Developing of the appropriateness evaluation protocol for public hospitals in Iran

Background: Employment of utilization review instruments is a method for managing costs and efficiency in the healthcare systems. Objectives: This study developed an instrument for measuring the level of inappropriate acute hospital admissions and days of care in Iran. Patients and Methods: The American version of the Appropriateness Evaluation Protocol (AEP) was modified, using the agreement method, by a multidisciplinary group of physicians. We conducted a retrospective descriptive study of 273 randomly selected patients admitted to Imam Khomeini Hospital of Tehran University of Medical Sciences in Tehran, Iran. For the reliability study, two nurses were asked to review patients� medical records using the instrument. Validity was appraised by pairs of clinicians, including two general surgeons, two internists and two gynecologists. The degree of consensus between the three pairs of clinicians was compared with that of the nurses. Results: Inter-rater and intra-rater reliability testing revealed an excellent level of consensus between the two nurses employing the AEP in all the studied departments. Overall agreement was > 92, while the specific appropriate agreement and specific inappropriate agreement were > 88 and > 83, respectively. External validity testing of the instrument yielded a sensitivity > 0.785, specificity > 0.55, and positive and negative predictive values > 0.775 and > 0.555, respectively. The kappa statistic for the nurses who applied the AEP and clinicians using personal judgment were perfect (k > 0.85) and substantial (k > 0.68), respectively. Conclusions: The results illustrate that the Iranian version of the AEP (IR-AEP) could be a reliable and valid instrument for assessing the level of inappropriate acute hospital admissions and days of care in the Iranian context. © 2015, Iranian Red Crescent Medical Journal

Study of direct thermal energy storage technologies for effectiveness of concentrating solar power plants

In this paper, numerical comparisons are devised among different direct thermal energy storage (TES) technologies of concentrating solar power (CSP) plants with possible alternatives in design, plantwide control and global economic considerations and therefore, leading the process up to the sustainable power production through the day and night. The first design is based on the conventional direct double-tank thermal energy storage CSP plant, and afterwards, the modification on the design of this plant is proposed. The modification on the plantwide control is followed by recycling the heat transfer fluid (HTF) through the solar field and decreasing the degradation of temperature of the storage in discharge period. In addition, the analogues analysis is performed towards the solutions of the stable behavior on dynamic of the storage and power production. Owing to the fact that the single-tank storage technology eliminates using an extra storage volume in process design, consequently, it decreases the capital cost of the plant, the dynamic design of the single-tank storage technology is presented. Avoiding the greater degradations of the parameters is considered and improved through the heat exchanger trains as a challenging issue in storage technologies along with the plantwide control. In this work, considerations of process control to improve the quality of storage, operational issues, and flexibility related to the selected TES technologies are discussed due to making decisions for optimal control and covering the demanded energy generated by CSP plant

The experience of implementing the board of trustees� policy in teaching hospitals in Iran: An example of health system decentralization

Background: In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy of teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in each hospital and significant modifications in hospitals� financing. Since the reform aimed to improve its predecessor policy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as enhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were never realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of trustees� policy did not achieve its perceived objectives. Methods: We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 and 10 participants, respectively) with experts at high, middle, and low levels of Iran�s health system, using purposive and snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed verbatim and analyzed thematically, following a mixed inductive-deductive approach. Results: Three main themes emerged from the analysis. The implementation approach (including the processes, views about the policy and the links between the policy components), using research evidence about the policy (local and global), and policy context (health system structure, health insurers capacity, hospitals� organization and capacity and actors� interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization policies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration of the above factors in policy implementation into account. Conclusion: The implementation of the board of trustees� policy did not achieve its desired goals in teaching hospitals in Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not prepared appropriately and key stakeholders, particularly the government, did not support the decentralization of Iran�s health system. © 2015 by Kerman University of Medical Sciences

Stakeholders' perspective on health equity and its indicators in Iran: A qualitative study

Background: To reduce the health inequity, it is necessary to measure and monitor these inequalities. In this regard, in Iran a plan was developed and accordingly 52 indicators to measure equity in health were developed and announced by the Ministry of Health in collaboration with other sectors. This study aims to obtain a deeper understanding of the development of health equity indicators and identify their implementation challenges and proposed solutions from the perspective of policy makers and executives responsible for the indicators development and implementation. Methods: In this qualitative study, data were gathered using semi-structured interviews with 15 Stakeholders involved in the development and implementation of these health equity indicators (at national and provincial levels), and the review and analysis of relevant documents including meeting minutes, working plans and working progress reports. Data were analyzed using a framework analysis approach. Results: Four main themes were identified, including the concept of equity in health and its importance, the use of health equity indicators and process of indicators development, challenges of development and implementation of the indicators and laying the groundwork for the establishment of indicators. The findings showed that policy makers' viewpoint on concepts and indicators is different from those of executives and their perceptions have little in common. The establishment of indicators requires accurate stakeholders' understanding and accurate insight into the issue of equity in health, political will, financing, training and empowerment of organization's employees, legal requirements, and finally a clear action plan. Conclusion: The development of the indicators requires a shared understanding among policy makers and executives. As the attention has been focused recently on the issue, in addition to knowledge improvement, proper solutions with an intersect oral collaboration approach in order to tackle challenges should be considered

