a Department of Social Medicine. Hadassah Medical Organization and the Braun School of Public Health and Community Medicine of the Hebrew University and Hadassah, Israel.
b Information and Computer Services. Ministry of Health, Israel.
c Clalit Health Services, Israel.
Rosa Gofin, Department of Social Medicine, Hadassah University Hospital, Ein Karem, Jerusalem 91120, Israel. E-mail: gofin{at}cc.huji.ac.il
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Abstract |
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Methods A nationwide random sample of injured children aged 017 attending emergency rooms (ER) during one year was selected (n = 11 058). The number of cases was weighted to 365 days and rates and odds ratios (OR) were calculated. Logistic regression was performed to study the OR of hospitalization in the total population and among Jews and Arabs controlling for independent variables.
Results The incidence of ER admissions among the Jews was 752.6/10 000 (95% CI: 738.1767.1), 1.5 times higher than among the Arabs (492.8/10 000, 95% CI: 472.8512.8). However, the rate of hospitalization was 1.1 times higher among Arabs than among Jews and the mortality rate was 3.2 times higher among Arabs than among Jews.
Conclusions The differences in injury rates for fatal and non-fatal injuries may be due to differences in the severity of injuries or in the use of services by the two populations. A study is underway to elucidate this point.
Keywords Unintentional injuries, causes, nature, outcome, inequalities, child, adolescence, wounds and injuries, emergency services, hospitalization/statistical and numerical data, causes of death, incidence, socioeconomic factors, ethnic groups, Israel/epidemiology
Accepted 10 January 2002
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Introduction |
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Israel is no exception to this problem, especially among the young. Similarly to other countries, mortality due to injuries is the leading cause of death among people aged 119 years.3 However, mortality, the statistics of which are readily available, is only the tip of the iceberg. Indeed, non-fatal injuries are a frequent cause of admissions to emergency rooms (ER), hospitalizations,4,5 disabilities and long term sequelae.1,2,6 They have serious implications for families, the community and health services.7
A noteworthy difference in the incidence of childhood and adolescent injury-caused mortality has been shown among ethnic4,8 and socioeconomic groups.913 This difference seems to exist with regard to non-fatal injuries as well.1416 However, not all studies have confirmed these findings with regard to non-fatal injuries. The ethnically related difference may be explained by a difference in access to medical care, while the socioeconomic differences may be due to the different environments,17 circumstances and risk behaviour,18 to which affluent and poor families are exposed.
In the present study we examine whether there are nationwide differences in the incidence of fatal and non-fatal injuries among Jewish and Arab children and adolescents.
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Population and methods |
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The survey was approved by the Ethics Committee of the Ministry of Health, and permission was obtained for a record review from the director of each hospital and each ER.
All ER records were reviewed and data relevant to the study (demographic information, causes and nature of injury and outcome) were extracted for each day that was included in the sample. All causes of injury fitting the E-codes 800999 (i.e. falls, traffic accidents, etc) were obtained, and in cases where only the diagnosis was recorded (International Classification of Diseases, Ninth Revision [ICD-9] 800999, i.e. fracture, laceration, concussion, etc),20 the data was also extracted. Details on cause and nature of injury appear in Table 1. Intentionality of the injury was recorded according to the medical file, and in this paper we present data only on unintentional injuries. Data on intentional injuries was presented elsewhere.21 Records were included for the first admissions to the ER only (n = 11 058). Aggregated data on all fatal cases were obtained from the Ministry of Health. E-codes follow the same categories as for ER admissions.
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Ongoing quality control of all data was performed; in order to assure a minimal misclassification of E-codes and nature of injury codes, the principal investigator or the research co-ordinator provided the training and selected cases were coded together with the 12 field workers. The fact that all data were entered into the computer by the research co-ordinator provided an additional measure of quality control.
Analysis of the data was carried out by SPSSWIN.23 The number of cases admitted to the ER was weighted to 365 days and crude and specific annual rates per 10 000 child years were calculated with the 1994 midyear population as the denominator. The calculation of the standard deviation (SD) of the weighted rates was based on the assumption assuming that the number of injured follows a Poisson distribution. Using these SD, the calculation of the 95% CI assumed a normal approximation for the Poisson distribution.
