This study analyzed both 2012 rates and 2002–2012 trends, for Israel as a whole and for its seven districts. For all of the services examined in this study, the 2012 rates were significantly different between the districts. The smallest differences between districts in 2012 were recorded for hysterectomies, with a rate ratio of 1.3, and the highest rate ratio was for CABG, with a rate ratio of 2.0.
Geographic variation in medical practice styles reflect not only differences in patient needs but might be due variations in practice of medicine, in resource allocation and in equal access to services. These unwarranted variations need to be addressed by countries who wish to improve healthcare performances. As the Darmoth project stats unwarranted variation in the practice of medicine and the use of medical resources are the inappropriate use of medical resources are the basis of ineffective care and must be addressed.1 This paper focuses on geographic variations in Israel so to learn and improve policy making. Usually, these unwarranted variations in the practice of medicine and the use of medical resources are being analyzed through several main general causes, among them: disease patterns among districts, degree of agreement between providers and supply-side factors, underuse of effective care, misuse of preference-sensitive care and overuse of supply-sensitive care. In order to provide a systemic approach for the policy makers in Israel, this paper will analyze the results via some of these methods.
With regard to the trends over time, at the national level, the study found a significant increase in knee replacement surgery, and significant declines in hip fracture repair surgery and hysterectomy. A decline in medical admissions was observed as well among all the seven regional trends. However, despite this decline there is still a consistent and clear gap between central and peripheral regions, reflecting the highest medical admission rate in the periphery and the lowest in the center of country.
In this section, we first consider possible explanations for the 2012 inter-regional differences and then consider possible explanations for the difference in trends across regions and services. We also discuss the extent to which the Israeli patterns and trends are similar to those found in other countries.
Possible explanations for the inter-regional differences
Some of the inter-regional differences in 2012 rates may be related to uneven access to care as well as differences in socioeconomic and health status between the regions. Although these differences had never been published through geographical areas, they were studied and published by the Ministry Of Health report on 2013 through socioeconomic perspectives.
3 Apparently, this Ministry of health 2013 report, demonstrated a significant difference both in obesity, smoking and in ischemic heart disease and had shown that low socioeconomic status have a direct linkage to these three risk factors and diseases. The extent to which rates, for particular procedures, vary across regions may also be related to the extent to which the relevant medical conditions can be prevented or controlled non-surgically. However, there isn’t any established explanation to the scale of all the variations in the different procedures. In the following paragraphs, we shall discuss the 5 procedures with the highest and lowest variations, by examining them systematically from three perspectives:
A) The disease patterns among districts B) The degree of agreement between providers C) The supply-side factors.
In addition, we shall discuss, when it is relevant, the results from additional perspectives: failure to provide effective care, failure to provide preference sensitive care, and overuse of supply sensitive care.
PTCA: The procedure which holds the highest variation with rate ratios of 1.98, in 2012, between the highest and lowest regional rate, is highest in the periphery (the northern and southern districts). Regarding the disease patterns, there is a direct correlation between ischemic heart diseases and the cardiovascular risk factors that are the highest in low socioeconomic status as mentioned earlier. Therefore, these differences are expected and will not change dramatically until there will be a reduction in smoking and obesity rates in the periphery. However, the high rates of CABG in the periphery could not be explained through the arguments of “degree of agreement” and “supply-side factors. This assumption derives from the fact that, the northern district, doesn”t hold a cardiac surgery unit, and the southern district holds only one.
This major variation correlates also to the underuse of effective care, as preventive medicine and glycemic control and also correlates to the Misuse of preference-sensitive care, in this case, cardiac catheterization (although the last one had increased dramatically in the last years).
Knee replacements, a procedure which holds the second highest variation with rate ratios of 1.78, in 2012, between the highest and lowest regional rate, is highest in the periphery. Regarding the disease patterns, this can be attributed to both the high rate of obesity and the lack of proper prevention in the periphery, which can be reduced by good obesity control and osteoarthritis treatment. Regarding the argument of “degree of agreement” there isn’t a clear indication for knee replacement, which can imply for an over use to this surgery in the periphery. Regarding “supply-side factors”, it is unreasonable that this is one of the reasons since most of the hospitals in the center of Israel hold several advances units, which specialized in knee replacement, where these units in the periphery are less developed.
This variation correlates also to the misuse of preference-sensitive care, in this case, conservative therapy such as physical therapy and weight loss.
The third procedure with the highest variation is cesarean section with rate ratios of 1.68, in 2012, between the highest (The city of Haifa) and lowest regional rate (The city of Jerusalem). This low rate in Jerusalem can be attributed to demographical and cultural reasons: In Jerusalem, which holds the lowest rates, the population is religious and therefore avoid Cesarean Section in order to reach high number of labors. In Chifa, which holds the highest rates, the population is secular with low rates of labors per capita.
