Trends and correlated outcomes in population-level prescription opioid and transdermal fentanyl use in Israel.

BACKGROUND: In the last twenty years, there was a documented increase in prescription opioid procurement in Israel. However, there is still little evidence of the association between opioid procurement rates, health service utilisation in secondary care, and enrollment rates to substance use disorder treatment programmes. In this study, we show trends in the reports of opioid-related hospitalisations, emergency department visits, enrollment to community-based outpatient treatment for Prescription Opioid Use Disorder and opioid-related mortality rates. Additionally, we examine potential correlations between these health service utilisation rates and prescription opioid procurement rates at the population level, with a focus on transdermal fentanyl. METHODS: A longitudinal study at the population level. We used seven-year data on indicators of opioid-related morbidity, prescription opioid procurement data for 2015-2021, and six-year opioid-related mortality data for 2015-2020. We measure the correlation between procurement rates of prescription opioids in Oral Morphine Equivalent per capita, and aggregated rates obtained from hospital administrative data for hospitalisations, emergency department visits, and patient enrolment in specialised prescription opioid use disorder outpatient treatment in the community setting. RESULTS: Between 2015 and 2021, procurement rates in primary care per capita for all prescription opioids increased by 85%, while rates of transdermal fentanyl procurement increased by 162%. We found a significant positive correlation at the population level, between annual opioid procurement rates, and rates per population of opioid-related visits to emergency departments (r = 0.96, p value < 0.01, [CI 0.74-0.99]), as well as a positive correlation with the rates per population of patient enrolment in specialised prescription opioid use disorder outpatient treatment (r = 0.93, p value = 0.02, [CI 0.58-0.99]). Opioid-related mortality peaked in 2019 at 0.31 deaths per 100,000 but decreased to 0.20 deaths per 100,000 in 2020. CONCLUSION: Data shows that all-opioid and transdermal fentanyl procurement has increased yearly between 2015 and 2021. This increase is positively correlated with a growing demand for community-based Prescription Opioid Use Disorder outpatient treatment. Efforts to reduce opioid-related morbidity may require effective approaches toward appropriate prescribing, monitoring, and further increasing access to prescription opioid outpatient treatment.

Does an Overcrowded Emergency Department Reduce Moral Hazard? Lessons from Emergency Department Visits to Three Hospitals in an Israeli Metropolitan Area

Metropolitan Haifa, Israel, has three hospitals: Rambam Health Care Campus, Bnai Zion Medical Center, and Carmel Medical Center. In 2007–2014, the length of stay at RHCC’s emergency department increased, while the number of visits decreased. We ask whether the increase in LOS is associated with the falling numbers of visits to other EDs, whether an increase in LOS induces more referrals to competing hospitals in the metropolitan area, and whether it pays to be a crowded ED in mitigating moral hazard. Average LOS at Rambam climbed from 3.5 h in 2000–2007 to 6.4 in 2008–2018. While the number of visits to Rambam decreased significantly, those to Bnai Zion increased significantly and quite linearly. A one-way ANOVA test reveals a statistically significant difference among the three hospitals. In addition, Rambam was significantly different from Carmel but not from Bnai Zion. When LOS stabilized at Rambam from 2016 to 2018 and increased at Bnai Zion, referrals to Rambam went up again. Policymakers should instruct all hospitals to publish LOS data, regulate referrals to EDs, and find an optimal LOS that will reduce competition, non-urgent visits, and moral hazard.

COVID-19 and severe mental illness in Israel: testing, infection, hospitalization, mortality and vaccination rates in a countrywide study.

