Journal of Evaluation in Clinical Practice ISSN 1365-2753

Managing the increasing shortage of acute care hospital beds in Israel Chanan Meydan BScMed,1 Ziona Haklai MA,2 Barak Gordon MD MHA,3,4 Joseph Mendlovic MD MHA5,6 and Arnon Afek MD MHA7,8 1 Physician, Tel Hashomer Medical Center, Ramat Gan, Israel 2Researcher and Manager, Health Information Division, Ministry of Health, Jerusalem, Israel 3Researcher, Medical Corps, Israeli Defense Forces, Ramat Gan, Israel 4Researcher, Sackler Faculty of Medicine, Tel Aviv University, Israel 5Researcher, Health Administration, Ministry of Health, Jerusalem, Israel 6Physician, Shaare Zedek Medical Center, Jerusalem, Israel 7General Manager, Ministry of Health, Jerusalem, Israel 8Head of New York Program, Sackler Faculty of Medicine, Tel Aviv University, Israel

Keywords health policy, public health Correspondence Mr Chanan Meydan Sackler Faculty of Medicine Tel Aviv University PO Box 39040 Tel Aviv 6997801 Israel E-mail: [email protected] Accepted for publication: 14 August 2014 doi:10.1111/jep.12246

Abstract Rationale, aims and objectives Israel’s healthcare system has been facing increasing hospital bed shortage over the last few decades. Community-based services and shortening length of stay have helped to ease this problem, but hospitals continue to suffer from serious overload and saturation. The objective of this study is to present hospitalization trends in Israel’s internal medicine departments. Methods The data is based on the National Hospital Discharges database (NHDR) in the Israeli Health Ministry, pertaining to hospitalizations in all internal medicine departments nationwide between 2000 and 2012. Results Total yearly hospitalization days, representing healthcare burden, had increased by 4.2% during the study period, driven mainly by the most advanced age groups. The rate of total hospitalization days per 100,000 people for all the age groups has decreased by 17.6%, but the oldest patient group had a modest reduction in comparison (7.5%). The parameter of age correlated with length of stay and readmission rates, and neither decreased during the surveyed years. Conclusions These results demonstrated that the healthcare burden on acute internal medicine services has been reduced mostly for middle-aged populations but only modestly for elderly populations. The length of hospital stay and the readmission rates have reached and maintained a plateau in recent years, regardless of age. The findings of this study call for planning specific to elderly populations in light of changing demographics. Possible directions may include renewed emphasis on internal medicine and geriatric medicine, and efforts to shorten hospitalization time by extended utilization of multidisciplinary primary care.

Introduction Touted as having ‘one of the most enviable healthcare services among OECD countries’ [1], Israel at the beginning of the 21st century boasts a capable, efficient and modern health care system. Although health care costs are rapidly rising in industrialized countries, Israel’s health expenditure growth is less than half the average of Organization for Economic Cooperation and Development (OECD) countries, reaching 7.9% of its gross domestic product in 2009 (the eighth lowest in the OECD) [1,2]. In 2009, the life expectancy for Israeli men and women at birth was 79.6 and 83.3 years, respectively, compared with the OECD average of 76.7

and 82.35 years [3]. This impressive achievement may be partly attributable to the systematic shift towards community-based health services provided by Israel’s four health maintenance organizations (HMOs), which are nationally funded (with co-payments by patients). Legislation introduced and enacted in 1995 ensured universal coverage for Israeli residents. Clinics and physicians in the community are encouraged to work in professional teams, and they are measured for performance indicators. Community health care is provided in larger, better-funded clinics relative to other countries [1]. The resulting strong community health services allow outpatient management of chronic morbidities, such as diabetes mellitus, for which Israel, with a similar