This variation correlates also to the misuse of preference-sensitive care, in this case, a regular labor, and also overuse of supply sensitive care, since cesarean section is considered to be a convenient solution in difficult labors.
Hysterectomy, this procedure holds the lowest variation with rate ratios of 1.31, in 2012, between the highest and lowest regional rate.
Regarding the disease patterns, there are not preventable risk factors for the clinical statues that cause the need for this procedure. This fact minimizes the gaps between the periphery and the center of Israel in the usage of this procedure and implies on the importance of gaining equality, not only in treatment, but also in preventive medicine. Regarding the arguments of “degree of agreement”, there is not always clear indication for this procedure but there are still several common well established indications for the procedure. As for “supply-side factors”, there isn’t any specific uniqueness regarding the tariff or pricing method of this procedure. Therefore, the fact that the risk factors are uniform nationally could be a proper explanation to the low variation.
The second procedure with a relatively low variation is surgery after hip fracture, with rate ratios of 1.44, in 2012, between the highest (The city of Tel-Aviv) and lowest regional rate (The city of Chifa). This fracture is common especially in old people and females. Regarding the disease patterns, there are clear preventable risk factors for a hip fracture, among them preventing and treating osteoporosis. However, after stratifying the population to age and gender, there is no clear correlation in this aspect, since the highest rates are not in the periphery. Regarding the argument of “degree of agreement” there is a clear indication for surgery after hip fracture5, which can well explain the low rate of variation. As for “supply-side factors”, this relatively low variation could be explained by close control of the ministry of health on hospital. This control aims to measure the delivery of this surgery in 48 h for patients who were admitted to hospital with a hip fracture. The outcomes of this control are reflected both on a national publication of the results and also in a differential Tariff for hospitals which operating this patients in less than 48 h after admission. It is suggested that this policy, had led all hospitals to acquire similar guide lines and protocols for treating patients with this diagnosis.
Following these results and analysis, it is clear that the appropriate community medicine, before reaching hospital, is crucial for reducing variations between different regions, especially between the periphery and the center. Hence, it is not surprising that a 2010 study had revealed significant gaps in the availability of secondary community-based medical services, with relative shortages in the periphery for internal medicine, surgery and various sub-specialties [
10]. This is consistent also with another finding of our research, which demonstrates higher rates of medical admissions in the periphery (with rate ratios of 1.34, in 2012, between the highest and lowest regional rate). The problematic availability of secondary community medical services in the periphery may have contributed to the transfer of activities from the community to hospitals, increasing the rate of hospital admissions. Interestingly, a related study found that gaps between the periphery and the center were also found in death rates [
11].
Possible explanations for the trends over time through local and international perspective
Generally speaking, the trends in health care activities and procedure rates at the national level in Israel over the past ten years have been similar to those observed in many other OECD countries.
Comparing trends in procedures and hospitalizations over the years 2001–2012 reveals that Israel has in most cases the same trends as the other countries that were measured in this study [
9]. There has been a general reduction in hospital medical admissions, in surgery after hip fracture and in hysterectomy rates. There has been a substantial increase in knee replacement and caesarean section rates. These findings are mostly relevant to the procedures with clear positive or negative trends and could be explained by the same reasons: The most significant increase was observed in knee joint replacement surgery, with an increase of more than half. This extremely positive trend could be easily explained by the fact that widespread usage of this technology is quite new. The second most positive trend is for caesarean sections, which could be attributed to the expanding demand from patients for this procedure, and the expanding phenomenon of defensive medicine. The decline in hysterectomy could be attributed to the relatively clear guidelines and indications for this procedure. The decline in medical admission rates could be mostly attributed to the improvement of medical services in the community, an improved prevention and more accurate reporting policy.
The only procedure for which Israel (along with Italy) doesn’t converge to the general international trend is PTCA [
11]. This phenomenon may be related to the fact that, in the early 2000’s, Israel used to have a very high rates relatively (Maximum of 401/100,000 population in 2003), which at that time was one of the highest rates in the OECD countries. Subsequently, this rate gradually converged to the prevailing international levels (293/100,000 population in 2011). As for an explanation to this relative high rates, especially in the early 2000’s but also later, one option could be attributed to the fact the tariff of PTCA was relatively very high In Israel, and therefore could have led to a high availability and performance via the mechanism Of supply induced demand. Only lately, (July 2013) the tariff had declined, but it is still relatively high, such as the rates of this procedure in Israel.
The trends regarding cardiac care procedures are mixed and difficult to interpret. On the one hand, as in many other OECD countries, there has been a sharp decline in CABG rates in Israel, as a higher share of people with ischemic heart disease were treated with less invasive procedures. These interventions where based on cardiac catheterization and aggressive preventive treatments which included both secondary prevention and primary, both in hyperlipidemia, pre-diabetes and diabetes, and after first coronary event.
On the other hand, the national standardized rate of coronary angioplasty (PTCA) also decreased between 2000 and 2011, which is not consistent with the trend observed in most other OECD countries.