The study was conducted by the Israel National Institute for Health Policy Research, based on data received from the country’s four health maintenance organizations—Clalit, Maccabi, Meuhedet and Leumit. The information is transferred anonymously from patients’ medical file for research purposes, so that unlike surveys and other studies based on partial samples and questionnaires, this report is based on real information.
Smoking is a risk factor which considerably raises the chance of cancer. Some studies have found that smoking is responsible for about one-quarter of all cases of cancer in the world. In Israel, 40 percent of the diagnosed cases of cancer are smoking-related.
Although there has been plenty of evidence in the past 50 years concerning the negative health effects of smoking, about one fifth of the adult population in Israel still smokes. The past few years have recorded a certain drop in the number of smokers. The smoking rate among people aged 16 to 74 decreased in the past five years from 21.1 percent in 2011 to 19.3 percent in 2015. The percentage of female smokers was 2.1 times lower than the percentage of male smokers—while 26.9 percent of men smoke, only 12.6 percent of women are smokers.
While many Israeli continue to smoke, there is also room for optimism. Among the 16-24 age group there is a lower smoking rate (10.8 percent) than among older age groups, although it’s always possible that young people lie to their family physicians, who may be treating their parents as well.
“In general, we are seeing a decline in the smoking rate in Israel,” says Prof. Orly Manor of the School of Public Health at the Hebrew University of Jerusalem and Hadassah and chairwoman of the board of the Israel National Institute for Health Policy Research. “Every drop of 1 percent is a success. When we manage to reduce the rate of smokers we save lives. It’s very important for a family physician to examine and ask his patient whether or not he smokes. We know for certain that such a conversation increases his chances of quitting.”
All HMOs offer smoking cessation programs and support groups in order to reduce the number of smokers, and the results can apparently be seen in the data.
“We know that the tobacco tax increase, which leads to an increase in the price of cigarette packs, influences people and mainly teenagers to stop smoking, which is why we see a lower number of young smokers,” says Liora Valinsky, director of clinical quality at Meuhedet Health Services. “In addition, we must remember that smoking is a social phenomenon, and so the ban on smoking in public places significantly reduces the smoking rate.”
The HMOs encourage family physicians to explain the risks of smoking to their patients out of their knowledge of each patient’s specific profile. “The doctor does it in a tailor-made way and tries not to nag,” Valinsky explains. “To a young woman, for example, he will explain about the risks of smoking during pregnancy, to diabetic patients he will explain about the meaning of imbalance following smoking, and to a young man before military service he will explain about the harm it causes his physical fitness.”
Obesity causes significant morbidity among all age groups and was already defined 20 years ago as a disease by the World Health Organization. Obesity is related to most of the common medical problems in the Western society, including type 2 diabetes, hypertension, many types of cancer, heart diseases and heart failure—diseases which generate high costs of treatment.
Only recently, prestigious medical journal The Lancet published a study which found that the only place in the world where life expectancy is not expected to grow is the United States, where researchers estimate that the population’s obesity will actually lead to a drop in life expectancy.
The obesity rate among Israeli adults (aged 20 to 74) has remained stable in the past three years at 24.1percent. The obesity rate is higher among women (25.3 percent) than among men (227 percent). According to the findings, the obesity rate increases with age, so it was the highest among the 65-74 age group at 33.8 percent.
The overweight rate—one level lower than obesity, which is considered a warning sign—has also remained stable among adults in the past three years at 34.2 percent. The rate was lower among women (28.9 percent) than among men (40.4 percent). The overweight rate increases with age as well, reaching 40.1 percent in the 55-64 age group.
“Israel is at pretty high spot when it comes to obesity and overweight,” says Prof. Manor. “The Health Ministry recently started eradicating this phenomenon, with a plan to label products and prevent the sale of unhealthy food in schools. I would like to believe that this activity will lead to an improvement in the situation, and I hope that in two or three years from now we will see a drop in obesity and overweight rates.”
“The figures we see in the quality measures are very serious,” adds Valinsky. “In order to deal with the obesity phenomenon, we use dieticians who not only provide a menu but also work on behavioral changes with the patients for several months, and now we also have support groups who encourage physical activity. Obesity is a phenomenon which we must destroy.”
Dr. Einat Elran, director of quality management at the Maccabi Health Services’ Health Division, says there are different needs in the communities which deal with this phenomenon. “We focus on special populations, such as poor families, where there is a higher overweight rate. We encourage them to exercise and to consume low-calorie food and offer them special care programs.”
Breast cancer is the most common malignant disease among women in Israel. Its morbidity rate is about 30 percent of the incidence of all types of cancer among women. The relative survival rates of women with cancer have improved in recent years, and this improvement is partly ascribed to an early detection of the disease.
The health system invests a lot of resources in performing the mammography test as a tool for early detection of breast cancer in women at an average risk, and funds the test for women over the age of 50 once every two years. The mammography uptake for early detection of breast cancer among women aged 51-74 has increased in the past five years, from 66.8 percent in 2011 to 70.8 percent in 2015. The uptake rate reaches 73.7 percent among women aged 65-69, and 67.1 percent among women aged 70-74.
“In Israel, there is an initiated program for performing a mammography test,” says Prof. Manor. “Women receive a letter which is sent to their homes, calling on them to take the test free of charge. But I believe that the fact that the HMOs have to report the number of patients who took the test also motivates and encourages them to make sure that more and more women take these tests.”
