The present study not only characterizes injuries and hospital resource utilization among elderly casualties during the last decade in Israel, but also focuses on the differences between Jews and Arabs. The results show that the proportion of hospitalized casualties aged 65 and above among all hospitalized casualties was 2.8 times greater than their proportion in the overall Israeli population. The data presented illustrates the similarities and differences between Jews and Arabs regarding injury related hospitalizations. No significant differences between the two ethnic groups were found with regard to mortality or undergoing surgery. However, Jews, in comparison to Arabs, were more likely to have longer hospital stays,, to be admitted to the ICU and to be discharged to a rehabilitation center. Our results are in partial discrepancy with other international findings which find that there are disparities in the risk of injury and health outcomes between ethnic groups [3, 5,6,7,8, 16].These disparities may be attributed to cultural, safety and behavioral differences .
It was found that the disparities in the risk of hospitalization due to injury between Jews and Arabs are age-dependent. The risk of injury related hospitalizations was greater among Arabs compared to Jews, up to age 79. Previous research, which studied the relationship between socio-economic status and injury in Israel, found that in every socioeconomic cluster, the risk of hospitalization due to injury is higher among Arabs compared to Jews, even after adjusting for age . While the Arab elderly are much younger than the Jewish elderly, they are more disabled . The percentage of Arab elderly who are disabled and need help with activities of daily living is twofold that of Jewish elderly (30% vs. 14%, respectively). In addition, about one-quarter of the Arab elderly living in the community are homebound, compared to 12% among Jewish elderly .
Hicks et al.  documented that disparities in survival after injury exist between white and black patients depending on their age group. Younger white patients have better outcomes after injury than younger black patients, while older black patients have better outcomes than older white patients. Commonly posited explanation for these age-dependent disparities is the insurance status, availability of Medicare, and consequently, better access to pre injury medical care, in the older population. However, in Israel the National Health Insurance Law provides health-care services for all Israeli residents regardless of religion, ethnicity, and gender. Therefore, Arabs and Jews are equally eligible to receive health services.
Although the proportion of Arabs among elderly drivers (65+) in Israel is only 4.5% , we found that they represent 14.6% of vehicle drivers hospitalized due to road accidents. In addition, one in three elderly Arab vehicle drivers who were hospitalized due to a RTI suffered severe/critical injuries. These findings can be attributed to low quality of road infrastructure in Arab villages and towns, inadequate safety behaviors, and unlawful driving. Not only is road infrastructure inferior in Arab towns, but Arabs are more likely to drive in older vehicles and refrain from using safety accessories, such as seatbelts. [21, 22].
In our study several differences between Jewish and Arab elderly casualties were reported. Most notably, Arabs, in comparison to Jews, were far less likely to be discharged to a rehabilitation center (OR = 2.4). Other previous studies support our results that ethnic minorities are less likely to utilize rehabilitation facilities compared to the ethnic majority [3, 5]. For example, in the United States , ethnic minority patients are less likely to be placed in rehabilitation than non- Hispanic white patients, even after accounting for insurance status, suggesting existence of systematic inequalities in access. In addition, our previous study which compared Jewish and Arab children showed that Jewish casualties were more likely to be discharged to rehabilitation facilities than Arabs . This fact can be attributed to various causes; including accessibility, culture and language. Residents living in the Northern district of Israel and in Jerusalem were reported to be 3–4 times less likely to receive inpatient rehabilitation compared to those living in the Center district . Fifty percent and 17% of the Arab elderly live in the North district and Jerusalem, respectively, while only 9% live in the Center district .
In addition, there are vast differences in family relations and composition; Arab nuclear families in Israel usually occupy several households in the same village, which are proximate to each other. Children and grandchildren abound, and are actively involved in the lives of their parents and grandparents . Arabs in Israel rated their culture as more tolerant toward their elders in comparison to Jews and spend more time with them . In the Arab nuclear family, it is both expected and customary for the elderly to live at home and be cared for by family members Language barriers may also contribute to the differences. While the native language of the Arab population is Arabic, Hebrew is the official language in Israel. Due to communication barriers, elderly Arabs may prefer home care rather than residing in a rehabilitation facility with few Arab speaking professionals.
Another difference is the fact that among Arabs, a relatively high proportion of severe/critical casualties were transported by private car. This could be explained by the lack of ambulance availability in many Arab communities . Moreover, in some of the Arab villages there is no exact address and it is difficult to direct the ambulance driver to a specific location. In addition, even though ambulance costs are often paid by health insurance, ambulance fees may be a deterrent. All of these reasons could contribute to the lack of ambulance use among Arabs.
Health policy decision makers and educators should aim to reduce the gaps between the two ethnic groups with regard to accessibility and availability of rehabilitation and ambulance services, as well as increase awareness regarding the availability and utilization of these pre and post hospital services.
Possible explanations for the differences in length of stay between Jews and Arabs may include geographic location and comorbidity. That is, maybe the longer length of hospital stay is due to preexisting conditions rather than the injury itself. In addition, since Arabs live in the periphery, they often arrive first at a level II trauma center after which are transferred to a Level I Trauma Center. Thus, the LOS may not reflect the total time of hospitalization. However, it should be reminded that among casualties suffering from head injuries, no differences in LOS or ICU were found between Jew and Arabs.
Implementing an in-depth study to explore the reasons contributing to disparities in health care utilization between Jews and Arabs is recommended. The outcomes of such a study will provide policy makers with evidence based data to reduce inequality between population groups.
Minority ethnic groups in the United State have a higher risk of mortality after injury than majority group [8, 9]. For example, African American and Hispanic casualties had higher odds ratio of death (1.17 and 1.47, respectively) compared to whites even after adjustment for demographic and injury severity variables . In contrast, the outcomes of our study showed no significant differences between ethnic groups in inpatient mortality. Non-American studies support our results that ethnicity is not an independent predictor of trauma mortality outcomes [3, 11].
The first limitation of our study is that it includes only hospitalized casualties, as those who were discharged following treatment in the emergency department and those who died at scene of the accident or on the way to the hospital are not included. A second limitation is the lack of data regarding socioeconomic status. However, according to Goldman et al. factors other than socioeconomic differences are the cause for injury disparities between Jews and Arabs. A third limitation is the lack of data regarding distance from the scene of the accident to the hospital . However, the INTR includes method of evacuation and transfer to the hospital, thus providing information regarding prehospital medical treatments.