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prevalence as OECD average, has the second lowest admission rate among the OECD countries [1]. Further strengths include monitoring of drug utilization by patients, robust prevention programmes for cancer and infections via immunization [1], and a national quality measurement programme [4]. At the same time, it is noteworthy that more and more Israelis choose to extend their health coverage even further by purchasing complementary health insurance from HMOs or by out-of-pocket services from private health care providers [1]. Israel’s for-profit health organizations have sustained the largest growth in per capita spending during the last decade, alongside increased expenditure by the government and the HMOs [2]. The emphasis on primary care pays dividends when considering the effect on inpatient services. As Israel’s population continues to grow, so does the number of hospitalizations in acute care hospitals, with correlating trajectories [5]. Moreover, the population has been outgrowing hospitalization numbers, with bed occupancy in 93–98% in recent years [5,6]. The hospital bed per capita rate for all acute care beds has gradually decreased from 2.68 in 1988 to 1.89 in 2012 [7] (Fig. 1). In this respect, primary care presently succeeds as a buffer gatekeeper for inpatient services, improving overcrowding in departments and reducing system-wide hospitalization costs. The emphasis on outpatient care resulted in Israel’s low length of inpatient stay, which was an average of 4.5 days in 2009 compared with the OECD average of 8.2 days [8]. The current study’s objective is to study nationwide trends in hospitalization practices in Israeli internal medicine departments, with age as a main differentiating factor. We focused on internal medicine departments as they arguably reflect interfaces between inpatient and outpatient care, where adequate primary management of chronic diseases (i.e. asthma, heart failure and diabetes) obviates hospitalization. We describe the mechanisms that are implemented to cope with low bed vacancy and overcrowding, two of the most ubiquitous challenges in contemporary internal medicine departments. Finally, we propose ideas for future planning in an era of constricting inpatient resources and changing demographics.

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Methods Study design and data acquisition The study is based on the National Hospital Discharge Register (NHDR) in the Israeli Health Ministry. It includes 133 internal medicine departments in 28 medical centres (secondary and tertiary hospitals) in Israel. There were a total of 3697 inpatient beds, yielding an average of 27.8 beds per department. The data were distributed from the medical centres to the NHDR, which is managed by the Israeli Ministry of Health. Reporting is mandated by Israeli legislation, thus creating a complete database on all internal medicine departments throughout the country. These data were used retrospectively for this study without any direct involvement by the wards. The data pertain to the period between 1 January 2000 and 31 December 2012.

Ethics approval No ethics approval was required as the study did not involve data collection from patients, clinical trials or animal studies.

Results The total number of admissions increased from 283 800 in 2000 to 284 300 in 2012 (Table 1). The trend for total admissions varied according to age groups, with a gradual increase of 49.7% being recorded for patients ≥85 years of age. The absolute admission numbers gradually decreased for populations aged 65–74 years (by 20.5%) and 15–54 years (by 12.2%). The age differential was also reflected in admission rates per 100 000 people (Table 1). There were modest decreases for patients aged ≥75 years (between 10 and 18%), and much greater reductions for those aged 55–74 years (between 36.9 and 39.1%). Table 1 and Fig. 2a display yearly hospitalization days (including readmissions) throughout the study period. The number of days for the population aged ≥75 years gradually increased by

Figure 1 Acute care bed rate in Israel, 1975– 2012. Data from Ministry of Health, Israel [6].


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Table 1 Admissions, readmissions and yearly hospitalization days in internal medicine departments in Israel (1 January 2000 to 31 December 2012) Age, years Total admissions (per 100 000 people)

Readmission rate 1 month from discharge Total yearly hospitalization days (per 100 000 people)

All ages 15–44 45–54 55–64 65–74 75–84 85+ All ages 15–44 45–64 65–74 75+ All ages 15–44 45–54 55–64 65–74 75–84 85+






283.8 (63.2) 41.6 (15.1) 32.8 (46.7) 41.8 (100.2) 69.2 (200.5) 66.3 (323.3) 32.0 (489.7) 19.40% 11.10% 16.90% 21.50% 22.70% 1285.2 (286.2) 132.7 (48.2) 119.2 (169.5) 178.1 (426.6) 331.1 (960.1) 348.2 (1698.1) 175.8 (2690.1)

294.9 (59.4) 40.4 (13.5) 33.8 (45.0) 44.0 (82.0) 63.8 (171.5) 76.9 (312.3) 36.1 (521.3) 19.10% 10.80% 16.30% 20.40% 22.60% 1312.2 (264.2) 126.5 (42.3) 119.8 (159.5) 174.2 (324.6) 299.0 (803.7) 396.3 (1610.2) 196.4 (2834.6)

305.4 (55.6) 41.8 (12.9) 31.1 (39.6) 49.5 (70.4) 58.7 (149.2) 76.6 (296.0) 47.7 (476.6) 19.80% 10.90% 17.20% 20.80% 23.20% 1297.9 (236.4) 128 (39.4) 104.4 (132.9) 186.8 (265.9) 253.0 (643.2) 374.2 (1445.3) 251.5 (2512.6)

287.2 (51.4) 39.0 (11.9) 28.4 (35.8) 46.6 (64.8) 55.0 (133.4) 71.6 (269.5) 46.6 (440.8) 19.20% 9.80% 16.70% 20.30% 22.60% 1300.5 (232.9) 123.3 (37.5) 101.0 (127.3) 188.3 (262.0) 253.0 (613.7) 376.5 (1416.5) 258.5 (2443.1)

284.3 (50.0) 37.6 (11.2) 27.7 (34.7) 44.1 (61.0) 55.0 (126.4) 72.0 (265.9) 47.9 (442.2) 19.40% 10.20% 16.60% 20.60% 22.80% 1339.5 (235.7) 122.6 (36.6) 102.7 (128.5) 192.4 (266) 260.6 (598.9) 391.4 (1446.0) 269.8 (2488.6)

Absolute numbers and rates per 100 000 people are shown.

