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עמוד בית
Mon, 22.07.24

May 2005

Click here for article written by Philip Sax, PhD. IMAJ 2005: 7: May: 286-291
 Background: Like most developed countries, in the last decade Israel's healthcare system has been subject to cost-containing measures in the drug sector.

Objective: To provide comparative information in an international context on the level of outpatient drug expenditures in Israel, both total and those publicly financed, and to analyze how these have changed with time during the last decade.

Methods: Using definitions of the OECD (Organization of Economic Cooperation and Development), internationally comparable data on total expenditure and public expenditure on medicines in Israel are provided. The Israeli estimates are based on data from the Ministry of Health audited reports of financial activities of the health management organizations and from the family expenditure surveys carried out by the Central Bureau of Statistics. Per capita total and public expenditures in Israel are analyzed over time, as are their share of national expenditure on health and of gross domestic product. Israel expenditures are then compared with those for individual member countries of the OECD, as well as a 21 country average, from 1992 to 2002.

Results: Analysis of the Israeli expenditure data shows a considerable reduction in growth of per capita total and public expenditures on medicines since 1997. Growth in the share of total drug expenditure of NEH[1] and of GDP[2] has also been constrained since 1997. In an international context, per capita expenditure on medicines in Israel, particularly what is publicly financed, is one of the lowest. Furthermore, its share of NEH and GDP is also very low compared to other countries. This substantive gap in spending on medicines between Israel and other countries has increased since 1997.

Conclusions: Israel, a medium-income country with a lower than average level of expenditure on health compared to OECD countries, has a particularly low level of expenditure on medicines. Whereas the share of health expenditure of GDP in Israel is similar to the international average, the share of drug expenditure of GDP is well below the average. In addition to structural and longer-term factors contributing to Israel's low per capita spending on medicines, such as the young population and the apparently low level of actual prices paid by most institutional purchasers, recent years are witness to the growing impact of National Health Insurance budgetary pressures on HMOs[3] as well as continual increases in prescription cost sharing by patients. The impact is felt both on the demand side (higher co-payments, administrative and prescribing restrictions) and perhaps more crucially on the supply side (price competition, mainly from generics). Substantial extra public funding for the addition of new drugs to the NHI[4] basket in recent years has had no overall impact on these longer-term spending patterns.


[1] NEH = national expenditure on health

[2] GDP = gross domestic product

[3] HMO = health maintenance organization

[4] NHI = National Health Insurance

N. Bitterman and I. Shalev
 Background: In light of changes in the medical profession, the different requirements placed on physicians and the evolving needs of the healthcare system, the need arose to examine the medical education curriculum in Israel. This survey, conducted by the Samuel Neaman Institute for Science and Technology summarizes 20 years of medical education in Israel's four medical schools, as the first stage in mapping the existing state of medical education in Israel and providing a basis for decision-making on future medical education programs.

Objectives: To characterize the academic background of graduates, evaluate their attitudes towards current and alternative medical education programs, and examine subgroups among graduates according to gender, medical school, high school education, etc.

Methods: The survey included graduates from all four Israeli medical schools who graduated between the years 1981 and 2000 in a sample of 1:3. A questionnaire and stamped return envelope were sent to every third graduate; the questionnaire included open and quantitative questions graded on a scale of 1 to 5. The data were processed for the entire graduate population and further analyzed according to subgroups such as medical schools, gender, high school education, etc.

Results: The response rate was 41.3%. The survey provided a demographic profile of graduates over a 20 year period, their previous educational and academic background, additional academic degrees achieved, satisfaction, and suggestions for future medical education programs.

Conclusions: The profile of the medical graduates in Israel is mostly homogenous in terms of demographics, with small differences among the four medical schools. In line with recommendations of the graduates, and as an expression of the changing requirements in the healthcare system and the medical profession, the medical schools should consider alternative medical education programs such as a bachelor’s degree in life sciences followed by MD studies, or education programs that combine medicine with disciplines such as law, engineering, computer science, etc.