In recent years, in light of the findings, the HMOs and other organizations have decided to raise women’s awareness to the test. “We saw that there is less awareness to this issue in the Arab sector,” says Prof. Manor. “So Mammography mobile units were sent to Arab villages and communities, and Arabic-speaking staff members were trained to raise awareness in this sector.”
Will we see in the next report another increase in the number of women taking the test? According to Valinsky, probably not. “I believe we won’t see a rise in the number of women receiving mammography screening. We approach the patients through letters and phone calls. A woman who hasn’t taken the test yet is usually a woman who is actively against taking the test rather than someone who is unaware of it.”
Colorectal cancer is the second most common malignant tumor among women and men in Israel and the second leading cause of cancer-related death in the country. Some 3,150 new cases are diagnosed every year. The survival rate of colorectal cancer patients has to do with the stage of the disease at the time of its detection. A tumor that is diagnosed at the initial stages can be completely cured. Colorectal cancer usually originates in a benign tumor, which slowly progresses and develops for years into a malignant tumor. The slow development makes it possible to detect the disease in its early stages, when its natural course can still be changed.
The Health Ministry recommends that Israelis with a normal risk of colorectal cancer perform an occult blood test once a year from age 50 to 74, as well as a colonoscopy—an optic test which provides a direct observation of the intestine. The uptake of colorectal cancer screening among Israelis aged 50 to 74 has gone up in the past 12 years from 11.5 percent in 2003 to 59.1 percent in 2015. Women take the test more than men (60.4 percent compared to 57.7 percent), and the number of patients willing to take the test increases with age, starting from 49.2 percent in the 50-54 age group to 66.3 percent in the 70-74 age group.
Cervical cancer is the fourth most common cancer in women worldwide, and the most common risk factor is the human papillomavirus (HPV). In the early stages of the disease, there are usually no symptoms. In 2012, about 528,000 women in the world were diagnosed with cervical cancer, and around 250,000 women died from the disease. Unlike other Western countries, Israel has not recorded a drop in the cervical cancer cases in recent years. Every year, about 200 women are diagnosed with the disease in Israel and about 80 women die from it. The Health Ministry recommends a Pap smear screening from women aged 25-65 every three years.
“Less than half the women take the cervical cancer screening tests, and these are alarming figures,” says Prof. Manor. “More efforts must be put into increasing the number of women from a low socioeconomic status who take these tests.”
The uptake of cervical cancer screenings was 1.7 times lower among women from a low socioeconomic status (23 percent) compared to their percentage in the general population (38.8 percent).
“Many times, we see that people who live in the periphery or in areas of a low socioeconomic status find it difficult to come and take the screening tests,” says Dr. Elran. “Some have to take three buses in order to reach the institute where the test is performed, and they don’t have a private car. In the past few years we have begun narrowing these gaps, but there is still a lot that needs to be done in this area.”
Influenza, unlike a cold or a runny nose, can be a serious and even fatal disease. Seasonal flu is considered the leading cause of death from a disease that can be prevented by a vaccination. Every year, one billion people around the world get the flu, and half a million of them die. Global research which examined the efficiency of flu vaccines in preventing hospitalizations due to pneumonia and long-term flu among adults, found that the vaccination is clearly linked to a 27 percent drop in the risk of hospitalization due to the flu or pneumonia. The Health Ministry recommends that every person from the age of 65 receive a flu vaccination.
The report reveals that the flu vaccination coverage among people over the age of 65 increased in the past five years from 58.7 percent in 2011 to 63.2 percent in 2015. The vaccination coverage was lower among women (61.4 percent) than among men (65.6 percent), but no significant differences were found between people from a low socioeconomic status and those who come from a strong economic background. The flu vaccination coverage was higher among people aged 75 and up than among the 65-74 age group.
‘An improvement in almost all trends’
The National Quality Measures Program began in 2000 as a research project of a team of researchers from Ben-Gurion University. In light of its success, the project was adopted by the Health Ministry and turned in 2004 into a regular national program, led by the National Institute for Health Policy Research and funded by the Health Council.
In 2008, the management of the program was turned over to the staff members of the School of Public Health at the Hebrew University of Jerusalem and Hadassah, led by Prof. Orly Manor.
“In the world, it’s customary to conduct programs in order to measure the quality of medicine,” says Prof. Manor. “It’s common in developed countries like the United States, Britain and Australia. Only recently, the OECD paid us a visit and examined the Israeli quality measures program, and found that it is one of the best programs in the world. We must also remember that it’s not a survey, but rather real date recorded in patients’ medical files.”
Th full program includes dozens of measures, which examine morbidity, preliminary tests and a healthy lifestyle.
“The program’s success is primarily thanks to the family physicians who measure and examine the patients. We see an improvement in almost all trends every year,” Prof. Manor says. “Every HMO draws lessons based on the findings and improves the quality of the treatment. Patients gain from the results of this research, there’s no doubt about it.”
How is that reflected?
“If the HMO knows how many of its patients undergo colorectal cancer screening, it builds a plan aimed at encouraging more people to take the tests, thereby reducing the number of patients. That’s wonderful. When the number of smokers is recorded and monitored, it can launch prevention activities, thereby reducing the number of smokers,” says Prof. Manor.
“As far as we’re concerned, this program is like a spotlight lighting up places in need of improvement. At the end of the day, every HMO doctor receives a situation report on his patients and should learn from it and improve,” Dr. Elran concludes.