenses. The terror attacks lead to increasing length of stay and the use of supplementary medical support. The authors detail the relevant global reports and working papers on terrorism that included the cost of injury and the over-all economic impact assessment. CONCLUSION: The medical costs result from hospital and outpatient treatment support. There is a clear need to track the long-term fate of the victims of terror. The authors recommend that future research should include all sectors of the healthcare system, including the whole rehabilitation process and have a precise tracking system for all victims.

Learning from negative findings.

A recent IJHPR article by Azulay et al. found no association between the patient activation measure (PAM) and adherence to colonoscopy after a positive fecal occult blood test result. This commentary will use that article as a jumping-off point to discuss why studies sometimes get negative results and how one should interpret such results. It will explore why the Azulay study had negative findings and describe what can be learnt from this study, despite the negative findings.It is important to publish studies with negative findings to know which interventions do not have an effect, avoid publication bias, allow robust meta-analyses, and to encourage sub-analyses to generate new hypotheses.To support these goals authors must submit articles with negative findings with sufficient detail to support the above aims and perform sub-analyses to identify additional relationships that merit study.The commentary will discuss the importance of publishing articles in which the hypothesis is not proven and demonstrate how such articles should be written to maximize learning from their negative findings.

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.

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.

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.

The effect of clinical interventions on hospital readmissions: a meta-review of published meta-analyses.

BACKGROUND: The economic impact and ease of measurement of all-cause hospital readmission rates (HRR) have led to the current debate as to whether they are reducible, and whether they should be used as a publicly reported quality indicators of medical care. OBJECTIVE: To assess the efficacy of broad clinical interventions in preventing HRR of patients with chronic diseases METHOD: A meta-review of published systematic reviews of randomized controlled trials (RCTs) of clinical interventions that have included HRR among the patients' outcomes of interest. MAIN FINDINGS: Meta-analyses of RCTs have consistently found that, in the community, disease management programs significantly reduced HRR in patients with heart failure, coronary heart disease and bronchial asthma, but not in patients with stroke and in unselected patients with chronic disorders. Inhospital interventions, such as discharge planning, pharmacological consultations and multidisciplinary care, and community interventions in patients with chronic obstructive pulmonary diseases had an inconsistent effect on HRR. MAIN STUDY LIMITATION: Despite their economic impact and ease of measurement, HRR are not the most important outcome of patient care, and efforts aimed at their reduction may compromise patients' health by reducing also justified re-admissions. CONCLUSIONS: The efficacy of inhospital interventions in reducing HRR is in need of further study. In patients with heart diseases and bronchial asthma, HRR may be considered as a publicly reported quality indicator of community care, provided that future research confirms that efforts to reduce HRR do not adversely affect other patients' outcomes, such as mortality, functional capacity and quality of life. Future research should also focus on the reasons for the higher efficacy of community interventions in patients with heart diseases and bronchial asthma than in those with other chronic diseases.