Between 45,000 and 50,000 people die in Israel yearly, mostly from noncommunicable diseases linked to preventable activities such as smoking, gaining excess weight and a lack of physical exercise.
With a primary prevention program, a health economist says, the country could reduce its death rate by 1,700-3,200 people annually and prevent between 42,000 and 79,000 deaths in the next 25 years.
Dr. Gary Ginsberg’s “Economic Savings and Mortality Reductions as a Result of Interventions to Prevent Chronic Diseases in Israel” was made public for the first time on May 31 at a National Institute for Health and Care Research conference in Tel Aviv.
Ginsberg, CEO of Health Economics Consultancy, spent nearly 40 years working for the Health Ministry, first as a senior health economist and then as the director of its Medical Technology Assessment Sector.
He prepared the report for the ministry at the request of Dr. Yakir Kaufman of the Hospitalization Department and submitted it nearly two years ago. However, until now, the plan has yet to be implemented. The ministry said it could not respond by deadline.
10 interventions to help save Israeli lives
According to Ginsberg, the adoption of 10 interventions would cost the country around NIS 25 billion over 25 years (NIS 1.4b. in year one, based on mid-2021 price levels), resulting in an expected savings of between NIS 70b. and NIS 126b. in treatment costs over 25 years.
The 10 interventions are:
- Smoking prevention
- Reducing sugar consumption
- Preventing overweight and obesity
- Increasing physical exercise
- Reducing malnutrition
- Preventing hypertension
- Preventing diabetes
- Screening to prevent colorectal cancer
- Delaying dementia by raising the retirement age
- Reducing air pollution from motor vehicles
The effects on various diagnoses of these 10 interventions were modeled and estimated based on peer-reviewed literature in academic medical journals, publications found in Internet searches and internal Israeli sources – including data from Israel and the international health community. Preventive projects on a national scale in Israel are rare.
“There are many interventions whose impact on disease prevalence gradually accumulates over the years,” Ginsberg explained to The Jerusalem Post. “If we eat well now or exercise, we will have fewer heart attacks in a decade. So, I built a model that took these long-term factors into account over a 25-year period.”
Moreover, although he reports specifically on mortality and cost savings, he said the interventions would likewise reduce morbidity and, therefore, hospitalizations, drug use and visits to the emergency room and intensive care unit.
“This is what you call a win-win,” Ginsberg said. “If you implement these interventions, you are making people healthier, and it is not costing the country one shekel net.”
The program centers around what Ginsberg calls a “hybrid national prevention project” (NPP) that could provide seven of the 10 individual interventions to all citizens over 45 through a “single-stop” case manager who will provide advice against multiple risk factors and illnesses.
“Our general practitioners are very busy,” Ginsberg said. “Some only have seven to eight minutes to meet with you. A person, 45, comes in with multiple risk factors, and the doctor doesn’t have time to deal with him. But what if a case manager – a nurse or other paramedic – could sit with him and devise a health plan monitored by a mobile app?”
This plan could include enrolling in an anti-smoking program, tools to reduce blood pressure and advice to increase physical exercise. The nurse could also encourage the person to substitute water and lemon juice for sugary drinks.
Economies of scale could be generated by the NPP, making it cost around NIS 24.5b. over 25 years for NIS 94b. to NIS 139b. in savings in averted treatment costs and 40,100 to 66,100 in lives.
Ginsberg admitted that not all people would be receptive to all of the projects. For example, “We know from research literature that not everyone will stop smoking – probably only 3%-4%. If 4% of the 7,000 people who die yearly from smoking are saved, that is already 280 people yearly.”
Around 20% of Israelis over the age of 20 smoke, according to the most recent data, and tobacco use is the single most preventable cause of death, Ginsberg said. He wrote that up to half the world’s more than one billion smokers will die prematurely because of a related disease.
The leading causes of death from smoking in Israel are cardiovascular (45%), malignant neoplasms (39.2%) and respiratory diseases (15.5%). Moreover, passive smoke accounted for an additional 11% of smoking-attributable mortality. Exposure of the fetus to the mother’s smoking and residential fires also caused deaths.
“Reducing the burden of disease from smoking is obviously of paramount importance in the field of public health,” the report said.
Ginsberg showed that raising the tobacco tax and distributing nicotine patches and gum could reduce the number of smokers by an average of 17.9% over the next 25 years.
SOME 6,401 annual deaths are attributable to overweight and obesity in Israel, of which sugar consumption is a significant factor – more than a third from coronary arterial disease.
Ginsberg’s research shows that a national program based on a United Kingdom modeling study of reducing energy from sugar consumption from 12.45% to 10% over five years is “a very feasible short-term goal” and could prevent around 237 deaths, 9,917 days of hospitalization and approximately 180,000 fillings. It would also result in NIS 121 million in saved treatment costs.
A more ambitious target would be reducing energy consumption from sugar to 5% over 15 years, which would prevent nearly 500 deaths annually, 20,699 days of hospitalization and 336,000 fillings, and NIS 244m. in treatment costs.
Regarding overweight and obesity, the research shows that around 28.6% of persons aged 25-34 and 41.8% of those 55-84 are overweight. Moreover, 14.5% of 25-34-year-olds are obese and 32% of 55-85-year-olds. These individuals had health costs 12.2% above the average healthcare costs of persons with normal or sub-normal weight ratios.