Original Articles
J. Bishara, G. Livne, S. Ashkenazi, I. Levy, S. Pitlik, O. Ofir, B. Lev and Z. Samra

Background: The prevalence of extended-spectrum β-lactamase-producing organisms and their antimicrobial resistance patterns may vary between geographic areas.

Objectives: To evaluate the prevalence and susceptibility of ESBL[1]-producing organisms among Klebsiella pneumoniae and Escherichia coli isolated from adult and pediatric patients in two Israeli hospitals.

Methods: ESBL production was tested according to recommendations of the Clinical and Laboratory Standards Institute, using ceftazidime (30 μg) and a combination of ceftazidime/clavulanate (30/10 μg) disks with a ≥5 mm difference indicating positivity. Antibiotic susceptibilities were determined by the disk diffusion method according to CLSI[2] standards. Minimum inhibitory concentrations were determined by the E-test.

Results: The prevalence of ESBL-producing organisms was significantly higher among K. pneumoniae than E. coli isolates – 32% (241/765) vs. 10% (57/547) respectively (P < 0.001), and more frequently isolated from adults than children (odds ratio 2.27 for K. pneumoniae and 12.94 for E. coli). Resistance rates for amoxicillin/clavulanate, piperacillin-tazobactam, amikacin, and ciprofloxacin among the ESBL-producing K. pneumoniae and E. coli isolates were 95%, 82%, 49% and 77% for K. pneumoniae, and 77%, 35%, 25% and 100% for E. coli. Two (0.8%) ESBL-producing and 4 (0.7%) ESBL-negative K. pneumoniae isolates showed intermediate susceptibility (MIC[3] 6 μg/ml) to meropenem. All isolates were sensitive to ertapenem and colistin.  

Conclusion: ESBL production among K. pneumoniae and E. coli is more prevalent in the adult population than the pediatric population and is associated with multidrug resistance.

[1] ESBL = extended spectrum β-lactamase

[2] CLSI = Clinical and Laboratory Standards Institute (formerly the NCCLS)

[3] MIC = minimum inhibitory concentration


A. Ben-Chetrit, D. Hochner-Celnikier, T. Lindenberg, D. Zacut, S. Shimonovitz, H. Gelber and I.M. Spitz
 Background: Relief of climacteric symptoms is currently the main role of hormone therapy. However, vaginal bleeding complicating this therapy is among the leading causes for its early discontinuation.

Objectives: To assess the effect of a vaginal ring delivering estradiol and progesterone in postmenopausal women and to determine whether continuous administration can relieve climacteric symptoms, produce an acceptable pattern of vaginal bleeding and control endometrial proliferation.

Methods: Twenty-nine postmenopausal women with an intact uterus were studied. All had climacteric symptoms. The vaginal rings contained 0.36 g estradiol and either 3.6 g progesterone (high dose progesterone) or 1.8 g (low dose progesterone), and were kept in place for 4–6 months. Serum progesterone, estradiol and estrone were measured and endometrial thickness determined. All women kept a daily diary of bleeding/spotting and completed a questionnaire on climacteric symptoms at monthly intervals. The low dose progesterone group comprised 14 women and the high dose progesterone group 15 women.

Results: A total of 18 patients (9 in each group) completed the study. Mean levels of estradiol, estrone and progesterone were at their peak after 2 to 4 weeks. All rings were effective in alleviating vasomotor symptoms, although there was evidence of the "escape from effect" in month 6. Endometrial thickness increased in 6 of the 29 women but biopsy in each case showed no evidence of hyperplasia. Of the 18 women who completed the study, 5 had amenorrhea throughout, 7 had amenorrhea after 3 months, and the remainder had one or two bleeding episodes after 3 months. Therapy was discontinued in 11 women.

Conclusions: A vaginal ring delivering estradiol and progesterone controlled climacteric symptoms, prevented endometrial proliferation, and provided an acceptable bleeding pattern. It should be viewed as a promising alternative for short-term estrogen-progesterone therapy.

E. Segev, D. Keret, F. Lokiec, A. Yavor, S. Wientroub, E. Ezra and S. Hayek
 Background: The preferred conservative treatment for congenital idiopathic clubfoot deformity remains a controversial issue.

