Change in prevalence of preterm birth in Israel following publication of national guidelines recommending routine sonographic cervical-length measurement at 19-25 weeks' gestation.

OBJECTIVE: To compare the prevalence of preterm birth (PTB) (delivery before 37 weeks) in Israel before and after publication of national guidelines recommending second-trimester sonographic cervical-length (CL) measurement. METHODS: The Israeli Society of Obstetrics and Gynecology (ISOG) guidelines, issued on 1 January 2012, specified that CL should be measured transabdominally or, if this is not possible, transvaginally, at the 19-25-week ultrasound anomaly scan and that CL < 25 mm should indicate further work-up and treatment, although the type of treatment was unspecified. In 2000, the Israel Ministry of Health issued a legal requirement for the submission of delivery records to a national registry. These data were used to compare PTB prevalence in the period before (2000-2011) and that after (2012-2020) publication of the guidelines, as well as trends within each time period. Information was available on singleton and multiple pregnancy and maternal age and parity, as well as low birth weight (< 2500 g). RESULTS: During the period 2000-2020, there were 3 403 976 infants liveborn in Israel: 1 797 657 before and 1 606 319 after publication of the ISOG guidelines. There were 247 187 PTBs overall, with a prevalence of 7.64% (95% CI, 7.52-7.77%) before publication of the guidelines and 6.84% (95% CI, 6.43-7.24%) afterwards (P < 0.0002, two-tailed). The annual PTB prevalence was static in the first time period but declined by 0.18% per annum during the second period, after publication of the guidelines. The proportionate reduction in PTB prevalence after compared with before publication of the guidelines was 10% overall, 9% for PTB at 33-36 weeks, 18% for PTB at 28-32 weeks and 24% for PTB at < 28 weeks. After publication of the guidelines, reduced prevalence of PTB was observed among singletons (5.49% before vs 4.83% after, P < 0.0001), but not among infants in twin or higher-order multiple pregnancy. There was a statistically significant reduction in the rate of PTB following publication of the guidelines in both nulliparous and parous women and in the 19-39-year-old maternal-age group. Although reductions in PTB prevalence were also noted in high-risk age groups (maternal age < 19 years and ≥ 40 years), these did not reach statistical significance. Following publication of the guidelines, there was a statistically significant reduction in the prevalence of birth weight under 2500 g, of a magnitude similar to that for PTB prevalence. CONCLUSIONS: The publication of national guidelines recommending routine CL measurement at the time of the second-trimester anomaly scan was associated with a fall in PTB prevalence in singleton pregnancies. Whilst direct evidence linking screening with this fall in prevalence is lacking, it is likely that implementation of routine CL screening played an important role in the reduction of PTB rate. Our experience indicates that screening can be incorporated into the second-trimester anomaly scan. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Body mass index and infectious disease mortality in midlife in a cohort of 2.3 million adolescents.

BACKGROUND: Obesity was linked to altered immunity, but also to favorable outcomes among patients with infectious disease (ID) in some settings. We assessed the association between adolescent body mass index (BMI) and ID mortality. METHODS: BMI of 2 294 139 Israeli adolescents (60% men; age 17.4±0.3 years) was measured between 1967 and 2010. The outcome, obtained by linkage with official national records, was death due to ID as the underlying cause. Multivariable Cox proportional hazards models were applied. RESULTS: During 42 297 007 person-years of follow-up (median 18.4 years), there were 689 deaths from ID (mean age 44.1±10.5 years). Adjusted hazard ratios (HR) were 1.039 (1.011-1.068) and 1.146 (1.099-1.194) among men and women, respectively, per unit increment in BMI (P for sex interaction=4.4 × 10-5). Adjusted hazard ratios among men were 1.2 (1.0-1.5), 1.9 (1.4-2.5) and 2.5 (1.5-4.2) for those with high-normal BMI (22.0-24.9 kg m-2), overweight and obese, respectively, compared with the 18.5⩽BMI<22 kg m-2 reference group, and 1.7 (1.1-2.6), 2.6 (1.6-4.3) and 6.6 (3.3-13.1) among women, respectively. The increased risk among underweight (<18.5 kg m-2) boys was attenuated when the study sample was restricted to those with unimpaired health at baseline. A multivariable spline model indicated a minimum risk for total ID mortality at 20.7 and 18.0 kg m-2 for men and women, respectively, with significantly increased risk seen above adolescent BMI values of 23.6 and 24.0 kg m-2, respectively. The association with BMI was particularly evident for bacterial infections (predominantly sepsis), airways and central nervous system infections (63% of the ID deaths). CONCLUSIONS: Adolescent overweight and obesity were strongly associated with ID mortality, especially of bacterial origin and among women.