Death rates were calculated per 100 000 child years.
Logistic regression was performed to study the odds ratio (OR) of hospitalization in the total population and among Jews and Arabs separately. The variables introduced in the model were: age, gender, place of residence (dichotomized <100 000 residents and 100 000), SES (categorized as low, middle and high), hospital of admission (categorized by existence of trauma centres and by region in Israelnorth, centre and south). Interaction terms between population group and each of the other variables were introduced into the regression in order to determine whether there were differences in the OR of hospitalization between Jews and Arabs according to the different variables.
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Results |
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More Jewish than Arab children attended the ER during the night and early morning hours (19:008:00).
Referral to emergency room
Most children and adolescents in both population groups arrived at the ER after attending other sources of care such as a physician's office, other first aid services or school services: 47.9% among Jews and 64.1% among Arabs (P = 0.000).
Means of arrival at the emergency room
The average rate of arrival at the ER by ambulance was 5% (6% among Jews and 3% among Arabs [P = 0.000]).
Admissions to the emergency room
The highest rates of injuries among Arab children were in the 59 age group, while among Jews it was in the age groups 10 and above (Table 1). The Jewish:Arab rate ratio was also higher in these age groups than in the younger ages. Children living in urban areas of 200 000 or more inhabitants presented the lowest injury rates in both ethnic groups. Among Arabs, the highest rates were found among those living in rural areas with less than 2000 inhabitants. While the rate of presentation at the ER was markedly higher among Jews than among Arabs living in large urban settings, the differences among the ethnic groups decreased markedly in populations with less than 100 000 inhabitants. No socioeconomic information on denominator data was available by population group, therefore the specific rates could not be calculated.
Causes of injury
For both Jews and Arabs, the most frequent cause of injury was falls, followed by being struck by objects and traffic accidents (Table 1). Injuries caused by unintentionally being struck/ caught by objects, bites and stings and foreign bodies were about twice as high among Jewish than among Arab children and adolescents. Only for burns were the rates similar among Jews and Arabs. Most of these burns were scalds caused by hot liquids both among Jews (57%) and Arabs (65%), while burns caused by fire and flames were less frequent among Jews (14%) than among Arabs (20%).
Nature of injuries
Fractures, burns and poisonings presented similar rates in both population groups, while intracranial injuries were more frequent among Arab than Jewish children. The rate of superficial injuries (contusions/lacerations), dislocations/sprains and other injuries was higher among Jewish than among Arab children (Table 1).
In both ethnic groups there were twice as many boys than girls brought to the ER with fractures. The gender rate ratio for intracranial injury was 1.7 among Jews and 0.7 among Arabs (not in Table). While among Jews boys were diagnosed with burns 1.6 times more than girls, the gender ratio among Arabs equalled 1.
Outcome
Hospitalizations
The proportion of hospitalization out of those who reached the ER was higher among Arabs (14.4%) than among Jews (8.1%), resulting in 1.15 higher rates of hospitalization among Arabs (70.5/10 000, 95% CI: 68.172.9) than Jews (60.8/10 000, 95% CI: 59.662.1).
In Figure 1 data on the proportion of children hospitalized is presented by socio-demographic factors, hospital of admittance and the cause of injury. Boys and girls presented the same proportion of hospitalization within each ethnic group. The proportion of hospitalization decreased monotonically with age in both ethnic groups, but it was similar between the two groups only among adolescents aged 1517.
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For each cause of injury, the proportion of hospitalization was higher among Arabs than among Jews. The most striking difference was among children and adolescents who were hospitalized for burns. Despite a low incidence of attendance at the ER, as shown in Table 1, they required a high rate of hospitalization: 49.2% among the Arab children, more than twice the rate among Jews. Only among those children admitted to hospital because of suffocation by foreign bodies were Jews admitted in higher proportion than Arabs.
Differences by gender, age, place of residence, socioeconomic status and cause were all significant by Mantel-Haenzel test, while the differences by admitting hospital were not.