Relationship between personal characteristics of specialist physicians and choice of practice location in Iran

Introduction: Uneven geographic distribution of physicians is a major healthcare issue in Iran. This study aimed to explore the relationship between personal characteristics of the recently graduated specialist physicians in Iran and their choice of practice location. Methods: A cross-sectional study was conducted to extract information with regard to 3825 recently graduated specialist physicians from all medical schools across Iran between 2009 and 2012. The relationship between physicians' personal attributes and their desire to practise in underdeveloped areas was analyzed using �2 test and logistic regression analysis. Results: Birthplace, sex, exposure to rural practice before residency program, place of residence, and year of graduation were associated with physicians' desire to practise in an underdeveloped area. The logistic regression showed that female physicians were less likely to choose underdeveloped areas to practise as compared with their male counterparts (OR=0.659, 95CI, 0.557-0.781, p�0.001). Physicians who lived in underdeveloped areas were nine times more likely to choose underdeveloped areas to practise as compared with those living in other areas (OR=8.966, 95CI, 4.717-17.041, p�0.001). Physicians who did not have previous exposure to rural practice were 28 less likely to choose to serve in the underdeveloped areas as compared to those who had such exposure (OR=0.780, 95CI, 0.661-0.922, p=0.004). Neither physicians' marital status nor their success in the board certification exam was associated with their choice of practice location. Conclusions: It seems that increasing the enrollment of physicians with a rural background in residency programs may solve the problem of uneven distribution of specialist physicians in Iran. Because female physicians are less willing to work in the underdeveloped areas than male physicians, increasing the number of male student admissions to residency programs, particularly in certain specialties that are more in demand in the underdeveloped areas, could alleviate the problem of uneven distribution of physicians in the short run. Further, programs that support raising the admissions of female students with a rural background into local medical universities along with providing incentives to encourage them to live and work in rural areas should be put on the policy agenda. © James Cook University 2016

Safety and efficacy of transcranial magnetic stimulation (TMS) and repetitive transcranial magnetic stimulation (rTMS) in treatment of major depressive disorder: Systematic reviews and meta-analysis

Background: Prevalence of major depressive disorder allocated significant contribution of disease burden in developed and developing countries because of involving active and productive age groups and communities in recent decades. Different methods are used to manage and treat this disorder that one of them is Transcranial Magnetic Stimulation (TMS). The purpose of this study was assessment of safety, effectiveness and cost-effectiveness of Transcranial Magnetic Stimulation and Repetitive Transcranial Magnetic Stimulation (rTMS) technology in treatment of major depressive disorder. Methods: In order to gather evidence, main databases Cochrane Library, Centre for Reviews and Dissemination (CRD), PubMed, Scopus, Trip, Embase, Inahta, PsycINFO, Google Scholar were searched with appropriate keywords and strategies. After quality assessment of studies, consequences of safety and efficacy of the technology were extracted and Stata 12 software was used, if needed, for meta-analysis. Findings: From a total of 273 studies, 43 studies were entered firstly and 8 studies were selected after final review. The amount of standardised mean difference (SMD) was equal to -0.3 with a %95 confidence interval of -0.82 to 0.23 for rTMS-treated group versus sham group with a substantial rate and significant heterogeneity (P < 0.001, I-Squared = 81.9%). Conclusion: Repetitive Transcranial Magnetic Stimulation is a method with significant and high safety. On other side, its efficacy, compared to sham group, is not very significant. © 2015, Isfahan University of Medical Sciences(IUMS). All rights reserved

Senior managersâ viewpoints toward challenges of implementing clinical governance: a national study in Iran

Background: Quality improvement should be assigned as the main mission for healthcare providers. Clinical Governance (CG) is used not only as a strategy focusing on responding to public and governmentâs intolerance of poor healthcare standards, but also it is implemented for quality improvement in a number of countries. This study aims to identify the key contributing factors in the implementation process of CG from the viewpoints of senior managers in curative deputies of Medical Universities in Iran. Methods: A quantitative method was applied via a questionnaire distributed to 43 senior managers in curative deputies of Iran Universities of Medical Sciences. Data were analyzed using SPSS. Results: Analysis revealed that a number of items were important in the successful implementation of CG from the senior managersâ�� viewpoints. These items included: knowledge and attitude toward CG, supportive culture, effective communication, teamwork, organizational commitment, and the support given by top managers. Medical staff engagement in CG implementation process, presence of an official position for CG officers, adequate resources, and legal challenges were also regarded as important factors in the implementation process. Conclusion: Knowledge about CG, organizational culture, managerial support, ability to communicate goals and strategies, and the presence of effective structures to support CG, were all related to senior managersâ attitude toward CG and ultimately affected the success of quality improvement activities. © 2016, Kerman University of Medical Sciences. All rights reserved

