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

Policies and Programs for Prevention and Control of Diabetes in Iran: A Document Analysis

Trend analysis in 2005 to 2011 showed high growth in diabetes prevalence in Iran. Considering the high prevalence of diabetes in the country and likely to increase its prevalence in the future, the analysis of diabetes-related policies and programs is very important and effective in the prevention and control of diabetes. Therefore, the aim of the study was an analysis of policies and programs related to prevention and control of diabetes in Iran in 2014. This study was a policy analysis using deductive thematic content analysis of key documents. The health policy triangle framework was used in the data analysis. PubMed and ScienceDirect databases were searched to find relevant studies and documents. Also, hand searching was conducted among references of the identified studies. MAXQDA 10 software was used to organize and analyze data. The main reasons to take into consideration diabetes in Iran can be World Health Organization (WHO) report in 1989, and high prevalence of diabetes in the country. The major challenges in implementing the diabetes program include difficulty in referral levels of the program, lack of coordination between the private sector and the public sector and the limitations of reporting system in the specialized levels of the program. Besides strengthening referral system, the government should allocate more funds to the program and more importance to the educational programs for the public. Also, Non-Governmental Organizations (NGOs) and the private sector should involve in the formulation and implementation of the prevention and control programs of diabetes in the future

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

Factors influencing the geographic distribution of physicians in Iran: A qualitative study

Introduction: The uneven geographic distribution of physicians has been a longstanding important issue worldwide. Different policies have been recently employed in Iran, with the aim of bridging the gap. This study aimed to explore factors influencing the distribution of specialist physicians in Iran and investigate the effects of newly established policies on attracting and retaining physicians in rural and remote areas. Methods: This qualitative study was conducted in 2012. Qualitative data were obtained through an open-ended questionnaire and by reviewing relevant documents. Participants were 82 key officials from medical universities, who were directly involved in the distribution of physicians across the country, including vice chancellors for treatment affairs, managers for treatment affairs, and human resources experts. Thematic analysis was used to analyse qualitative data. Results: Four main factors influencing the distribution of physicians were explored, namely external, contextual, individual, and organizational factors. The decision to practice in rural areas was mainly influenced by socioeconomic characteristics of the designated areas and personal attributes of physicians, including sex, income expectations, and rural background. Participants also asserted that the implemented policies had a major positive influence on the distribution of physicians. In addition, participants believed that the improvement in the distribution of physicians had both positive economic and health impacts in underdeveloped areas. Conclusions: It seems that the regional distribution and supply of physicians have been improved in the light of the implemented policies in recent years. The study also revealed that a number of factors influence physician choices to stay and practice in rural and underdeveloped areas. Policies such as providing more financial and non-financial incentives, reducing disparities between physicians' income in rural and metropolitan areas, selection of students with rural background, and supportive measures for physicians working in underserved areas were recommended. © H Ravaghi, E Taati, Z Abdi, A Meshkini, S Sarvarizadeh, 2015

Assessors' attitudes toward and experiences of national quality standards: A qualitative study in Iran

To establish a national accreditation system for medical laboratories, Iran has set national standards based on the international standard ISO 15189. Central to the accreditation process are the technical assessors. Their attitude in this regard and their experiences should be identified. This study aims to explore assessors' attitudes toward national laboratory accreditation and their experiences of assessment process in order to identify current gaps and suggest required interventions to solve them. A qualitative study using an open-ended questionnaire was employed. A total of 150 assessors working in the General Directorate of Laboratory Affairs participated in the study. While almost all Iranian laboratory accreditation assessors were generally supportive about the necessity of laboratory accreditation and cited benefits of this process, they pointed to improvement areas including developing assessor selection and appraisal criteria, continuous training, taking into consideration the heterogeneity of laboratories throughout the country, participation of professional associations and adopting measures to increase laboratories' involvement. © 2014 Springer-Verlag Berlin Heidelberg

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

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

Agenda setting analysis for maternal mortality reduction: Exploring influential factors using Kingdon�s stream model Analyse de la définition des enjeux prioritaires pour la réduction de la mortalité maternelle: Exploration des facteurs influents à l'aide du modèle des flux de Kingdon

Background: Maternal mortality is considered as unacceptable death. Aims: This study aimed to analyse the agenda setting process for maternal mortality reduction policies in nine successful countries in achieving Millennium Development Goal 5 (MDG 5) using the Kingdon�s multiple streams theory. Methods: This comparative study analysed the agenda setting process in nine successful countries which achieved MDG 5. The agenda setting analysed the use of the Kingdon�s multiple streams model. To extract similarities and differences in the agenda setting process, the content analysis method, available documents and reports, and the comparative table were used. Results: The initial attention to the problem of high rate of maternal mortality was different in the studied countries, but MDGs and the countries� official reports were the main driver. Political stability, political will, key person�s contribution and legislation were considered influential factors strengthening political stream. International technical or financial support, regional and international conferences, national plans and enabling factors, which provide technical feasibility, were the most important factors influencing the policy stream. Enabling factors included approving regulations and legislation, increased quantity and quality of human resources, organizational structure, service delivery enhancement, infrastructure development, providing medicines and equipment, and strengthening health information system. Conclusions: The three streams: problem, policy and politics are not separate from each other. Political stability and commitment, having a national plan and benefiting from technical or financial support of international entities was a common feature among almost all the studied countries. The key actions leading to the opening of the window of opportunity were those actions that led to highlighting the problem. © World Health Organization (WHO) 2019. Some rights reserved

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

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