Relatedly, approximately NIS 1.5b. in direct healthcare costs were attributed to sedentariness in Israel in 2008. Around 5.8% of Israelis have diabetes, the report added, with an additional 4.2% who are considered prediabetic. Another 21% of Israelis over the age of 21 have physician-diagnosed hypertension.
Ginsberg showed that in previous research, individuals who received diet and physical activity advice developed 43% fewer cases of Type II diabetes than controls over a nearly four-year follow-up program. He noted that the impact of a prevention program would reduce the number of people with Type II diabetes in Israel from an expected 548,000 to as few as 347,000 in 2046.
Israel has rolled up two small hypertension prevention programs: The Ashkelon Hypertension Detection and Control Program and the Israel Blood Pressure Control Program, which operates in general practices. Based on the success of these and other international programs, he said between 35% and 65% of people’s hypertension would be controlled.
Regarding malnutrition: The report said that around 60,401 general hospital days, 558 deaths and NIS 145m. in direct health costs were attributable to being underweight annually in Israeli adults. Visiting a nutritionist five times over six months as part of a community intervention was assumed to reduce underweight-associated mortality and treatment costs by up to 5.4%.
GINSBERG SAID the only intervention that would cost more money than it saves is implementing colorectal cancer screening every 10 years with a colonoscopy. However, his report showed that if Israel increased its colonoscopy compliance rates from 26.2% to an achievable 90% for people between ages 50 and 80, the country could reduce colorectal cancer rates and mortality by around a third.
The last two interventions would not be managed by the case manager: increasing the compulsory retirement age and reducing air pollution by legislating that vehicles use electricity or liquid petroleum gas. However, because they are tied more to legislation than to treatment, they cost less to implement – NIS 31m. and NIS 148m., respectively.
According to Ginsberg’s report, around 9% of people over 65 have dementia, costing around NIS 8.6b. in direct care costs in 2021.
“One way of postponing or even averting dementia is to raise the retirement age in healthy persons who are not involved in manual labor,” the report said.
If 75% of Israelis could delay their retirement by two years, it would reduce the prevalence of dementia between 2021 and 2045 by 6.3%, according to Ginsberg. A five-year delay would reduce the prevalence even more by around 11.9% by 2045.
According to the report, ambient air pollution leads to more than 2,200 deaths in Israel per year and up to 542,000 hospital days. Air pollution is tied to cardiovascular disease, lung cancer, stroke, diabetes and respiratory illness.
“The mortality, morbidity and monetary burden of disease attributable to air pollution from particulate matter in Israel is of sufficient magnitude to warrant the consideration of and prioritization of technological interventions available to reduce air pollution from industrial, power generating and vehicular sources,” according to the report.
About 15.6% of particulate matter smaller than 2.5 mm. (PM2.5) is caused by motor vehicle polluting emissions. If all cars, taxis and small vans shifted to electric power, it would reduce PM2.5 from vehicles by 40.5% and a minimum of a 4.4% reduction in air pollution-related deaths within 15 years, Ginsberg wrote. If buses and trucks were converted to liquid petroleum gas, the percentage of vehicular PM2.5 emissions would drop by 95.5%, and deaths would be reduced by more than 10% within 15 years.
Ginsberg’s cost estimates include human resources, laboratory tests, individual and group guidance, transport, advertising and management.
He said that since it is unlikely that all 10 could be funded and rolled out simultaneously, he recommends groups of interventions that could have the most impact. For example, he says reducing sugar consumption, overweight/obesity and diabetes would have the most cost savings – up to 66% of the expected total savings. If reducing smoking, malnutrition and hypertension were added (six interventions), 90% to 95% of cost savings could be achieved.
The adoption of reducing smoking prevalence, malnutrition and sugar consumption would achieve as much as 72% of mortality decreases that would be attained if all 10 interventions were implemented.
Ginsberg stressed that cost savings would already be seen within two years of the program, which he hopes will make it more palatable for any government to invest in and get credit for during the government’s life span.
He added that these are not the only interventions and that others could be considered in addition or instead, but that “these are big issues and ones that can be worked on and that have solutions.” He said if he were working in another health system, he would come up with a similar list.
Ginsberg’s cost-benefit analysis is reminiscent of the World Health Organization’s “best buys” for preventing noncommunicable diseases, which were updated in May at the World Health Assembly. However, Ginsberg further includes the widespread uptake of hybrid cars, which WHO still needs to offer a methodology for carrying out.
WHO says that noncommunicable diseases are the world’s biggest killers.
“Investing in evidence-based policies is an investment in a healthy future,” WHO said.
THE PROGRAM was independently reviewed by Prof. Cyrille Cohen, head of the Laboratory of Tumor Immunology and Immunotherapy at Bar-Ilan University. He said, “I definitely agree with this study. So many lives and so much money are wasted because we do not invest enough in prevention.”
He noted that a recent study showed that almost 50% of all cancers are preventable. The main culprits were smoking, obesity, alcohol and lack of physical activity.
“And, of course, it doesn’t stop at cancer. Diabetes and other metabolic disorders are shortening lives,” Cohen said. “An ounce of prevention is worth a pound of cure.”