Previous studies on psychiatric patients infected with COVID-19 have reported a more severe course of disease and higher rates of mortality compared with the general population. This cohort study linked Israeli national databases including all individuals ever hospitalized for a psychiatric disorder (cases), and COVID-19 testing, infection, hospitalization, mortality, and vaccinations, between March 1st 2020 and March 31st 2021. Cases were 125,273 individuals aged 18 and above ever hospitalized in a psychiatric facility (ICD-10 F10-F69 or F90-F99), compared to the total population, n = 6,143,802. Compared with the total population, cases were less likely to be tested for COVID-19, 51.2% (95% CI: 50.8-51.7) vs 62.3% (95% CI 62.2-62.4) and had lower rates of confirmed COVID infection, 5.9% (95% CI: 5.8-6.1) vs 8.9% (95% CI: 8.9-8.9). Among those infected, risks for COVID-19 hospitalization, COVID-19 attributed mortality and all-cause mortality were higher for cases than the total population, adjusted odds ratios were 2.10; (95% CI: 1.96-2.25), 1.76; (95% CI: 1.54-2.01) and 2.02; (95% CI: 1.80-2.28), respectively. These risks were even higher for cases with non-affective psychotic disorders and bipolar disorder. Age adjusted rates of vaccination were lower in cases, 60.4% (95% CI: 59.9-60.8) vs 74.9% (95% CI: 74.8-75.0) in the total population, and particularly low for cases with non-affective psychotic disorders, 56.9% (95% CI: 56.3-57.6). This study highlights the need to increase testing for COVID-19 in individuals ever hospitalized for a psychiatric disorder, closely monitor those found positive, and to reach out to encourage vaccination.

The effect of the COVID-19 pandemic on non-COVID respiratory ED visits in Israel.

BACKGROUND: The COVID 19 pandemic has had a crucial effect on the patterns of disease and treatment in the healthcare system. This study examines the effect of the COVID-19 pandemic on respiratory ED visits and admissions broken down by age group and respiratory diagnostic category. METHODS: Data on non-COVID related ED visits and hospitalizations from the ED were obtained in a retrospective analysis for 29 acute care hospitals, covering 98% of ED beds in Israel, and analyzed by 5 age groups: under one-year-old, 1-17, 18-44, 45-74 and 75 and over. Diagnoses were classified into three categories: Upper respiratory tract infections (URTI), pneumonia, and COPD or asthma. Data were collected for the whole of 2020, and compared for each month to the average number of cases in the three pre-COVID years (2017-2019). RESULTS: In 2020 compared to 2017-2019, there was a decrease of 34% in non-COVID ED visits due to URTI, 40% for pneumonia and a 35% decrease for COPD and asthma. Reductions occurred in most age groups, but were most marked among infants under a year, during and following lockdowns, with an 80% reduction. Patients over 75 years old displayed a marked drop in URTI visits. Pediatric asthma visits fell during lockdowns, but spiked when restrictions were lifted, accompanied by a higher proportion admitted. The percent of admissions from the ED visits remained mostly stable for pneumonia; the percent of young adults admitted with URTI decreased significantly from March to October. CONCLUSIONS: Changing patterns of ED use were probably due to a combination of a reduced rate of viral diseases, availability of additional virtual services, and avoidance of exposure to the ED environment. Improved hygiene measures during peaks of respiratory infections could be implemented in future to reduce respiratory morbidity; and continued provision of remote health services may reduce overuse of ED services for mild cases.

Excess mortality during the COVID-19 pandemic in Israel, March-November 2020: when, where, and for whom?

BACKGROUND: Excess all-cause mortality has been used in many countries as an estimate of mortality effects from COVID-19. What was the excess mortality in Israel in 2020 and when, where and for whom was this excess? METHODS: Mortality rates between March to November 2020 for various demographic groups, cities, month and week were compared with the average rate during 2017-2019 for the same groups or periods. RESULTS: Total mortality rates for March-November were significantly higher by 6% in 2020, than the average of 2017-2019, 14% higher among the Arab population and 5% among Jews and Others. Significantly higher monthly mortality rates were found in August, September and October by 11%, 13% and 19%, respectively, among Jews and Others, and by 19%, 64% and 40% in the Arab population. Excess mortality was significant only at older ages, 7% higher rates at ages 65-74 and 75-84 and 8% at ages 85 and above, and greater for males than females in all ages and population groups. Interestingly, mortality rates decreased significantly among the younger population aged under 25. The cities with most significant excess mortality were Ramla (25% higher), Bene Beraq (24%), Bat Yam (15%) and Jerusalem (8%). CONCLUSION: Israel has seen significant excess mortality in August-October 2020, particularly in the Arab sector. The excess mortality in March-November was statistically significant only at older ages, over 65. It is very important to protect this susceptible population from exposure and prioritize them for inoculations. Lockdowns were successful in lowering the excess mortality. The excess mortality is similar to official data on COVID-19 deaths.