Developing a quality and safety assessment framework for Iran's military hospitals.

BACKGROUND: The first crucial step towards military hospitals performance improvement is to develop a local and scientific tool to assess quality and safety based on the context and aims of military hospitals. This study introduces a Quality and Safety Assessment Framework (Q&SAF) for Iran's military hospitals. METHODS: This is a literature review which continued with a qualitative study. The Q&SAF for Iran's military hospitals was developed initially, through a review of the WHO's framework for hospital performance, literature review (other related framework), review of military hospital-related local documents, consultations with a national and sub-national expert. Finally, the Delphi technique used to finalize the framework. RESULTS: Based on the literature review results; 13 hospital Q&SAF were identified. After reviewing literature review results and expert opinions; Iran's military hospitals Q&SAF was developed with 58 indictors in five dimensions including clinical effectiveness, safety, efficiency, patient-centeredness, and Responsive Management (Command and Control). The efficiency dimension had the highest number of indictors (19 indictors), whereas the patient-centered dimension had the lowest number of indices (4 indictors). CONCLUSION: Regarding the comprehensiveness of the developed assessment framework due to its focus on the majority of quality dimensions and important components of the hospital's performance, it can be used as a useful tool for assessing and continuously improving the quality of hospitals, particularly military hospitals.

Hospital Performance Evaluation Checklist in Context of COVID-19 Pandemic: Design and Validation.

OBJECTIVE: Around the world, pandemics have been considered among the main hazards in the last 2 decades. Hospitals are 1 of the most important organizations responding to pandemics. The aim of this study was to design and develop a valid checklist for evaluating the hospitals' performance in response to COVID-19 pandemic, for the first time. METHODS: This study is a mixed method research design that began in February, 2020 and was conducted in 3 phases: Designing a conceptual model, designing a primary checklist structure, and checklist psychometric evaluation. Known-groups method has been used to evaluate construct validity. Two groups of hospitals were compared: group A (COVID-19 Hospitals) and group B (the other hospitals). RESULTS: The checklist's main structure was designed with 6 main domains, 23 sub-domains, and 152 items. The content validity ratio and index were 0.94 and 0.79 respectively. Eleven items were added, 106 items were removed, and 40 items were edited. Independent t-test showed a significant difference between the scores of the 2 groups of hospitals (P < 0.0001). Pearson correlation coefficient test also showed a high correlation between our checklist and the other. The internal consistency of the checklist was 0.98 according to Cronbach's alpha test. CONCLUSIONS: Evaluating the hospitals' performance and identifying their strengths and weaknesses, can help health system policymakers and hospital managers, and leads to improved performance in response to COVID-19.

Budgeting in Healthcare Systems and Organizations: A Systematic Review.

Background: Budgeting is the process resource allocation to produce the best output according to the revenue levels involved. Among the constraints that healthcare organizations, including hospitals, both in the public and private sectors, grapple with is budgetary constraints. Therefore, cost control and resource management should be considered in healthcare organizations under such circumstances. Methods: We aimed to identify methods of budgeting in healthcare systems and organizations as a systematic review. To extract and analyze the data, a form was designed by the researcher to define budgeting methods proposed in the literature and to identify their strengths, weaknesses, and dimensions. The search was conducted in Google Scholar, Web of science, Pub med and Scopus databases covering the period 1990-2022. Results: Overall, 33 articles were included in the study for extraction and final analysis. The study results were reported in four main themes: healthcare system budgeting, capital budgeting, global budgeting, and performance-based budgeting. Conclusion: Each budgeting approach has its own pros and cons and requires meeting certain requirements. These approaches are selected and implemented depending on each country's infrastructure and conditions as well as its organizations. These infrastructures need to be thoroughly examined before implementing any budgeting method, and then a budgeting method should be selected accordingly.

Cost-Effectiveness of Remote Cardiac Monitoring With the CardioMEMS Heart Failure System: A Systematic Review.