Objectives: To compare the outcomes of two groups of CICF[1] patients who underwent two different treatment protocols.

Methods: The study cohort included 72 infants treated in our hospital from August 1998 to December 2002. Group 1 comprised 40 infants (61 clubfeet) who were treated by a traditional method (a modification of the Kite and Lovell technique), and group 2 consisted of 32 infants (48 clubfeet) who were treated with the Ponseti technique. Both groups were similar in age, gender and severity of the deformity (Dimeglio scoring system)

Results: After an average follow-up of 54.9 months (range 44–68), 35 (57%) clubfeet in group 1 required surgical intervention and 27 (44%) clubfeet had a residual deformity at last follow-up. In the Ponseti group, 45 (94%) clubfeet were fully corrected at last follow-up (average 29.2 months, range 16–45) while 3 (6%) clubfeet had residual deformity and required surgery. Tendo-Achilles tenotomy was performed with no complications in 47 clubfeet (in group 2) at an average age of 2.4 months (range 2–4 months).

Conclusions: Even after a relatively short follow‑up period, our success rate with the Ponseti approach already appears to be significantly higher and to bear fewer complications than the traditional treatment, in agreement with the results published by other medical centers. We now endorse the Ponseti technique of conservative manipulative treatment for congenital idiopathic clubfoot in our department.


[1] CICF = congenital idiopathic clubfoot

S. Dollberg, Z. Haklai, F.B. Mimouni, I. Gorfein and E.S. Gordon
 Background: Lacking curves of “intrauterine” growth, most birthing centers in Israel use United States-based curves as standards.

Objective: To establish population-based standards of birth weight of singletons in Israel.

Methods: Data on birth weight and gestational age were obtained from the registries of the Israel Ministry of Health and Ministry of the Interior. During the 8 year study period there were 1,074,122 infants delivered in Israel; 787,710 (73%) were included in this analysis.

Results: In this study we provide data of birth weight by gestational age of live infants born in Israel between 1993 and 2001. Ranges of birth weight by gestational age are also depicted for singleton and multiple pregnancies. Fetuses in multiple pregnancies grow in a similar manner to singletons until 30 weeks of gestation, after which their growth slows down.

Conclusions: Use of these data as a standard for “intrauterine” growth better represents the Israeli neonatal population than the American standards. In addition, curves of multiple pregnancies are significantly different from those of singleton pregnancies and might be more appropriate in these pregnancies.

S. Maslovitz, M.J. Kupferminc, J.B. Lessing and A. Many
 Background: Foreign workers in Israel are not covered by the comprehensive medical insurance that all Israelis receive. They have national insurance and injury-related coverage, which does not include routine pregnancy follow-up

Objectives: To compare perinatal outcome between partially insured non-resident migrants in Israel and comprehensively insured Israeli women.

Methods: Parameters of perinatal outcome were compared between 16,012 Israeli and 721 foreign women living in Israel. Outcome measures included birth weight, distribution of gestational age at delivery, neonatal complications, cesarean section, neonatal intensive care unit admission, intrauterine fetal death rates, and duration of post-partum hospitalization.

Results: Deliveries prior to 28 weeks gestation occurred more frequently among non-residents (1.3% vs. 0.6%, P < 0.001). Gestational diabetes and preeclamptic toxemia were significantly more prevalent among non-residents (3.2% vs. 1.9%, P < 0.05 and 4.9% vs. 3.1%, P < 0.05, respectively). The cesarean rates were 18% and 35% for residents and non-residents, respectively (P < 0.001), and the post-cesarean recovery period was longer among non-residents (4.8 vs. 3.6 days, P < 0.05). The mean birth weight was similar in the two groups (3,214 vs. 3,231 g), although macrosomia (>4,000 g) was more prevalent among non-residents, who also had higher rates of NICU[1] admission ((9.6% vs. 8%, P < 0.05) and intrauterine fetal death (6.6/1,000 vs. 3.7/1,000, P < 0.05).

