Challenges, barriers and solutions for implementing clinical practice guidelines: a qualitative study in southern Iran.

BACKGROUND: Identifying the challenges of implementing clinical practice guidelines (CPGs) can provide valuable information for decision-makers and health policymakers at the national and local levels. The implementation of CPGs requires the development of strategies to facilitate their use. This research aimed to determine the challenges, barriers and solutions for implementing CPGs from the expert point of view in Bushehr University of Medical Sciences. METHODS: This qualitative research uses content analysis conducted in 2022 in southern Iran. In-depth interviews were conducted with the physicians and experts in the health system. Interviewing continued until reaching the saturation level. Altogether, 22 experts were interviewed. The interview guide was used to explore experts' opinions. All the interviews were recorded and then transcribed. Finally, coding and data analysis was done using MAXQDA 2022 software. RESULTS: The analysis revealed 4 main themes and 20 subthemes. The four main themes included challenges related to physicians, medical education, the health system and patients. The most common themes were the lack of sufficient training (related to the medical education system), equipment and infrastructure, and the lack of adaptation of clinical guidelines (related to the health system). The solutions included 4 main themes and 19 subthemes. CONCLUSION: The most mentioned topic by the experts was training CPGs in medical schools. In Iran's current medical education system, the training of CPGs is not included in the curriculum. It is proposed to reform the medical education system in Iran. In addition, health inequalities such as lack of access to equipment, supplies and insurance in under-resourced areas and disparities in research/training/medical education should be addressed to improve the validity of guidelines.

A survival analysis of socio-demographic and clinical predictors among hospitalized COVID-19 patients in Southern Iran.

BACKGROUND: This study aimed to evaluate the socio-demographic, clinical, and laboratory risk factors in hospitalized COVID-19 patients during the first 6 months of the SARS-CoV-2 epidemic. METHOD: This retrospective hospital-based cross-sectional study included all laboratory-confirmed cases of the COVID-19 virus that were admitted to the Shohadaye-Khalije-Fars Hospital in Bushehr, Iran, from February 22, 2020 to September 21, 2020. The patients' records were reviewed during the hospitalization period. The global COVID-19 clinical platform, i.e., the World Health Organization Rapid Case Report Form was used as the data collection tool. We conducted the survival analysis using the Kaplan-Meier and the Stepwise Cox regression analyses. RESULTS: The analysis included 2108 confirmed cases of COVID-19 with a mean age of 47.81 years (SD 17.78); 56.8% men, 43.2% women and 6.3% (n = 133) deaths. After adjustment, it was found that factors associated with an increased risk of death consisted of chronic kidney disease, intensive care unit admission, cancer, and hemoptysis. The 7-day survival rate was 95.8%, which decreased to 95.1%, 94.0%, and 93.8% on days 14, 21, and 28 of hospitalization, respectively. DISCUSSION AND CONCLUSION: Older COVID-19 patients with manifestation of hemoptysis and a past medical history of chronic kidney disease and cancer, should be closely monitored to prevent disease deterioration and death, and also should be admitted to the intensive care unit.

Transparency in public pharmaceutical sector: the key informants' perceptions from a developing country.

BACKGROUND: Policymaking in the pharmaceutical sector plays a pivotal role in achieving the health systems' goals. Transparency in the pharmaceutical policy could increase confidence in decision-making processes. This study aims to assess transparency in the public pharmaceutical sector of Iran. METHODS: This qualitative study with a content analysis approach was conducted in 2017 using the World Health Organization tool to explore pharmaceutical transparency. The perceptions of the various stakeholders of the health system through semi-structured interviews with a maximum variation of stakeholders were obtained in eight functions, including registration, licensing, inspection, promotion, clinical trials, selection, procurement, and distribution of medicines. RESULTS: There are some problems in two main categories: (1) General problems, including lack of transparency, conflict of interest, centralization, and monopoly. (2) Ethical problems include illegal payments, gifts, bribes, conflicts of interest, hidden power, hoarding, relationship-oriented behavior, medicine trafficking, and counterfeit medicine. Suggested solutions include evidence-based decision-making, the use of transparent and accountable processes, standardization, needs assessment, declaring a conflict of interest, skilled human resources, and tracking prescription. CONCLUSION: Despite the development of effective pharmaceutical policy in the health care system and government interventions for the control of the market, in some functions, reviewing the pharmaceutical policy is essential. Additionally, declaring a conflict of interest statement must be at the core of policy development to provide greater transparency.

The inappropriateness of brain MRI prescriptions: a study from Iran.

