Total Healthcare Expenditures from the 2017 Iran’s National Households Income and Expenditure Survey: The Application of Two-Part Models

 Introduction: Although the precise estimates of healthcare expenditures are critical for health policy-makers, the right-skewed distribution and a substantial number of zero values of the measures of healthcare expenditure make such estimates challenging. The present study used conventional two-part (CTP) and marginalized two-part (MTP) models to handle the skewness and zero-inflation in expenditure distribution as two serious challenges. Materials and Methods: Data was used from the 2017 Households Income and Expenditure Survey (HIES; 38,252 households), a national cross-sectional study in Iran. CTP and MTP models were utilized to estimate the medical supplies, outpatient, inpatient and total medical expenditures. The rural-urban difference in total medical expenditures and other health services were also examined.   All data analyses were performed using SAS. For all tests, two-sided p-values <0.05 were interpreted as statistically significant.Results: The mean (SD) out-of-pocket spending for total healthcare was $143 ($488) per capita, and $182 ($650) and $105 ($239) for urban and rural areas, respectively. The mean (SD) medical supplies cost per capita was $48 ($240), and the mean (SD) of outpatient cost per capita and inpatient cost per capita were $61 ($245) and $34 ($294), respectively. Both CTP and MTP models suggested that urban population spent more money on total expenditures than rural populations (p<0.05). Although both models gave the same set of parameter estimates, the AIC indicated that the MTP-GG model was a more appropriate fit.Conclusion: The marginalized models provided better estimates in documenting inequalities/healthcare expenditures. Unlike the CTP model, the estimation of covariate effects on the marginal mean of the whole population via using the MTP model is straightforward. However, the MTP model may not outperform the CTP model in all cases. The applications of such models need to be considered in the future research to provide better estimates/documentations of healthcare expenditure and healthcare inequalities. In addition, these findings suggest a substantial inequality in healthcare expenditures between urban and rural areas. Considering the differences in urbanity and rurality can be of interest to health economists and policymakers.     

Stress Coping Styles in Family and Relatives of Coronavirus Disease 2019 (COVID-19) Patients in the South of Iran:Application of Lazarus and Folkman’s Theory of Stress Coping

Background: The ongoing outbreak of Coronavirus disease 2019 (COVID-19) is a major challenge for mental health care systems and causes and exacerbates mental anxiety. Objective: This study sought to investigate the coping styles of stress in families and relatives of COVID-19 patients in the south of Iran, according to Lazarus and Folkman’s Transactional theory of Stress coping model. Methods: The present cross-sectional study was performed in the period from March 5 to July 5, 2020. Data collection was done electronically using a standard questionnaire on Lazarus and Folkman’s coping methods. Finally, the output data of the electronic questionnaire were analyzed using descriptive and inferential statistics. Results: A total of 276 people participated in the present study. There was a statistically significant difference between age and all emotion-oriented coping style domains (P &lt;0.05), except planful problem solving (P = 0.817) and positive reappraisal (P = 0.153). The results of the present study showed that from the emotion-oriented coping, the domain of self-controlling (%55.9) received an unfavorable score, but in the problem-oriented coping (60.02%), the two domains of social support (%71.27) and positive reappraisal (70%) obtained scores above 50%. Conclusion: Families and relatives need help to improve coping with stress in the area of self-controlling. The results of the present study showed that emotion-oriented coping (self-controlling) had less effect on family stress than problem-oriented coping (domains of social support and positive reappraisal). Also, with domains of social support and positive reappraisal, the stress in the families was reduced. Factors influencing coping styles were age, literacy, source of information, and underlying disease. Since the COVID-19 pandemic condition is a unique stressful situation, it is necessary to implement psychological and educational interventions to gain the ability to control stress, especially in relatives with COVID-19.</p

Factors affecting blood donation intervals and patterns of return based on a sample in southern Iran : a follow-up design