Conclusions: Non-resident parturients in Israel are more susceptible to an adverse perinatal outcome than their Israeli counterparts. We suggest that governmental subsidization of non-residents' health expenditures would reduce the differences in perinatal outcome between these two groups.


[1] NICU = neonatal intensive care unit

D. Ben-Amitai, A. Metzker and H.A. Cohen
 Background: Mastocytosis is a heterogeneous group of diseases characterized by the abnormal infiltration of mast cells in the skin and, sometimes, other organs. Some patients may experience symptoms related to mast cell mediator release.

Objective: To analyze the clinical features of cutaneous mastocytosis in a large series of children.

Methods: We conducted a file review of all children clinically diagnosed with cutaneous mastocytosis in our department over the last 20 years. We evaluated gender, age at onset, character and distribution of the lesions, associated symptoms, and course of the disease.

Results: Altogether, 180 patients with cutaneous mastocytosis were identified. The male to female ratio was 1.5:1. About one-third of patients had a mastocytoma, which was present at birth in over 40% and appeared during the first year of life in most of the remainder. Urticaria pigmentosa was noted in 65% of the patients, presenting at birth in 20% and during the first year in most of the remainder. The majority of lesions was distributed over the trunk and limbs. Different kinds of associated symptoms were noted. Prognosis, in general, was good. Only 11% of the cases, all urticaria pigmentosa, were familial.

Conclusions: Most cases of pediatric mastocytosis are sporadic and appear during the first 2 years of life, especially on the trunk. Urticaria pigmentosa is the most frequent variant. The prognosis of pediatric mastocytosis, in general, is good. 

M. Mekel, A. Mahajna, S. Ish-Shalom, M. Barak, E. Segal, A. Abu Salih, B. Bishara, Z. Shen-Or and M.M. Krausz
 Background: Minimal invasive surgery for parathyroidectomy has been introduced in the treatment of hyperparathyroidism.

Objective: To evaluate the contribution of the sestamibi-SPECT (MIBI) localization, cervical ultrasonography, and intraoperative rapid turbo intact parathormone assay in minimal invasive parathyroidectomy.

Methods: Between August 1999 and March 2004, 146 consecutive hyperthyroid patients were treated using the MIBI and ultrasound for preoperative localization and iPTH[1] measurements for intraoperative assessment.

Results: Parathyroid adenoma was detected in 106 patients, primary hyperplasia in 16, secondary hyperplasia in 16, tertiary hyperplasia in 5 and parathyroid carcinoma in 1 patient. Minimal invasive exploration of the neck was performed in 84 of the 106 patients (79.2%) with an adenoma, and in 17 of them this procedure was performed under local cervical block anesthesia in awake patients. Adenoma was correctly diagnosed by MIBI scan in 74% of the patients, and by ultrasound in 61%. The addition of ultrasonography to MIBI increased the accuracy of adenoma detection to 83%. In 2 of the 146 patients (1.4%) iPTH could not be significantly reduced during the initial surgical procedure. Minimal invasive surgery with minimal morbidity, and avoiding bilateral neck exploration, was achieved in 79.2% of patients with a primary solitary adenoma.


[1] iPTH = intact parathormone

T. Monos, J. Levy, T. Lifshitz and M. Puterman
 Patients with silent sinus syndrome typically present for investigation of facial asymmetry. Unilateral, spontaneous enophthalmos and hypoglobus are the prominent findings at examination. Imaging of the orbit and sinuses characteristically show unilateral maxillary sinus opacification and collapse with inferior bowing of the orbital floor. It has been suggested that SSS[1] is due to hypoventilation of the maxillary sinus secondary to ostial obstruction and sinus atelectasis with chronic negative pressure within the sinus. Treatment involves functional endoscopic sinus surgery for reestablishing a functional drainage passage, and a reconstructive procedure of the floor of the orbit for repairing the hypoglobus and cosmetic deformity. Ophthalmologists, otorhinolaryngologists, and radiologists must be familiarized with this relatively newly reported disease.

[1] SSS = silent sinus syndrome

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