key: cord-0947703-a6wr818y
authors: Shaked, O.; Korn, L.; Shapira, Y.; Zigdon, A.
title: Socio-demographic characteristics and their relation to medical service consumption among elderly in Israel during the COVID-19 lockdown in 2020 compared to the corresponding period in 2019
date: 2022-01-31
journal: nan
DOI: 10.1101/2022.01.29.22269933
sha: 375ca07428da84e554c30c7b7d9d58bf47f84c06
doc_id: 947703
cord_uid: a6wr818y

Purpose: The COVID-19 pandemic has led to the isolation of the population in Israel, including the elderly, some of whom are chronically ill. The present study examines the consumption of medical services among adults over the age of 65 in Israel at the time of the first COVID-19 lockdown relative to the corresponding period the year before, according to various socio-demographic variables: gender, age, marital status, ethnicity, degree of religiosity and socioeconomic status. Methods: A retrospective longitudinal observational quantitative research based on the Natali Healthcare Solutions Israel database of subscribers. Company subscribers over the age of 65 (N=103,955) were included in the sample (64.5% women) in two time periods, before the COVID-19 outbreak-P1, in 2019, and during the first COVID-19 lockdown- P2 in 2020. Medical needs included referrals to a medical or emergency services, ordering an ambulance, physician home visits and service refusal. Results: The average number of referrals to services was lower during the COVID-19 lockdown period (M=0.3658, SD=0.781) compared to the corresponding period the previous year (M=0.5402, SD=0.935). At the time of the COVID-19 lockdown, the average number of referrals to medical services was lower, but the average number of ambulance orders, physician visits and service refusals was higher compared to the same period in the previous year. During both time periods, women (P1- M=0.5631, SD=0.951; P2- M=0.3846, SD=0.800) required significantly more (p<.000) services than men (P1- M=0.5114, SD=0.910; P2- M=0.3417, SD=0.753). In both time periods, subscribers who were older, widowed, living in non-Jewish/mixed localities or in average or below average socioeconomic status localities required more services relative to younger, married people living in Jewish localities, or in above-average socioeconomic localities (p<.000). Summary and Conclusions: In a large sample of elderly in Israel, findings indicate a decrease in referrals to medical care during the first COVID-19 lockdown period, yet an increase in ambulance orders, physician visits and service refusals. There were no significant differences between the periods according to different socio-demographic characteristics. The period of the first COVID-19 lockdown was characterized by a higher incidence of medical service refusals compared to routine times. The incidence of requiring medical service at the time of the first COVID-19 lockdown was 2.5 times higher among those who required services during the previous year, 1.7 times higher among unmarried seniors, and 1.4 times higher among the older age group of 85 and over in comparison to the younger seniors.

The COVID-19 pandemic has caught the world population with insufficient readiness, 106 especially with respect to the elderly who are particularly vulnerable to serious health 107 consequences. Travel restrictions, including the prohibition of leaving homes, as well as the 108 fear of contracting the disease have made it difficult for the elderly. Elderly and people who without the support of a partner has a negative impact on the management of chronic illness 154 and medical condition. An article by Liao and colleagues found that mutual support between 155 elderly spouses improves lifestyle and reduces complications among chronic patients, 156 especially in the initial prevention phase of disease deterioration [20] . Older people were found by low socioeconomic status, inaccessibility to medical services, exacerbation of morbidity 179 and complications of the disease, and are at increased risk for exposure to COVID-19 within 180 their workplaces and in their more crowded living situations [28] . 181 In Israel, various organizations provide a wide range of services to the elderly, including 182 medical services such as a doctor's home visit, ambulance services, and telephone counseling 183 as well as various logistical services such as medication purchasing and hot meal deliveries. 184 "Natali Healthcare Solutions in Israel" is one of the more prominent Israeli companies for 185 providing these services, in which the subscriber contacts the center and speaks to a medic who 186 personally tailors the service required to them. In life-threatening situations, an ambulance will 187 be dispatched to provide immediate medical assistance to the patient, whereas in situations 188 where there is no imminent risk, the call center may supply other services such as telephone 189 counseling or a doctor's home visit. In terms of logistic services, a wide range of options is 190 available, for instance: laundry services, medication home delivery, and hot meals service. The is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. ; https://doi.org/10.1101/2022.01.29.22269933 doi: medRxiv preprint elderly in Israel during the first COVID-19 lockdown in comparison to the corresponding 204 period in the previous year, by distribution of various socio-demographic variables, as well as 205 how this demand for medical services is characterized according to different socio-206 demographic variables: gender, age, marital status, ethnicity, degree of religiosity and 207 socioeconomic status. We hypothesize that service consumption would be lower during the 208 COVID-19 pandemic compared to the corresponding period in the previous year, and that men, 209 widowers, adults in the younger age group as well as non-Jews will consume fewer services in 210 comparison to women, married, older individuals and Jews. The study is based on a database from "Natali Healthcare Solutions in Israel", which is 220 a private company for the provision of medical services that has been operating in Israel for 221 over 30 years. The company provides a wide range of medical and non-medical services to 222 elderly subscribers and is part of a range of organizations operating in the field medical service 223 provision to Israeli residents. The company's services include telemedicine services supported 224 by call center representatives who have been trained as emergency call medics, as well as 225 medical consultation calls with various physicians, emergency medical services such 226 ambulance services and physicians' home visit services. As part of the service, the company 227 . CC-BY 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The study was approved by the Ariel University institutional ethics committee 230 (Approval No. AU-HEA-AZ-20200624) and has also received the approval of "Natali 231 Healthcare Solutions in Israel" management to conduct the research. Data from the research 232 file was taken retrospectively and anonymously from the company's database without 233 identifying details of the subjects. The subjects' records were kept in an encoded file in a 234 manner which ensured the identification of the subjects stayed concealed and that no link could 235 be made between the data and the individuals sampled.

