The Use of Evidence-Informed Deliberative Processes for Health Insurance Benefit Package Revision in Iran.

BACKGROUND: Iran considers the revision of its health insurance benefit package (HIBP) as a means to achieve universal health coverage (UHC). Yet, its decision-making process has been criticised for being weak in terms of accountability and transparency. This paper reports on the development and implementation of the HIBP revision in Iran in the period 2019-2021, employing evidence-informed deliberative processes (EDPs), a framework for benefit package design with the explicit aim of optimising the legitimacy of decision-making. METHODS: The High Council for Health Insurance (HCHI) is coordinating the HIBP revision: it planned the six steps of the EDP framework with support from World Health Organization (WHO) and Radboudumc in 2019, and conducted a pilot project on multiple sclerosis (MS) diagnosis and treatment in 2020. RESULTS: Implementation of the MS pilot project concerned the installation of advisory committees (involving some 60 stakeholders in supportive task forces, a technical working group [TWG] and a national advisory committee [NAC]), the selection of decision criteria (relating to quality of care, necessity, and sustainability), the inclusion of services for evaluation (nine in total), and the assessment and appraisal of these services. CONCLUSION: Implementation of the priority setting process for MS diagnosis and treatment services has likely improved the legitimacy of decision-making by involving stakeholders who engaged in deliberation based on available evidence in a stepwise, transparent process. It is expected to improve the quality of care for MS patients as well as its financial accessibility, at a zero net budget impact. The pilot project has served to help Iran's health system move faster toward UHC for a broader range of essential health services.

A comparison between on-demand usage of rFVIIa vs prophylaxis use of emicizumab in high titer inhibitory hemophilia A patients in Iran: A cost-utility analysis.

BACKGROUND: Hemophilia A (HA) is an inherited X-linked bleeding disease with costly treatment, especially for high titer inhibitory patients. Emicizumab, a new humanized bispecific antibody, has been approved for use to prevent or reduce the frequency of bleeding episodes in HA patients with inhibitors. This study evaluated the cost-utility of emicizumab prophylaxis (EP) in comparison with recombinant factor VII activated on-demand treatment in HA patients with inhibitors. METHODS: A life-time Markov model with payer and societal perspectives was developed in different age groups with different annual bleeding rates (ABR). Efficacy of treatments were extracted from HAVEN trials. Utilities were retrieved from published evidence. Costs were calculated based on Iran food and drug administration official website, national tariff book for medical services and hospital data. One-way deterministic sensitivity analysis was performed. RESULTS: EP was dominant choice in comparison with on-demand administration of recombinant factor VII activated in all age groups with ABR 20 and 25, and it remained dominant in patients with age 2 and age 12 at start point with ABR 16 and 17. The reported incremental cost-effectiveness ratio for the group with ABR 18 at the age 20, was 12,936 United States Dollars which is lower than the acceptable threshold of cost-effectiveness in Iran (1-3 gross domestic product per capita) and EP can be considered as cost-effective choice in this scenario. CONCLUSION: EP was found to be a dominant and cost-effective choice for Iranian HA patients with factor VIII inhibitors with ABR 18 and above with considerable cost saving.

Economic Evaluation for Benign Prostatic Hyperplasia in Iran: Surgical Treatment or Dutasteride.

Benign prostatic hyperplasia is a common chronic disease that is age-dependent. There are two main types of interventional treatment, transurethral resection of prostate as a gold standard (TURP) and open prostatectomy (OP); also, there are two pharmacological groups for managing BPH: alpha-blockers and 5-alpha-reductase inhibitors (5-ARIs). In this economic evaluation study, one 5-ARIs, dutasteride and two main surgical treatments are compared as alternatives for treating moderate BPH in Iran. A cost-utility study with an Iranian health provider perspective was conducted. Markov model in a cohort of 1000 patients with BPH with annual cycle length and ten years' time horizon was developed by using MS EXCEL 2013. The effectiveness measure was an improvement in the IPSS score and transformed to the utility. The transition probabilities, utilities and adverse events were extracted from published clinical trials. The direct medical costs were measured in the 2017 US Dollar. One way sensitivity analysis and scenario analysis were conducted.For treating moderate BPH, seventy-year-old men, in the base case scenario, the utility of pharmacotherapy is 18 QALY less than surgery, and the cost of pharmacotherapy is 136,301.1 $ less than surgery. ICER for pharmacotherapy was 7,572.3 $ compared to surgery. In the sensitivity analysis, the model is not sensitive to most variables but the unit cost of dutasteride. Based on scenario analysis conducted for different age groups, pharmacotherapy with dutasteride is preferred to surgery in patients over 60 years of age in Iran. However, for younger adult men between 40-60 years old, surgery is a cost-effective alternative.

Evaluation of Urban and Rural Family Physician Program in Iran: A Systematic Review.

BACKGROUND: Global experience as well as expert views weight the Family Physician program (FPP) as a primary solution for various problems of healthcare system in Iran. In spite of the valuable information has been collected during conducting FPP, few studies have been done to evaluate the actual performance of this program. This study reviewed the studies related to the evaluation of the FPP systematically. METHODS: The authors systematically searched PubMed, Web of Science, Scopus, Embase, Irandoc and SID for articles published in English and Persian until Nov 2017 without limitation for starting time. Selection stages of the articles were done based on PRISMA flow diagram guidelines. RESULTS: Of all articles evaluated, 19 were selected. Four articles were removed due to inadequate quality of the study. Only one article evaluates urban and the rest are about rural. Eight articles were categorized as the process evaluations and 12 outcome assessments (one of them was common). CONCLUSION: We achieved three main findings. First, the rural FPP has improved access to the healthcare services, but improvement in patient finding and quality of cares remains questionable. Second, there are considerable concerns in the referral system between levels I and II in both urban and rural programs. Third, there was no efficient planning to implement the FP as the gatekeepers of health care system effectively. These issues deprived the efficiency aim of FPP and need serious consideration.