Completed suicide and suicide attempts in the Arab population in Israel.

Completed suicide and suicide attempts among four Arab groups defined by religious affiliation in Israel: Bedouins, Muslims (other than Bedouin), Christians and Druze were investigated using national databases of suicide (1999-2011), and suicide attempts (2004-2012). Age specific and age-adjusted rates and ratio of suicides to suicidal behavior were calculated, and compared with the total Israeli population rates. Age-adjusted suicide rates were lowest among the non-Bedouin Muslims, 2.5, followed in ascending order by Bedouins, 3.2, and Christian Arabs, 3.3 per 100,000 population, respectively. The highest rate was found among the Druze, 8.7, per 100,000 population, particularly for young males. The rates among the Arab groups were lower than for the total Israeli population, 7.9 per 100,000 population, except for the Druze. The pattern of suicide rates by gender, higher for males than females, was similar in all groups. The rates among the Arab Israelis were highest for the 15-24 year old age group, while in the total population the rates increased with age. Age-adjusted suicide attempt rates were higher amongst non-Bedouin Muslims, 84.8 per 100,000 population, followed by the Bedouin, 72.4; Druze. 64.9; and lowest among Christian Arabs, 58.6, all per 100,000 population. In the total Israeli population, the rate was even higher, 89.8 per 100,000 population. Suicide attempt rates were higher for women in all groups, except among the Druze. Rates were higher in most groups for ages 15-24. In this age group, the rates for female Muslims and Bedouins and for male Druze were higher than among the total population. Arab elderly had low rates of both suicide and suicide attempts. The ratio of suicides to suicide attempts increased with age for all groups, except for the Christian Arabs. It was markedly higher for the Druze, compared to 7.3 % for the total population for ages 15 and over. Findings highlight the importance of investigating the differential distribution of suicidal behavior by specific ethno-religious groups.

Intentional injuries among the young: presentation to emergency rooms, hospitalization, and death in Israel.

PURPOSE: To study the incidence and outcome of intentional injuries requiring emergency room (ER) care among children and adolescents in a national sample. METHOD: The population included 0- to 17-year-olds who presented to the ER for injuries in 23 hospitals over a 1-year period. A 6% to 9% random sample of days was selected in each hospital, and for each selected day the relevant ER record was reviewed for cause, nature, and outcome of injuries and sociodemographic information. RESULTS: The annual incidence for intentional injuries resulting in ER visits was 19.6 in 10,000 children and adolescents aged 0 to 17 [95% confidence interval (CI) 17.4-21.8 in 10,000]. Fights/assaults constituted 54.1% of the presentations, abuse and rape, 10.3%, and self-inflicted injuries, 10.8%. Overall rates were higher among 10- to 17 year olds than at younger ages. The rates were higher among boys than girls for fights/assaults and abuse, whereas attempted suicide and rape were three times higher among girls than boys. Nearly twice as many Jewish children and adolescents presented to the ER for intentional injuries than Arab children and adolescents, with the ratio becoming even greater for attempted suicide. Of all the intentionally injured, 21.7% were hospitalized. The mortality rate was 1.1 in 100,000 (95% CI =.7-1.7/100,00) with no significant gender difference observed. No cases of suicide were reported for the Arab population. CONCLUSIONS: Adolescents aged 10 years and older are at higher risk for intentional injuries than younger children. The ethnic differences evident in this study, especially for attempted and completed suicide, may be real or the result of differential disclosure of information owing to sociocultural norms or differential recording by health professionals.

Coronary heart disease mortality among Arab and Jewish residents of Jerusalem.

Information on coronary heart disease (CHD) in the Palestinian population is sparse. We compared mortality rates in the largely Palestinian Arab population of Jerusalem with the Jewish population of the district between 1984 and 1997 based on official Israeli statistics. CHD mortality and all-cause mortality rates were significantly higher among Arab residents than among Jewish residents aged 35-74 years. Whether the excess CHD mortality reflects increased incidence of events, higher case fatality, or both remains to be established. Possible explanations include a higher prevalence of conventional risk factors such as diabetes, obesity, and smoking in Palestinians, stress effects related to the complex political situation and socioeconomic inequalities, and suspected differences in medical care.