OBJECTIVE : The main goal of blood transfusion centers is to recruit and retain more qualified blood donors. This study aimed to identify the factors influencing the return of volunteer blood donors. MATERIAL AND METHODS : A cohort study was conducted on all blood donors who donated blood for the first time, from March 21, 2013, to March 20, 2014. They were followed up for five years (up to March 20, 2018). Demographic characteristics, type of blood donation and time interval between two blood donations were recorded as recurrent events. Data were then analyzed using Logit Model for Multinomial Responses and Cox's shared frailty model. RESULTS : Of the 2010 blood donors, 33.7% as the repeated donor and 16.2% as the regular donor had regular donations. The frequency of blood donation was in the range of 1 to 20 with a mean of 4.54±3.29. There was a significant reverse relationship between the number of donations and the time interval between two donations. The variables of gender, marital status and occupation had a significant effect on the blood donation of the repeated and regular donors. Genders, age at the time of the first donation, marital status and occupation had a significant effect on the intervals between blood donations. CONCLUSION : Most of blood supply of Iran is provided by men and first-time donors. Since the decision to donate and keep donating blood involves many complex issues applied programs are require to convert women and first-time donors into regular donors.http://www.romj.org/Statistic

Stress coping styles in family and relatives of coronavirus disease 2019 (COVID-19) patients in the South of Iran : application of Lazarus and Folkman’s theory of stress coping

AVAILABILITY OF DATA AND MATERIALS : The data supporting the findings of the article is available from corresponding author [E.M] upon reasonable request.BACKGROUND : The ongoing outbreak of Coronavirus disease 2019 (COVID-19) is a major challenge for mental health care systems and causes and exacerbates mental anxiety. OBJECTIVE : This study sought to investigate the coping styles of stress in families and relatives of COVID-19 patients in the south of Iran, according to Lazarus and Folkman’s Transactional theory of Stress coping model. METHODS : The present cross-sectional study was performed in the period from March 5 to July 5, 2020. Data collection was done electronically using a standard questionnaire on Lazarus and Folkman’s coping methods. Finally, the output data of the electronic questionnaire were analyzed using descriptive and inferential statistics. RESULTS : A total of 276 people participated in the present study. There was a statistically significant difference between age and all emotion-oriented coping style domains (P <0.05), except planful problem solving (P = 0.817) and positive reappraisal (P = 0.153). The results of the present study showed that from the emotion-oriented coping, the domain of self-controlling (%55.9) received an unfavorable score, but in the problem-oriented coping (60.02%), the two domains of social support (%71.27) and positive reappraisal (70%) obtained scores above 50%. CONCLUSION : Families and relatives need help to improve coping with stress in the area of self-controlling. The results of the present study showed that emotionoriented coping (self-controlling) had less effect on family stress than problem-oriented coping (domains of social support and positive reappraisal). Also, with domains of social support and positive reappraisal, the stress in the families was reduced. Factors influencing coping styles were age, literacy, source of information, and underlying disease. Since the COVID-19 pandemic condition is a unique stressful situation, it is necessary to implement psychological and educational interventions to gain the ability to control stress, especially in relatives with COVID-19.https://openpublichealthjournal.comam2023Statistic

Clinical predictors of flare and drug-free remission in rheumatoid arthritis: preliminary results from the prospective BIO-FLARE experimental medicine study

Objectives: Huge advances in rheumatoid arthritis (RA) treatment mean an increasing number of patients now achieve disease remission. However, long-term treatments can carry side effects and associated financial costs. In addition, some patients still experience painful and debilitating disease flares, the mechanisms of which are poorly understood. High rates of flare and a lack of effective prediction tools can limit attempts at treatment withdrawal. The BIOlogical Factors that Limit sustAined Remission in rhEumatoid arthritis (BIO-FLARE) experimental medicine study was designed to study flare and remission immunobiology. Here, we present the clinical outcomes and predictors of drug-free remission and flare, and develop a prediction model to estimate flare risk. Design, setting and participants: BIO-FLARE was a multicentre, prospective, single-arm, open-label experimental medicine study conducted across seven National Health Service Trusts in the UK. Participants had established RA in clinical remission (disease activity score in 28 joints with C reactive protein (DAS28-CRP)<2.4) and were receiving methotrexate, sulfasalazine or hydroxychloroquine (monotherapy or combination). Interventions: The intervention was disease-modifying anti-rheumatic drug cessation, followed by observation for 24 weeks or until flare, with clinical and immune monitoring. Outcome measures: The primary outcome measure was the proportion of participants experiencing a confirmed flare, defined as DAS28-CRP≥3.2 or DAS28-CRP≥2.4 twice within 2 weeks, and time to flare. Exploratory predictive modelling was also performed using multivariable Cox regression to understand risk factors for flare. Results: 121 participants were recruited between September 2018 and December 2020. Flare rate by week 24 was 52.3% (95% CI 43.0 to 61.7), with a median (IQR) time to flare of 63 (41–96) days. Female sex, baseline methotrexate use, anti-citrullinated peptide antibody level and rheumatoid factor level were associated with flare. An exploratory prediction model incorporating these variables allowed estimation of flare risk, with acceptable classification (C index 0.709) and good calibration performance. Conclusion: The rate of flare was approximately 50%. Several baseline clinical parameters were associated with flare. The BIO-FLARE study design provides a robust experimental medicine model for studying flare and remission immunobiology. Trial registration number: ISRCTN registry 1637138