In the regression analysis, the OR of being hospitalized was 1.29 higher for Arabs than for Jews, controlling for gender, age, economic status, place of residence, cause of injury and admitting hospital. Age and cause of injury were significantly associated with the OR for hospitalization in both population groups (Table 2). The introduction of interactions between age and population group, and between cause of injury and population group into the model increased the OR of hospitalization of Arabs as compared with that of Jews from 1.29 to 1.92 (95% CI: 0.794.64). However, only the interaction with cause of injury reached levels of significance (P = 0.004), where traffic accidents and suffocation by foreign bodies were significantly higher among Jews than among Arabs.
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Discussion |
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The findings that there was a higher rate of ER visits for Jewish children than for Arab children and adolescents, similar hospitalization rates in both groups and a higher mortality rate among Arab children compared to Jewish children point to potential sources of differences. These may be due to differences in the injury itself, the care available, the use of services, or any combination of them.
Regarding the injury itself, it may be that Arab children and adolescents reach the ER with more severe injuries, as shown by their higher proportion of hospitalizations as compared to Jewish children and adolescents. The severity of the injuries could also be indicated by the type of injuries that the children suffered. While the rates of fractures were similar in both populations, as has been shown in other studies looking at populations with different degrees of affluence,24 the rates of burns (with a higher proportion of hospitalization, especially among Arabs) and intracranial injuries provide an indirect measure of the severity of the injuries reaching the ER, indicating that Arab children reached the ER with more severe injuries. These differences may be attributed to the environment to which they are exposed and to the circumstances surrounding the injury. Differences had already been shown among the Arab Bedouin population in the South of the country (regarding burns), and among Arab children in the North (for falls). This may be due to the specific way of life of nomadic Bedouins or those in transition to urban life25 and the housing characteristics of urban Arabs in the North, who tend to inhabit unfinished housing26 with no stair rails or barriers on upper floors. Housing overcrowding and lack of play spaces could be contributing factors, although we do not have specific information on these aspects. These characteristics are also related to the conditions in lower socioeconomic groups, where the Arab population is over-represented. This was demonstrated by the higher proportion of hospitalized Arab children and adolescents than Jewish ones in the lower and middle SES group, and a similar proportion between the two groups hospitalized in the higher SES group. However, in the logistic regression, the association with SES was not significant in either population group. This lack of association can be ascribed to the type of measurement we used (of an ecological nature) which was not sufficiently discriminative in a multivariate analysis or a real finding.
A contributing factor to the severity of the injury could be delayed care. Coverage by medical insurance could be a likely explanation for differences in ER attendance patterns, since at the time of the data collection the coverage of people under age 18 was 96.7% among the Jewish population and 90.0% among Arabs (Goldwag R, Brookdale Institute of Jerusalem, personal communication). This would not be the case today since under the National Health Insurance Law in force since 1995 there is universal coverage. In 1994, even for those insured there was an out of pocket payment for accessing the ER without referral, which explains the relatively high proportion of the population that attended other sources of care before reaching the ER, especially among Arabs. Nevertheless, there may be differentials in the availability of the ER services due to the distance to the hospital, availability of transport and other such factors. It may be that Jewish parents tend to use the ER more frequently for non-severe injuries with the notion that if there is a need for tests or X-rays this can be done in a single place, or that the professional competence of doctors is better in hospitals than in primary care clinics.
There were some limitations in this study. The study does not include two general hospitals serving predominantly the Jewish population, and three hospitals serving only the Arab population. They represent 6.5% and 5.1% of the paediatric beds in the country, respectively.27 None of these hospitals had orthopaedic, surgical or intensive care units, and therefore they were unlikely to receive cases of serious injury. No weighting for missing cases was carried out as it was assumed that their inclusion, were it possible, would not significantly alter the distribution of injuries described here.
In 14.2% of cases (15.6% among Jews and 7.9% among Arabs) the cause of injury was not recorded. These cases were excluded only for the cause-specific calculations; hence they do not affect the total or other specific rates. Problems with injury documentation and coding have been recognized in the US,28,29 and the Committee on Injury and Poison Prevention of the American Academy of Pediatrics has recently provided specific recommendations to improve recording and coding ER and hospitalization.30
In conclusion, there are differences between Jewish and Arab children in the incidence of injuries leading to ER attendance. Their outcome as measured by hospitalization and death may indicate differences in the use of services by the two populations or in the severity of the injuries. A study is underway to elucidate this point.
KEY MESSAGES
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Acknowledgments |
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