Determinants of hospital utilization: the content of medical inpatient care in Israel.

BACKGROUND: The increasing utilization of general internal medicine hospital wards in Israel during the last decade is a source of concern for health policy makers. OBJECTIVES: To report on the distribution of selected main and secondary diagnoses among GIM inpatients, and to estimate the proportion of disorders for which appropriate care in the community will reduce the need for hospital admissions and re-admissions. METHODS: Data from the Health Information and Computer Services of the Israel Ministry of Health (national hospitalization database) for a one year period were analyzed by distribution of diagnostic entities (ICD-9-CM) in GIM and in medical subspecialty wards. RESULTS: Of the 313,824 discharges from hospital divisions of medicine in 1995, 256,956 (81.9%) were from GIM and 56,868 (18.1%) from specialty wards. Main and secondary discharge diagnoses were available for 188,807 GIM and 35,992 specialty patients. Of all main diagnoses in GIM wards, 27% were coded as "general or systemic symptoms and signs" or as "abnormal laboratory or ill defined manifestations" (ICD-9-CM codes 780-799, 276,277), and heart diseases comprised another 27%. The remaining main diagnoses covered almost all medical conditions. The combined proportion of "ambulatory care sensitive hospital admissions" (bronchial asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, diabetes) constituted 12% of all main diagnoses in GIM, and respiratory symptoms or signs comprised another 11%. A by-product of this analysis was an insight into the experience of undergraduate medical students in GIM. CONCLUSIONS: Assuming that 12-75% of admissions for "ambulatory care sensitive disorders" are preventable, an improved review before hospital discharge and a closer outpatient follow-up may reduce the load on GIM wards by 1-17%. This wide range justifies controlled trials to determine the effect of improved community care on hospital utilization. GIM wards offer valuable learning opportunities, but they cannot be a substitute for primary care clinics. The unexplained high proportion of GIM inpatients who were discharged with an unspecified main diagnosis could be detrimental for the accuracy of hospitalization statistics, and justifies investigation by chart audits into physicians' habits of documentation.

Determinants of hospital utilization: the situation in Israel and selected countries.

BACKGROUND: In 1995 hospital costs constituted about 42% of the health expenditures in Israel. Although this proportion remained stable over the last decade, hospital discharge rates per 1,000 population increased, while hospitalization days per 1,000 population and average length of stay declined. OBJECTIVE: To gain an insight into the forces behind these changes, we compared the trends in hospital utilization in Israel with those in 21 developed countries with available data. MATERIALS AND METHODS: Our data were derived from The "Hospitals and Day Care Units, 1995" report by the Health Information and Computer Services of the Israel Ministry of Health, and the Organization for Economic Cooperation and Development Health Data, 98. We examined the numbers of acute care hospital beds, of patients on dialysis and of doctors' consultations, health expenditures and age structure of the population in 1995 or closest year with available data, as well as changes in DRs, HDs and ALOS between 1976 and 1995. RESULTS: In Israel the DRs increased from 130 in 1976 to 177 in 1995 (36%), HDs declined from 992 to 818 (18%), and ALOS declined from 7.60 to 4.51 days (41%). Relative to other countries, in 1995 Israel had the lowest ALOS; low HDs similar to those in the UK, Portugal, Spain, the USA and Sweden; and intermediate DRs similar to those in Belgium, Germany, Sweden and Australia. The number of acute care beds per 1,000 population was directly related to HDs (r = 0.954, P = 0.000) and to DRs (r = 0.419, P = 0.052). Health expenditures (% of the gross national product) correlated with the number of patients on dialysis per 1,000,000 population (r = 0.743, P = 0.000). Between 1976 and 1995, HDs and ALOS declined in most countries, however the trends in DRs varied from an increase by 119% in the UK to a decline by 29% in Canada. CONCLUSIONS AND HYPOTHESES: The increase in DRs in Israel from 1976 to 1995 was shared by many but not all countries. This variability may be related to differences in trends in local practice norms and in available hospital beds. If the number of patients on dialysis is a valid index for use of expensive treatment modalities, the correlation of health expenditures with the number of patients on dialysis suggests that the use of expensive technology is a more important determinant of health care costs than the age of the population or hospital utilization. Since the use of expensive technology is highest during the first few days in hospital, decisions about health care policy should consider the possibility that the savings incurred by a further decline in HDs and ALOS may be offset by a possible increase in per diem hospital costs and in health care expenditures after discharge from hospital.