Population and sample description 238 The study population is adults over the age of 65 in Israel who are "Natali Healthcare 239 Solutions in Israel" subscribers. Of the full subscriber list for the years 2019-2020, the 240 following customers who did not meet the study criteria were removed: those under the age of 241 65, those whose services were terminated for various reasons (cancellation, death, service 242 freeze -2% of the sample), those whose number of calls to the center was over 400 inquiries 243 in both periods (n=17). The sample size meeting the study criteria was 103,955. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. Statistics 25 software. To adapt the data to the senior population in Israel, the data file was 308 weighted by gender and age. The data in Table 1 presents descriptive statistics for the sample 309 by the Frequency command, before and after weighting the data. Missing values were omitted 310 from the description of the variables in Table 1 , which displays the valid percent value as well 311 as the raw number value of the subjects in each category. Table 2 presents averages and 312 standard deviations using a T test for paired variables comparing between the two periods. The 313 2-tailed significance of the T value analysis is presented. Table 3 presents the averages of the 314 index comprised of "service demand" by period. A Two-way mixed ANOVA with Bonferroni 315 correction for pairwise comparisons, was used to examine the differences by group, time, and 316 by the interaction between group and time while examining significance by Bonferroni.

Similarly, Table 4 presents the same analysis for the dependent variable of service refusal.

Values displayed in Bold -are those significantly higher values than the other groups. Table 5 319 presents logistic regression results for predicting service demand according to the study's 320 socio-demographic variables. For this purpose, the dependent variable "service demand" was is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. It can be seen from Table 2 

That is, during P2, there was a lower average of calls to the center relative to P1. Ambulance is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. It can be seen from Table 3 that Similarly, to what is shown in Table 3 , Table 4 shows the average of ambulance or is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint group refused service more than the younger age groups, and unmarried seniors-single, 379 divorced and widowers refused service more than married seniors significantly. No significant is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. ; https://doi.org/10.1101/2022.01.29.22269933 doi: medRxiv preprint [24] . It was found that people avoided going to emergency rooms and at times, even when is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. ; https://doi.org/10.1101/2022.01.29.22269933 doi: medRxiv preprint room and being exposed to a greater number of people thus endangering themselves with 446 unnecessary exposure to patients.

Older people require more medical services than young people [14] . The current study 448 also found that the average service requirement among older adults over the age of 85 is higher.

This is also the age group that refused more of the services. Moreover, the widowed subscribers 450 consumed on average more services than single and divorced individuals, and significantly 451 more than married ones. In this study, marital status was found to be a substantial and 

When examining the literature to explore consumption of medical services by gender, 455 it is shown that women more than men, tend to consume more medical services, adhere more 456 to medical guidelines, obtain more of the required tests, and arrive more at the emergency room is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. 

The study's findings indicate a decrease in medical service demand during COVID-19 489 which can be explained due to the elderly's fear of being exposed to the disease through various 490 service providers such as medical staff or other patients in different inpatient facilities, thus 491 refraining from initially obtaining services. It is also possible that this concern dictated more 492 refusals to receive a service offered by the call center operator. However, the increase in the 493 demand for ambulance services and doctor's home visits can be explained by the fact that when 494 the subscribers did finally make the call for help, their situation was already more complex. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. ; https://doi.org/10.1101/2022.01.29.22269933 doi: medRxiv preprint Subscribers who did not go to the hospital on their own remained at home and were treated by 496 various service providers as a substitute for hospital care. Another reason for the increase in 497 the consumption of medical services is the reduction in the accessibility of community health 498 services at the beginning of COVID-19. The Israeli health maintenance organizations tended 499 to alienate patients from reaching the clinics due to the risk of infection. As alternatives, they 500 suggested phone calls with the attending physician and receiving prescriptions remotely.

A very large sample of adults in Israel who consume medical services during routine 502 times, is one of the main strengths of the present study. The data file of "Natali Healthcare 503 Solutions in Israel", a leading private company in Israel for providing medical care to the 504 elderly, was analyzed here for the first time. Another strength of the study is its being a 505 longitudinal study, based on the same subjects in both time periods, which contributes to the 506 strength its findings. On the other hand, part of the study limitations is the lack of information 507 pertaining to additional data such as the degree of religiosity, which could not be unequivocally 508 examined since the data was based solely on place of residence, and not based on self-report.

Another study limitation is that potential intervention variables such as disease severity, 510 number of diseases, mental state, and nutritional balance, were not taken into account in this 511 study, given the unavailability of this data.

The findings of the study show that there is a decrease in referrals to medical centers 513 during times of emergency as well as during the first COVID-19 lockdown period, but an 514 increase in the demand for medical services such as ambulance orders and doctor's home visits 515 as well as service refusals. There is no significant difference in the trends of the findings 516 between the time periods according to different socio-demographic characteristics. The 517 pandemic period raised concerns among the elderly about receiving medical care, possibly due 518 to fear of contracting the disease, and was characterized by a higher incidence of medical 519 service refusals during the pandemic. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. ; https://doi.org/10.1101/2022.01.29.22269933 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 31, 2022. ; https://doi.org/10.1101/2022.01.29.22269933 doi: medRxiv preprint

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P1=pre-COVID-19 period; P2=during COVID-19 lockdown; M=Mean

=Interaction significant; N=Number of subjects; SES Socioeconomic status 699 Significance testing for differences between groups a ≠ b ≠ c ≠ d where-a represents the higher value

P1=pre-COVID-19 period; P2=during COVID-19 lockdown; M=Mean

=Interaction significant; N=Number of subjects

*p<.05, **p<.01, ***p<

We would like to express our sincere gratitude to Mr. Nimrod Altman,