Background: Heart Failure (HF) imposes a relevant burden and a considerable health concern, with high prevalence and mortality rates. This study was conducted to assess the cost-effectiveness of remote cardiac monitoring with the CardioMEMS Heart Failure System. Methods: In the present systematic review, several scholarly databases were searched and updated from inception up to September 20, 2022. The objective of the present review was formulated according to the patient/population, intervention, comparison and outcomes format. Mortality rate, hospitalization rate, quality-adjusted life year (QALY), total costs, and the incremental cost-effectiveness ratio regarding the use of the CardioMEMS System were the key outcomes of the present study. The quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS) checklist. Results: Finally, 5 articles were retained and analyzed in the present systematic review. All studies employed the Markov and decision tree models. Results show that the CardioMEMS system reduced mortality and hospitalization rate and created a higher QALY. In all selected countries the CardioMEMS method is a more expensive method than the standard of care (SoC), with the highest cost in the United States (US) ($201,437) and the lowest cost in the United Kingdom ($25,963), respectively. the highest willingness to pay in the US and the lowest in Italy ($100,000 and $33,000 per QALY), respectively. Results showed that the most cost per QALY for the CardioMEMS system was in the US and the lowest was in the Netherlands ($46,622 and $26,615 per QALY), respectively. Conclusion: In all selected countries, CardioMEMS is a cost-effective method for monitoring and managing pulmonary artery pressures in HF patients. Strategies such as CardioMEMS, which decrease the rate of hospitalization, are likely to be only more cost-effective in the future.

Cost-benefit analysis of Intensive Care Unit with Activity-Based Costing approach in the era COVID-19 pandemic: A case study from Iran.

BACKGROUND: Providing intensive care to acute patients is a vital part of health systems. However, the high cost of Intensive Care Units (ICU) has limited their development, especially in low-income countries. Due to the increasing need for intensive care and limited resources, ICU cost management is important. This study aimed to analyze the cost-benefit of ICU during COVID-19 in Tehran, Iran. METHODS: This cross-sectional study is an economic evaluation of health interventions. The study was conducted in the COVID-19 dedicated ICU, from the provider's point of view and within one-year horizon. Costs were calculated using a top-down approach and the Activity-Based Costing technique. Benefits were extracted from the hospital's HIS system. Benefit Cost ratio (BCR) and Net Present Value (NPV) indexes were used for cost-benefit analysis (CBA). A sensitivity analysis was performed to evaluate the dependence of the CBA results on the uncertainties in the cost data. Analysis was performed with Excel and STATA software. RESULTS: The studied ICU had 43 personnel, 14 active beds, a 77% bed occupancy rate, and 3959 occupied bed days. The total costs were $2,372,125.46 USD, of which 70.3% were direct costs. The highest direct cost was related to human resources. The total net income was $1,213,314.13 USD. NPV and BCR were obtained as $-1,158,811.32 USD and 0.511 respectively. CONCLUSION: Despite operating with a relatively high capacity, ICU has had high losses during the COVID-19. Proper management and re-planning in the structure of human resources is recommended due to its importance in the hospital economy, provision of resources based on needs assessment, improvement of drugs management, reduction of insurance deductions in order to reduce costs and improve ICU productivity.

A Systematic Review and Meta-Analysis of Health Care Quality in Iran Based on the Comprehensive Quality Measurement in Health Care Model.

Background: Comprehensive assessment of health care quality is the first step in improving care and achieving health service goals. Therefore, this study aimed to conduct a systematic review and meta-analysis of health care quality in Iran based on the Comprehensive Quality Measurement in Health Care model. Methods: In this study, the databases of PubMed, Scopus, Web of Science, Iranian Scientific Information Database (SID), MagIran, and Google Scholar were searched using English and Iran keywords without time limit. STATA 16 software and a random effect model were used for conducting meta-analysis. Results: Of the 750 articles found, 20 were finally included; 13 of which were related to service quality, five to customer quality, and four to technical quality. Overall mean score of service quality was 7.79 [95% CI 7.43-8.15, df = 12, I2 = 98.48, P value < 0.000] out of 10, and overall mean score of customer quality was 73.20 ± 4.56 [95% CI 65.18-81.22, df = 5, I2 = 99.34, P value < 0.001] out of 100. Among the 12 dimensions of service quality, the confidentiality dimension (9.55 ± 0.12) had the highest mean score and the group support dimension (5.92 ± 0.901) had the lowest score. In general, from the viewpoint of service receivers, the technical quality is relatively favorable. Conclusions: According to the results of this study, the quality of health care in Iran is significantly far from ideal. Therefore, planning to improve providing health care is essential.

Intensive Care Unit Risk Assessment: A Systematic Review.