26.2%, and that for patients aged ≥85 years increased by 53%. The rate of yearly hospitalization days per 100 000 people went down for all age groups (Table 1; Fig. 2b): the reduction was smallest for the population aged >85 years and greatest for the population aged between 55 and 74 years. The average length of stay for each hospitalization in 2012 varied according to age, ranging from 3.3 days for patients aged 15–44 years to 5.6 days for patients aged ≥85 years (Fig. 3). These rates remained stable throughout the survey (data not shown). The cumulative inpatient days per year for patients, including re-admissions, increased according to age in 2012, ranging from 4.0 days for the group aged 15–44 years to 9.0 days for the group age ≥85 years. Readmission rates also increased according to age and remained stable throughout the survey (Table 1).

Discussion The dataset provided in this study presents an overview of hospitalizations in internal medicine wards in Israel. Examination of the data identified a number of trends from 2000 to 2012. The health care burden on internal medicine departments, represented by yearly total hospitalization days, increased by a modest 4.2%. The population largely responsible for this increase was in the age group of ≥75 years, especially those aged ≥85 years (Figs 2a & b; Table 1). The burden on health care in internal medicine departments was reduced for all other ages throughout the study period. Two conclusions may be drawn from the results of the current study, which showed that Israeli health care establishment has thus far managed to minimize the impact of population growth on internal medicine resources. First, the Israeli health care system’s substantial development in community-based services has succeeded in buffering hospitals from overload. Internal medicine departments have the greatest opportunity to benefit from robust

© 2014 John Wiley & Sons, Ltd.

primary care, as chronic diseases, such as heart failure, pulmonary diseases and diabetes, are being increasingly managed in outpatient settings. There has also been some rerouting of patients within inpatient services, from internal medicine departments to specialized health care units. For example, 58% of patients with cerebrovascular accidents as primary diagnosis were admitted to internal departments in 2000, with 35% being admitted to neurological, vascular or intensive care units: by 2012, this changed to 45 and 50%, respectively. Similarly, 60% of patients with myocardial infarct were admitted to internal departments in 2000, compared with only 35% in 2012 [9]. The second observation is that age is an increasingly important differentiating factor in the burden on internal medicine departments. Even though population growth is evident across all ages, it is especially apparent among older populations (≥75 years). Furthermore, age does not correlate with health care burden in a linear fashion: the 55–74-year age group had the greatest reduction in the yearly rate of hospitalization days (Fig. 2b). Although the current health care system can be considered as having taken great strides, especially with regard to middle-aged populations, older populations have not benefited to the same extent. As the portion of older people increases in the general population, it offsets reductions in health care burden achieved in younger age groups. Possible explanations for this may include substantially longer length of hospital stay; greater prevalence of multiple co-morbidities, complicating both outpatient and inpatient treatment; and psychosocial circumstances associated with older age. The results of the current study should be viewed with respect to the underlying Israeli health care doctrine, which is the product of tightly regulated national health care expenditure. It involves the attempt to shift the provision of health care from inpatient to outpatient services, as primary care is considered as being more cost-effective. At the same time, outpatient management is benefi81

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15–54 years

55–74 years

≥75 years


All ages

15–54 years

55–74 years

cial to the population with respect to nosocomial infection control, avoiding the psychosocial impact of hospitalization, and continuing the patient–caregiver therapeutic alliance and follow-up. Under these policies, the length of stay in acute care hospitals progressively decreased throughout the 1980s and 1990s, and stabilized during the 2000s (Fig. 4) on low values relative to the OECD [7]. Decreasing the length of hospital stay may have exhausted itself as a main goal for acute care, and new strategies are called for which should account for changing demographics with a burgeoning elderly population [10]. In light of the current study findings, it would appear that the health system as a whole (with its outpatient and inpatient arms) is better geared towards young and middle-aged populations, with recent improvement for the latter (Figs 2a & b). Israel’s elderly are expected to grow both in absolute numbers and in their share of the entire population in forthcoming years [10–12]. Thus, health care for the elderly population is an emerging challenge that requires 82