BACKGROUND: Inappropriate prescriptions can lead to adverse consequences for patients. It also imposes excessive cost on the patients, payers and health systems. The current study aimed at estimating the rate of inappropriate brain Magnetic Resonance Imaging (MRI) prescriptions and their financial burden in Iran. METHODS: Using systematic stratified sampling method, this cross-sectional study recruited 385 participants from three public teaching hospitals in Shiraz, Iran. Demographic information, questions related to brain MRI prescription and its indications checklist were collected using study-specific data collection tools. The completed indications checklist was compared to the appropriateness status table of indications and scenarios to detect the percent of the appropriateness of prescriptions. RESULTS: About 21 percentage of total brain MRI prescriptions are inappropriate. Previous treatment, number of referrals to physician, having other diagnostic tests and the applicant of MRI (P < 0.01) had significant relationships with prescription appropriateness. The estimated financial burden of inappropriate brain MRIs in Shiraz teaching hospitals was 99,988 US dollar in 2017. CONCLUSIONS: More than one-fifth of brains MRIs were inappropriate (i.e. prescriptions without medical indications). It caused 99,988 United States Dollar (USD) financial burden which is 17 times that of Iran's Gross Domestic Product (GDP) per capita. To better allocate resources for the provision of MRI services to health system, rationing policies for controlling moral hazard and reducing provider induced demand can be helpful.

Analyzing inappropriate magnetic resonance imaging (MRI) prescriptions and resulting economic burden on patients suffering from back pain.

INTRODUCTION: Back pain is a common global disorder and magnetic resonance imaging (MRI) is one method of assessing its cause. The lack of official and general clinical guidelines is the cause of inadequate supervision of lumbar MRI prescriptions. The goal of this research was to analyze inappropriate lumbar MRI prescriptions and the resulting economic burden on individuals. METHOD: This is a descriptive-analytical study carried out on a sample of 614 patients who visited four hospitals in Tehran. The appropriateness or inappropriateness of the MRI prescriptions was determined using clinical guidelines and a questionnaire based on previous studies. The economic burden created by inappropriate prescriptions for MRIs was determined after calculating the total direct and indirect costs. FINDINGS: The total MRI prescription cost paid by the study sample was $26 071, and the cost of inappropriate prescriptions was $10 310. The MRI prescription rate had a significant relationship with gender, age, education, employment, primary insurance type, and supplemental health insurance. CONCLUSION: The research findings revealed relatively high rates of inappropriate MRI prescriptions in the private and public sectors. Hence, policymakers should design, create, and develop clinical guidelines and enforce the policies and rules to decrease inappropriate MRI prescriptions.

Eliminating Healthcare-Associated Infections in Iran: A Qualitative Study to Explore Stakeholders' Views.

BACKGROUND: Although preventable, healthcare-associated infections (HAIs) continue to pose huge health and economic burdens on countries worldwide. Some studies have indicated the numerous causes of HAIs, but only a tiny literature exists on the multifaceted measures that can be used to address the problem. This paper presents stakeholders' opinions on measures for controlling HAIs in Iran. METHODS: We used the qualitative research method in studying the phenomenon. Through a purposive sampling approach, we conducted 24 face-to-face interviews using a semi-structured interview guide. Participants were mainly key informants, including policy-makers, health professionals, and technical officers across the national and subnational levels, including the Ministry of Health (MoH), medical universities, and hospitals in Iran. We performed thematic framework analysis using the software MAXQDA10. RESULTS: Four main interdisciplinary themes emerged from our study of measures of controlling HAIs: strengthening governance and stewardship; strengthening human resources policies; appropriate prescription and usage of antibiotics; and environmental sanitation and personal hygiene. CONCLUSION: According to our findings, elimination of HAIs demands multifactorial interventions. While the ultimate recommendation of policy-makers is to have HAIs among the priorities of the national agenda, financial commitment and the creation of an enabling work environment in which both patients and healthcare workers can practice personal hygiene could lead to a significant reduction in HAIs in Iran.

Exploring Measures to Control Road Traffic Injuries in Iran: Key Informants Points of View.

BACKGROUND: Injuries and fatalities from road traffic Injuries are global public health concerns, and a major problem in the Iran. This study aimed to explore strategies to control road traffic Injuries (RTI) in Iran. METHODS: We conducted a qualitative study to explore possible ways to reduce the occurrence of road traffic Injuries in Iran in 2016. Interviewees were purposively sampled from various sectors due to multidisciplinary nature of RTIs. Participants were mainly representatives from the police, Ministry of Road, Municipal, emergency services and Ministry of Health. Besides, public health authorities, researchers, and university professors were interviewed. We conducted in-depth interviews using generic guides. Data was analyzed using MAXQDA 10 software. Through content analysis, we interpreted core themes relevant to the accomplishment of our study objectives. RESULTS: Themes that emerged from our study include; road traffic management, governance, education, improving accident database, enforcement, driving license restrictions, and construction of pedestrian overpass. CONCLUSION: This study revealed key informants' views regarding available and affordable solutions to reduce RTIs in Iran. Many applicable strategies are identified in the control of RTIs in Iran. Although some solutions such as highway construction and/or expanding rail transportation have been suggested as effective measures for reducing accident, but they are costly and may not be fully applied in developing countries like Iran.

Prevention and control of health care-associated infections in Iran: A qualitative study to explore challenges and barriers.