BACKGROUND: It is of paramount importance to reduce the probability of clinical risks to improve the quality of health care services, make the relationship between service providers and patients more effective, enhance patient satisfaction, and decrease the rate of complaints regarding medical errors in hospitals. This study aimed at detecting potential and unacceptable risks occurring in the hospital ICUs. METHODS: In this systematic review, all studies examining the risk assessment of ICUs in hospitals using Failure Mode and Effect Analysis method were reviewed. Google scholar, PubMed, Scopus, SID, Magiran and Web of Science databases were searched to find relevant articles published from 1980 to 2019. RESULTS: The most frequent failures detected in the reviewed articles consisted of high risk of infection inwards for medical and nursing operations, high infection rates inwards for medical devices' operation within the unit, and early discharge. Moreover, the processes through which potential high-risk Failures were examined in these studies were injection or prescription process, suction process, the process of inserting or removing endotracheal tubes, the process of transferring patients from the operation room to the unit or vice versa, pressure ulcers, and processes related to the medical devices' operation. CONCLUSION: There are many possible reasons for failure occurring throughout these processes, and the failure modes occurring in these processes are more probable to cause serious damages to patients, have high repeatability with low probability of failure detection as the failures cannot be discovered by the personnel.

Determinants of Hospital Inpatient Costs in the Iranian Elderly: A Micro-costing Analysis.

OBJECTIVES: Aging is assumed to be accompanied by greater health care expenditures. The objective of this retrospective, bottom-up micro-costing study was to identify and analyze the variables related to increased health care costs for the elderly from the provider's perspective. METHODS: The analysis included all elderly inpatients who were admitted in 2017 to a hospital in Tehran, Iran. In total, 1288 patients were included. The Mann-Whitney and Kruskal-Wallis tests were used. RESULTS: Slightly more than half (51.1%) of patients were males, and 81.9% had a partial recovery. The 60-64 age group had the highest costs. Cancer and joint/orthopedic diseases accounted for the highest proportion of costs, while joint/orthopedic diseases had the highest total costs. The surgery ward had the highest overall cost among the hospital departments, while the intensive care unit had the highest mean cost. No statistically significant relationships were found between inpatient costs and sex or age group, while significant associations (p<0.05) were observed between inpatient costs and the type of ward, length of stay, type of disease, and final status. Regarding final status, costs for patients who died were 3.9 times higher than costs for patients who experienced a partial recovery. CONCLUSIONS: Sex and age group did not affect hospital costs. Instead, the most important factors associated with costs were type of disease (especially chronic diseases, such as joint and orthopedic conditions), length of stay, final status, and type of ward. Surgical services and medicine were the most important cost items.

Risk prediction models for intensive care unit readmission: A systematic review of methodology and applicability.

OBJECTIVE: We conducted a systematic review of primary models to predict intensive care unit (ICU) readmission. REVIEW METHODS: We searched MEDLINE, PubMed, Scopus, and Embase for studies on the development of ICU readmission prediction models that are published until January 2017. Data were extracted on the source of data, participants, outcomes, candidate predictors, sample size, missing data, methods for model development, and measures of model performance and model evaluation. The quality and applicability of the included studies were assessed using the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. RESULTS: We identified five studies describing the development of the primary prediction models of ICU readmission. Studies ranged in size from 343 to 704,963 patients with the mean age of 58.0-68.9 years. The proportion of readmission ranged from 2.5% to 9.6%. The discriminative ability of prediction models measured by area under the receiver operating characteristic curve was 0.66-0.81. None of the studies performed external validations. The quality scores ranged from 42 to 54 out of 62, and the applicability scores from 24 to 32 out of 38. CONCLUSION: We identified five prediction models for ICU readmission. However, owing to the numerous methodological and reporting deficiencies in the included studies, physicians using these models should interpret the predictions with precautions until an external validation study shows the acceptable level of calibration and accuracy of these models.

Comparing opium tincture and methadone for medication-assisted treatment of patients with opioid use disorder: Protocol for a multicenter parallel group noninferiority double-blind randomized controlled trial.

OBJECTIVES: This is the first study to compare the safety and efficacy of opium tincture (OT) with methadone for treatment of opioid use disorder. METHODS: In this multicenter, double-blind, noninferiority controlled trial, a stratified sample of 204 participants with opioid use disorder were recruited from community outreach, drop-in centers, and triangular clinics. Participants were excluded in case of active participation in another treatment program for opioid use disorder, hypersensitivity to trial medications, pregnancy, and certain serious medical conditions. They were randomized to receive either OT or methadone with an allocation ratio of 1:1 using a patient-centered flexible dosing strategy. Eligible participants were followed for a period of 12 weeks. Primary outcome is the difference in percentage of patients retained in the treatment. Secondary outcomes are craving, withdrawal symptoms, physical health, mental health, quality of life, and severity of substance use problems, cognitive function, safety profile, cost-effectiveness, and participants' satisfaction. Both intention-to-treat and per-protocol analyses will be conducted. The Ethics Board of the University of British Columbia and Tehran University of Medical Sciences approved the study. (clinicaltrials.gov; NCT02502175). RESULTS: To be reported after final analysis. CONCLUSIONS: If shown to be effective, OT will diversify the options for medication-assisted treatment of opioid use disorder.