≥75 years

Figure 2 (a) Yearly hospitalization days according to patient age. (+) indicates increased. (−) indicates decreased. (b) Change in rate of hospitalization days per 100 000 people.

adaptation both from primary care and inpatient resources. As elder populations increase in size in many parts of the world [13], the challenge presented in this study has global significance. In this respect, Israel’s shortage of hospital beds precedes similar situations elsewhere, with an average current occupancy of 96 versus 76% for the OECD countries [1]. Continued monitoring of Israel’s community health care and inpatient services may serve as a test bed for other OECD countries in planning for changing demographics in the forthcoming years.

Conclusions and recommendations The burden of health care on internal medicine departments has increased only modestly in recent years, but this rise has been driven mainly by the care of older populations, which have become greater in size and demand more management services. In our opinion, the health care system would benefit from targeting the

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15–44 years 45–54 years 55–64 years 65–74 years 75–84 years ≥85 years Figure 3 Average length of stay per hospitalization in internal medicine wards according to patient age.

Figure 4 Average length of stay (all acute care beds). Israeli length of stay is compared with selected Organization for Economic Cooperation and Development countries [7]. CAN, Canada; FRA, France; GER, Germany; ISR, Israel; UK, United Kingdom; USA, United States.

specific problems of outpatient management to alleviate the inpatient ones. Specifically, community-based services may very well lead to fewer hospital readmissions by greater collaboration among professionals (physicians, nurses, physiotherapists, nutritionists, etc.) and medical/surgical units, thus creating a more highly effective environment for the management of multiple co-morbidities. Follow-up after discharge, including rehabilitation with effective guidance of patients and caregivers, may also prevent readmission. State-of-the-art information technologies may facilitate communication between patients, professionals and other caregivers at bedside in the patient’s home. Inpatient services will also need to address the challenges by supplementing internal medicine departments with more resources, staff and hospital beds. New units with specific orientation towards older populations will need to be established, including subunits within specialized departments (e.g. geriatric neurology). Finally, efforts

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should be made towards efficient administrative handover of the individual from inpatient to outpatient settings [14].

Conflict of interest The authors declare no conflict of interest. The study was not funded or supported by sources external to the Ministry of Health.

References 1. OECD (2012) OECD reviews of health care quality: Israel. Executive Summary, Assessment and Recommendations. 2. Peleg, S., Brenner, N., Katz, M., Ansbacher, H. & Mizrahi, N. (2012) National expenditure on health 1962–2011. Central Bureau of Statistics. 3. OECD (2013) OECD Economic Surveys: Israel 2013. Paris: OECD Publishing.


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4. Rosen, B., Porath, A., Pawlson, L. G., Chassin, M. R. & Benbassat, J. (2011) Adherence to standards of care by health maintenance organizations in Israel and the USA. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care/ISQua, 23 (1), 15–25. 5. Ministry of Health DoHI (2011) Selected health for all indicators 2011. 6. Health Information Division, Israeli Ministry of Health (2012). Inpatient Institutions and Day Care Units in Israel 2011, Part I: Hospitalization Trends. pp. 77–237. 7. OECD (2013) OECD Health Statistics 2013. Paris: OECD Publishing. 8. OECD (2011) Health at a Glance 2011: OECD Indicators. Paris: OECD Publishing. 9. Haklai, Z., Meron, J., Aburba, M. & Gordon, A. S. (2013) Hospitalization in Internal Medicine Departments during 2000–2012. Jerusalem, Israel: Ministry of Health. Information Health Division.


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10. The elderly in Israel – 2003 statistical abstract. Central Bureau of Statistics. 11. Projections of Israel population until 2035. Central Bureau of Statistics. 12. Paliel, A., Sepulchre, M., Korilenko, I. & Maldonado, M. (2012) Long-range population projections for Israel: 2009–2059. Central Bureau of Statistics. 13. OECD (2013) Health at a Glance 2013: OECD Indicators. Paris: OECD Publishing. 14. Shepperd, S., McClaran, J., Phillips, C. O., Lannin, N. A., Clemson, L. M., McCluskey, A., Cameron, I. D. & Barras, S. L. (2010) Discharge planning from hospital to home. The Cochrane Database of Systematic Reviews, (1), CD000313.

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Managing the increasing shortage of acute care hospital beds in Israel.

Israel's healthcare system has been facing increasing hospital bed shortage over the last few decades. Community-based services and shortening length ...
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