Pulmonary hypertension: intensification and personalization of combination Rx (PHoenix): a phase IV randomized trial for the evaluation of dose‐response and clinical efficacy of riociguat and selexipag using implanted technologies

Approved therapies for the treatment of patients with pulmonary arterial hypertension (PAH) mediate pulmonary vascular vasodilatation by targeting distinct biological pathways. International guidelines recommend that patients with an inadequate response to dual therapy with a phosphodiesterase type‐5 inhibitor (PDE5i) and endothelin receptor antagonist (ERA), are recommended to either intensify oral therapy by adding a selective prostacyclin receptor (IP) agonist (selexipag), or switching from PDE5i to a soluble guanylate‐cyclase stimulator (sGCS; riociguat). The clinical equipoise between these therapeutic choices provides the opportunity for evaluation of individualized therapeutic effects. Traditionally, invasive/hospital‐based investigations are required to comprehensively assess disease severity and demonstrate treatment benefits. Regulatory‐approved, minimally invasive monitors enable equivalent measurements to be obtained while patients are at home. In this 2 × 2 randomized crossover trial, patients with PAH established on guideline‐recommended dual therapy and implanted with CardioMEMS™ (a wireless pulmonary artery sensor) and ConfirmRx™ (an insertable cardiac rhythm monitor), will receive ERA + sGCS, or PDEi + ERA + IP agonist. The study will evaluate clinical efficacy via established clinical investigations and remote monitoring technologies, with remote data relayed through regulatory‐approved online clinical portals. The primary aim will be the change in right ventricular systolic volume measured by magnetic resonance imaging (MRI) from baseline to maximal tolerated dose with each therapy. Using data from MRI and other outcomes, including hemodynamics, physical activity, physiological measurements, quality of life, and side effect reporting, we will determine whether remote technology facilitates early evaluation of clinical efficacy, and investigate intra‐patient efficacy of the two treatment approaches

Trends in the Prevalence and Incidence of Anxiety and Depression in Adult Population in Iran: Findings from Kerman Coronary Artery Diseases Risk factors Study (KERCADRS)

Abstract Background: Anxiety and depression (A&amp;D) are common mental disorders with high economical and health burdens. This study aimed to investigate the prevalence and the incidence rate of A&amp;D and their relationship with socio-demographic and other risk factors and co-morbidities in adults living in southeastern Iran.Method: We recruited adults (15 to 80 years) in two rounds (2009-2012, 2014-2018) of a population-based cohort study called Kerman coronary artery disease risk factors study (KERCADRS) in Kerman, Iran. The age-standardized A&amp;D prevalence was measured among all participants (n=9996) and the five-year A&amp;D incidence rate was measured in those who were free of A&amp;D in the first round (n = 2813). The relationship between A&amp;D and demographic characteristics, smoking, opium use, obesity and physical activity was assessed by logistic regression models. Results: Overall, the prevalence of anxiety (48.1% to 16.4%, P-value &lt;0.001) and depression (5.9% to 1.3% P-value &lt;0.001) decreased between the two rounds. The highest prevalence of anxiety was among people who were unemployed (%?), smokers (%?), and opium users (%?). Young adults, women, those divorced or widowed, and those with obesity and low physical activity had a higher chance for anxiety. The five-year incidence rate (person/1000 person-years) was 15.0 for anxiety and 3.9 for depression.Conclusion: Despite the overall decrease in the prevalence of A&amp;D, certain groups such as young adults, women, unemployed and those who smoke cigarettes or opium, people with low physical activity and obesity are in need of more targeted interventions.</jats:p

Marginalized Two-Part Joint Modeling of Longitudinal Semi-Continuous Responses and Survival Data: With Application to Medical Costs