A systematic review on risk factors associated with sepsis in patients admitted to intensive care units.

OBJECTIVE: We sought to systematically review data on the risk factors influencing the incidence of sepsis in patients admitted to intensive care units (ICUs). REVIEW METHODS: An electronic search was undertaken in PubMed, MEDLINE, Scopus, and the Cochrane Library for studies reporting the risk factors of sepsis from the earliest available date up to December 30, 2016. RESULTS: Among the 2978 articles, 14 studies met the inclusion criteria with a total of 56 164 participants from nine countries. The extracted risk factors were from the following categories: demographic, critical care interventions, surgery-related factors, pre-existing comorbidities, severity of organ injury, and biomarkers and biochemical and molecular indicators. From demographic factors, older age and male gender were associated with an increased risk of sepsis among ICU-admitted patients. CONCLUSION: Our analysis comprehensively summarised the risk factors of sepsis in patients admitted to medical, surgical, neurologic, trauma, and general ICUs. Age, sex, and comorbidities were non-modifiable risk factors; however, critical care interventions and surgery-related factors were modifiable factors and suggest that improving the care of surgical patients and effective management of critical care interventions may play a key role in decreasing the development of sepsis in patients admitted to the ICUs.

A Knowledge Map for Hospital Performance Concept: Extraction and Analysis: A Narrative Review Article.

BACKGROUND: Performance is a multi-dimensional and dynamic concept. During the past 2 decades, considerable studies were performed in developing the hospital performance concept. To know literature key concepts on hospital performance, the knowledge visualization based on co-word analysis and social network analysis has been used. METHODS: Documents were identified through "PubMed" searching from 1945 to 2014 and 2350 papers entered the study after omitting unrelated articles, the duplicates, and articles without abstract. After pre-processing and preparing articles, the key words were extracted and terms were weighted by TF-IDF weighting schema. Support as an interestingness measure, which considers the co-occurrence of the extracted keywords and "hospital performance" phrase was calculated. Keywords having high support with "hospital performance" are selected. Term-term matrix of these selected keywords is calculated and the graph is extracted. RESULTS: The most high frequency words after "Hospital Performance" were "mortality" and "efficiency". The major knowledge structure of hospital performance literature during these years shows that the keyword "mortality" had the highest support with hospital performance followed by "quality of care", "quality improvement", "discharge", "length of stay" and "clinical outcome". The strongest relationship is seen between "electronic medical record" and "readmission rate". CONCLUSION: Some dimensions of hospital performance are more important such as "efficiency", "effectiveness", "quality" and "safety" and some indicators are more highlighted such as "mortality", "length of stay", "readmission rate" and "patient satisfaction". In the last decade, some concepts became more significant in hospital performance literature such as "mortality", "quality of care" and "quality improvement".

The First Stages of Liberalization of Public Hospitals in Iran: Establishment of Autonomous Hospitals and the Barriers.

BACKGROUND: Liberalization and decentralization of public sector has been triggered in some developing countries and in Iran by the Ministry of Health and Medical Education (MOHME) that granted autonomy to 54 public hospitals. However, establishment of such a complex organizational reform was rather unsuccessful. We aimed to explore the obstacles and barriers caused such a failure and their mechanisms. METHODS: Using a qualitative approach in 2013, we consulted key informants at the autonomous hospitals and their affiliating universities. Data collection was done within two phases: (i) 276 unstructured questionnaires asking respondents of barriers, and (ii) 23 semi-structured interviews from the first phase's key respondents. The first phase data were analyzed using thematic analysis and the second's by framework approach based on the frame shaped at the first phase. RESULTS: Nine obstacles were recognized including "autonomous hospitals' board composition", "delay in announcing autonomous hospitals' charges by the MOHME", "lack of financing by the committed organizations", "poor follow up for implementation of the reform", "irregular board meetings", "lack of an external overseer", "shortage of full-time physicians", "lack of management stability", and "health insurance organizations' delayed payments". CONCLUSION: The MOHME and insurance organizations did not pay the reform expenses. There were some competing motives as well to slow the reform or to shut it down. The stages of policy formulation and implementation were done separately in Iran, so this big organizational reform encountered serious obstacles.

Brain metastasis from esophageal carcinoma.

Brain metastasis from esophageal carcinoma is rare. In our center, among 301 cases of esophageal cancer referred for radiotherapy during a 14-year period, brain metastasis from esophageal carcinoma was detected in one case. An unusual case of esophageal carcinoma that presented with brain metastasis is reported.