Regional variations in mortality and causes of death in Israel, 2009-2013.
BACKGROUND
Regional variations in mortality can be used to study and assess differences in disease prevalence and factors leading to disease and mortality from different causes. To enable this comparison, it is important to standardize the mortality data to adjust for the effects of regional population differences in age, nationality and country of origin.


METHODS
Standardized mortality ratios (SMR) were calculated for the districts and sub-districts in Israel, for total mortality by gender as well as for leading causes of death and selected specific causes. Correlations were assessed between these SMRs, regional disease risk factors and socio-economic characteristics. Implications for health policy were then examined.


RESULTS
Total mortality in the Northern District of Israel was not significantly different from the national average; but the Haifa, Tel Aviv, and Southern districts were significantly higher and the Jerusalem, Central, Judea and Samaria districts were lower. Cancer SMR was significantly lower in Jerusalem and not significantly higher in any region. Heart disease and diabetes SMRs were significantly higher in many sub-districts in the north of the country and lower in the south. SMRs for septicemia, influenza/pneumonia, and for cerebrovascular disease were higher in the south. Septicemia was also significantly higher in Tel Aviv and lower in the North, Haifa and Jerusalem districts. SMRs for accidents, particularly for motor vehicle accidents were significantly higher in the peripheral Zefat and Be'er Sheva sub-districts.


CONCLUSION
The SMR, adjusted for age and ethnicity, is a good method for identifying districts that differ significantly from the national average. Some of the regional differences may be attributed to differences in the completion of death certificates. This needs to be addressed by efforts to improve reporting of causes of death, by educating physicians. The relatively low differences found after adjustment, show that factors associated with ethnicity may affect mortality more than regional factors. Recommendations include encouraging good eating habits, exercise, cancer screening, control of hypertension, reduction of smoking and improving road infrastructure and emergency care access in the periphery.
['Gordon|Ethel-Sherry|ES|', 'Haklai|Ziona|Z|', 'Meron|Jill|J|', 'Aburbeh|Miriam|M|', 'Salz|Inbal Weiss|IW|', 'Applbaum|Yael|Y|', 'Goldberger|Nehama F|NF|']
D002423:Cause of Death D003644:Death Certificates D006801:Humans D007557:Israel D009026:Mortality D009369:Neoplasms D015995:Prevalence
Causes of death SMR Regional differences Periphery Medical services