BACKGROUND: Globally, the health and economic burden posed by health care-associated infections (HAIs) remains wide and severe. To curb the burden associated with HAIs, countries, including Iran, aim at HAI prevention and control. This study explores the challenges faced by the Iranian health system in addressing the issues associated with the prevention and control of HAIs. METHODS: A qualitative research method was adopted in exploring the phenomenon. We used the purposive sampling approach in reaching 24 key informants at the national and subnational levels. The thematic framework analysis was conducted for analyzing the interviews. RESULTS: Five main themes emerged from our study demonstrating the obstacles toward the prevention and control of HAIs. They include governance and stewardship, resources, safety culture, monitoring and surveillance systems, and inappropriate prescription of antibiotics. CONCLUSIONS: Strengthening of reporting and surveillance systems for HAIs coupled with proper governance and stewardship are crucial in order to improve the health and safety of patients. However, the availability of resources, through an intersectoral approach, is essential to achieve sustained output.

Developing an Appropriateness Criteria for Knee MRI Using the Rand Appropriateness Method (RAM)-2013.

BACKGROUND: Knee pain is one of the most common reasons patients visit their physician. In this regard Magnetic Resonance Imaging (MRI) is the tool of preference for diagnosis. The aim of this study was to determine appropriate guidelines for knee MRI administration using the RAND Appropriateness Method (RAM)-2013. METHODS: This qualitative study was done in the Mashhad University of Medical Sciences in 2013. The most appropriate approved knee MRI administration clinical guidelines were evaluated using Guidelines Evaluation and Research Appraisal (AGREE). Panel members consisting of six orthopedic and three rheumatologic doctors gave scores ranging from 1 to 9 for each scenario. The indications were grouped as appropriate, equivocal and inappropriate. Data were analyzed by descriptive statistics and SPSS ver. 18 software. RESULTS: Sixty-three scenarios were extracted from the guidelines and then the scenarios were evaluated in 26 indications. Thirty-two (50.79%) cases were considered appropriate, 12 (19.04%) cases uncertain and 19 (30.1%) cases inappropriate. CONCLUSIONS: The RAND appropriateness method is helpful in identifying the opinion of stakeholders in health care systems. Moreover, making practical use of clinical guidelines can improve patients' quality of care and prevent unnecessary costs.

Evidence for Policy Making: Clinical Appropriateness Study of Lumbar Spine MRI Prescriptions Using RAND Appropriateness Method.

BACKGROUND: MRI is a new and expensive diagnostic technology, which has been used increasingly all over the world. Low back pain is a worldwide prevalent disorder and MRI technique is one of the several ways to diagnose it. This paper aims to identify the appropriateness of lumbar spine MRI prescriptions in Shiraz teaching hospitals using standardized RAND Appropriateness Method (RAM) criteria in 2012. METHODS: This study consisted of two phases. The first phase involved a qualitative enquiry and the second phase had a quantitative cross-sectional nature. In the first phase RAM was used for developing lumbar spine MRI indications and scenarios. In the second phase, the finalized scenarios were compared with the history and physical examination of 300 patients with low back pain. The rate of appropriateness of lumbar spine MRI prescription was then calculated. RESULTS: Of 300 cases of lumbar spine MRI prescriptions, approximately 167 (56%) were considered inappropriate, 72 (24%) were uncertain, and 61 (20%) were deemed to be appropriate. The economic burden of inappropriate prescriptions was calculated at 88,009,000 Rials. In addition, the types of expertise and physical examination were considered as related factors to appropriateness of prescriptions. CONCLUSION: In conclusion, a large proportion of lumbar spine MRI prescriptions, which result in financial burden on the insurance companies and the patients alike is unnecessary. This study suggests that policy makers consider this evidence while decision-making. Our findings highlight the imperative role of Health Technology Assessment (HTA) and Clinical Practice Guidelines (CPGs). As a result, developing local clinical guidelines may create the commitment needed in physicians in prescribing appropriate prescriptions within the health sector. The study further recommends that appropriate scenarios should be considered as a criterion for payment and reimbursement.

Developing Criteria for Lumbar Spine Magnetic Resonance Imaging (MRI) Using RAND Appropriateness Method (RAM).

BACKGROUND: Studies show that a large proportion of healthcare offered may be inappropriate or unnecessary. Magnetic resonance imaging (MRI) is a new and expensive diagnostic technology which has been increasingly used all over the world. Moreover, this trend has been more rapidly increasing in Iran. Low back pain is a common disorder all over the world and MRI technique is one of the several ways to assess its cause. OBJECTIVES: The present study aims to develop scenarios for lumbar spine MRI. MATERIALS AND METHODS: In the present study, the RAND Appropriateness Method (RAM) was used in order to reach consensus regarding developing scenarios for lumbar spine MRI. We generated scenarios from valid clinical guidelines as well as the experts' opinion. The panel members included nine specialists from various medical specialties that had scored scenarios in two rounds, the first of which was without interaction, while the second one was with interaction. RESULTS: We extracted 97 scenarios for the lumbar spine MRI in the scenario extracting phase of the study and the panel members added 18 scenarios. After implementation of two rounds, the scenarios were categorized into three ranges. Sixty seven (58%) of the scenarios were considered as appropriate, 45 (39%) as uncertain, and three (2.6%) as inappropriate. CONCLUSIONS: RAM is useful for identifying stakeholder views in settings with limited resources. Since RAM has precise instructions for consensus developing, a large number of scenarios were considered as uncertain. Therefore, more research has to be conducted on the issue.