Fail to prepare and you can prepare to fail: The experience of financing path changes in teaching hospitals in Iran

Background: In 1995, teaching and public hospitals that are affiliated with the ministry of health and medical education (MOHME) in Iran were granted financial self-sufficiency to practice contract-based relations with insurance organizations. The so-called "hospital autonomy" policy involved giving authority to the insurance organizations to purchase health services. The policy aimed at improving hospitals' performance, hoping to reduce government's costs. However, the policy was never implemented as intended. This was because most participating hospitals gave up to implement autonomous financing and took other financing pathways. This paper analyses the reasons for the gap between the intended policy and its execution. The lessons learned from this analysis can inform, we envisage, the implementation of similar initiatives in other settings. Methods: We conducted semi-structured interviews with 28 national and 13 regional health policy experts. We also gathered a comprehensive and purposeful set of related documents and analyzed their content. The qualitative data were analyzed by thematic inductive-deductive approach. Results: We found a number of prerequisites and requirements that were not prepared prior to the implementing hospital autonomy policy and categorized them into policy content (sources of funds for the policy), implementation context (organization of insurance organizations, medical tariffs, hospitals' organization, feasibility of policy implementation, actors and stakeholders' support), and implementation approach (implementation method, blanket approach to the implementation and timing of implementation). These characteristics resulted in unsuitable platform for policy implementation and eventually led to policy failure. Conclusions: Autonomy of teaching hospitals and their exclusive financing through insurance organizations did not achieve the desired goals of purchaser-provider split in Iran. Unless contextual preparations are in place, hospital autonomy will not succeed and problematic financial relations between service providers and patients in autonomous hospitals may not be ceased as a result. © 2016 Doshmangir et al

The prevalence of migraine in Iran: A systematic review and meta-analysis

Context: Migraine is a major dilemma and problem which affects public health and results to reduced quality of life. This study aimed to determine the prevalence of migraine in Iran. Evidence Acquisition: A systematic search was conducted using Pub Med,Web of Science,Embase,Scopus,Ovid,Google Scholar,as well as Iranian databases including: MagIran,IranMedex and Scientific Information Databank,from 2000 to November,2015. The Der-Simonian/Laird�s random-effects model,with a 95 confidence intervalwasemployed to estimate the overall pooled prevalence. Heterogeneity was investigated using subgroup analysis based on sample size and time of study. Results: Thirty studies comprising 33,873 participants met the inclusion criteria for the analysis. The overall prevalence of migraine in Iran was 14 (95 CI,12 to 17),respectively. The overall prevalence was (8; 95 CI 6 to 11) according to the international classification of headache disorders (ICHD-1),(17; 95 CI 13 to 21) according to ICHD-2,and (18; 95 CI 7 to 30) according to the other questionnaire for migraine screener (ID Migraine),respectively. Meta-regression demonstrated that the prevalence of migraine increased by year of publication and decreased by sample size. Conclusions: The prevalence of migraine in Iran,which was estimated as 14,was similar or even higher than that reported worldwide. Migraine can have impact on the economic productivity of any country; therefore it is necessary to educate people on the early detection and the discovery of an effective treatment of migraine. More thorough review of further studies in this field is recommended. © 2016,Iranian Red Crescent Medical Journal

Oral health behaviours of children and adolescence in England, Wales and Northern Ireland: Findings from the 2013 Child Dental Health Survey

BACKGROUND: The 2013 Children's Dental Health Survey is the fifth in a series of national surveys. AIM: To describe the oral health behaviours in children and adolescents in England, Wales and Northern Ireland. METHOD: A representative sample of children (aged 5, 8 12 and 15 years) in England, Wales and Northern Ireland were invited to participate in dental examinations. Children and parents were also invited to complete a questionnaire about oral health behaviours. RESULTS: Overall, the majority of children and young people reported good oral health behaviours. For example, more than three quarters of the 12- and 15-year-olds reported brushing their teeth twice a day or more often. However, a sizeable proportion of the sample reported less positive behaviours. Nearly 30% of 5-year-olds first started to brush their teeth after the age of one year. Among 15-year-olds, 11% were current smokers and 37% reported that they currently drank alcohol. Sixteen percent of 12-year-olds reported to consume drinks containing sugar four or more times a day. Of particular concern was the marked differences that existed by level of deprivation. Children living in lower income households (eligible for free school meals) were less likely to brush their teeth twice a day, more likely to start brushing after six months, more likely to be a smoker and more likely to consume frequent amounts of sugary drinks. CONCLUSION: Despite some encouraging overall patterns of good oral health behaviours, a sizeable proportion of children and young people reported behaviours that may lead to poorer oral and general health. Preventive support should be delivered in clinical dental settings to encourage positive oral health behaviours. Public health strategies are also needed to reduce inequalities in oral health behaviours among children and young people