Non-negative continuous outcomes with a substantial number of zero values and incomplete longitudinal follow-up are quite common in medical costs data. It is thus critical to incorporate the potential dependence of survival status and longitudinal medical costs in joint modeling, where censorship is death-related. Despite the wide use of conventional two-part joint models (CTJMs) to capture zero-inflation, they are limited to conditional interpretations of the regression coefficients in the model’s continuous part. In this paper, we propose a marginalized two-part joint model (MTJM) to jointly analyze semi-continuous longitudinal costs data and survival data. We compare it to the conventional two-part joint model (CTJM) for handling marginal inferences about covariate effects on average costs. We conducted a series of simulation studies to evaluate the superior performance of the proposed MTJM over the CTJM. To illustrate the applicability of the MTJM, we applied the model to a set of real electronic health record (EHR) data recently collected in Iran. We found that the MTJM yielded a smaller standard error, root-mean-square error of estimates, and AIC value, with unbiased parameter estimates. With this MTJM, we identified a significant positive correlation between costs and survival, which was consistent with the simulation results.</jats:p

Trends in the prevalence and incidence of anxiety and depressive symptoms in Iran: findings from KERCADRS

ObjectivesAnxiety and depression (A&amp;D) are common mental disorders with high economical and health burdens. This study aimed to investigate the prevalence and the incidence rate of A&amp;D symptoms and their relationship with sociodemographic and other risk factors and comorbidities in adults living in southeastern Iran.DesignA population-based cohort study with random cluster household survey sampling method.SettingSecond round of Kerman Coronary Artery Disease Risk Factors Study (KERCADRS) (2014–2018) performed in Southeastern, Iran.ParticipantsWe recruited 9997 participants (15–80 years) in the second round of the study, from whom 2820 persons were the people who also participated in the first round of KERCADRS in 2009–2012. The age-standardised A&amp;D prevalence was measured among all participants, and the 5-year A&amp;D incidence rate was measured in those who were free from A&amp;D in the first round in 2009–2012 and were at risk of A&amp;D in the follow-up. The relationship between A&amp;D and demographic characteristics, smoking, opium use, obesity and physical activity was assessed by logistic regression models.ResultsOverall, the prevalence of anxiety (48.1% to 16.4%, p&lt;0.001) and depression (5.9% to 1.3%, p&lt;0.001) decreased between the two rounds. The highest prevalence of anxiety was among widowed (31.4%), unemployed (21.3%), obese (19.4%), and opium users (17.4%). Young adults, women, those divorced or widowed, and those with obesity and low physical activity had a higher chance of developing anxiety. The 5-year incidence rate (person/1000 person-years) was 15.0 for anxiety and 3.9 for depression.ConclusionDespite the overall decrease in the prevalence of A&amp;D symptoms in last 5 years in the area, young adults, women, unemployed, opium users, people with low physical activity and those with obesity had a higher chance of developing anxiety and are in need of more targeted interventions.</jats:sec

Trends in the prevalence and incidence of anxiety and depressive symptoms in Iran: findings from KERCADRS.

Anxiety and depression (A&amp;D) are common mental disorders with high economical and health burdens. This study aimed to investigate the prevalence and the incidence rate of A&amp;D symptoms and their relationship with sociodemographic and other risk factors and comorbidities in adults living in southeastern Iran. A population-based cohort study with random cluster household survey sampling method. Second round of Kerman Coronary Artery Disease Risk Factors Study (KERCADRS) (2014-2018) performed in Southeastern, Iran. We recruited 9997 participants (15-80 years) in the second round of the study, from whom 2820 persons were the people who also participated in the first round of KERCADRS in 2009-2012. The age-standardised A&amp;D prevalence was measured among all participants, and the 5-year A&amp;D incidence rate was measured in those who were free from A&amp;D in the first round in 2009-2012 and were at risk of A&amp;D in the follow-up. The relationship between A&amp;D and demographic characteristics, smoking, opium use, obesity and physical activity was assessed by logistic regression models. Overall, the prevalence of anxiety (48.1% to 16.4%, p&lt;0.001) and depression (5.9% to 1.3%, p&lt;0.001) decreased between the two rounds. The highest prevalence of anxiety was among widowed (31.4%), unemployed (21.3%), obese (19.4%), and opium users (17.4%). Young adults, women, those divorced or widowed, and those with obesity and low physical activity had a higher chance of developing anxiety. The 5-year incidence rate (person/1000 person-years) was 15.0 for anxiety and 3.9 for depression. Despite the overall decrease in the prevalence of A&amp;D symptoms in last 5 years in the area, young adults, women, unemployed, opium users, people with low physical activity and those with obesity had a higher chance of developing anxiety and are in need of more targeted interventions