Estimating the Costs of End-of-Life Care in Patients With Advanced Cancer From the Perspective of an Insurance Organization: A Cross-Sectional Study in Iran.

OBJECTIVES: Cancers are significant medical conditions that contribute to the rising costs of healthcare systems and chronic diseases. This study aimed to estimate the average costs of medical services provided to patients with advanced cancers at the end of life (EOL). METHODS: We analyzed data from the Sata insurance claim database and the Health Information System of Baqiyatallah hospital in Iran. The study included all adult decedents who had advanced cancer without comorbidities, died between March 2020 and September 2020, and had a history of hospitalization in the hospital. We calculated the average total cost of healthcare services per patient during the EOL period, including both cancer-related and noncancer-related costs. RESULTS: A total of 220 patients met the inclusion criteria. The average duration of the EOL period for these patients was 178 days, with an average total cost of $8278 (SD $5698) for men and $9396 (SD $6593) for women. Cancer-related costs accounted for 64.42% of the total costs, including inpatient and outpatient services. Among these costs, hospitalization was the primary cost driver and had the greatest impact on EOL costs. This observation was supported by the multiple linear regression model, which suggested that hospitalization in the final days of life could potentially drive costs in these patients. Notably, no specialized palliative care was provided to the patients included in this study. CONCLUSIONS: The results demonstrate that there is a significant rise in costs of care in patients receiving routine cancer care rather than optimized EOL care.

Assessment and Reduction of Human Error using SHERPA Technique in Chemotherapy Department of a Large Military Hospital.

Background: Medical errors are numerous in medical activities. Considering the sensitivity and importance of the medical group's professions, the emergence of an apparently simple error can cause the death of an individual or even a group of individuals. The present study aims the evaluation and reduction of human error using a system human error reduction and prediction approach System Human Error Reduction and Prediction Approach (SHERPA) in the nurses of Baqiyatallah hospital's chemotherapy ward in 2019. Materials and Methods: A cross-sectional study was conducted in the chemotherapy ward using the SHERPA technique. Then, the duties were determined in detail using Hierarchical Task Analysis (HTA). The errors were identified using the SHERPA checklist, and the risk outcomes and intensities were finally evaluated. Results: Based on the study findings, there are 109 possible errors for 48 sub-duties. The most frequent errors fall in the functional area (54%) and the least frequent errors pertain to the area of selection (3%). Conclusions: In order to reduce the errors and increase the quality of the services and safety of the patients, errors can be identified by using the SHERPA technique; after identifying these errors, using this technique, it is possible to prevent the recurrence of the identified errors by careful planning. Considering the fact that the most frequent error was found in the functional domain, modern protocols can be codified in this area, and standards can be observed for putting the problems of this section atop of the priority list and reducing the errors and increasing safety of the patients.

Using Relative and Absolute Measures for Socioeconomic Inequalities in Health: Experiences from a Retrospective Cohort Study on COVID-19.

Background: One approach to reducing the burden of diseases can be to identify socioeconomically vulnerable groups. We aimed to estimate the socioeconomic inequality of in-hospital deaths using relative and absolute indices of socioeconomic inequality. Methods: In this retrospective cohort study on Covid-19 patients; age, gender, marital status, education level, date of admission, diagnostic method, and final condition were measured. Socioeconomic inequality in inhospital death was assessed using three approaches. We used the relative index of inequality (RII) to measure relative inequality. We used two approaches to evaluate absolute inequality: the slope index of inequality (SII) and the concentration index (ci). Results: Overall, 587 patients' data were collected and 42 (7.2%) of these patients died in the hospital. There were statistically significant differences between the case-fatality rates of different levels of education (P<0.001). In addition, all the inequality indices showed that the distribution of COVID-19-related deaths was higher among the lower education levels. Accordingly, after controlling the effect of age, gender, and comorbidities the RII indicated that the case fatality rate in the lowest education level was 9.42 (95% CI: 2.23 to 39.01, P<0.001) times compared to the case fatality rate in the highest level of education. Conclusion: The results of all three approaches indicate considerable education inequality in CFR in favor of groups of high education levels. These results can improve the prioritization and impact of public health interventions, including prevention and diagnosis of Covid-19 in favor of vulnerable groups.

Efficacy of active and passive evidence-based practice training for postgraduate medical residents: a non-randomized controlled trial.

OBJECTIVE: This study examined the effects of two evidence-based practice (EBP) educational programs for postgraduate medical residents on their attitude, behavior, knowledge, outcome, and competencies in EBP. RESULTS: Forty-five and thirty-five medical residents were recruited in the active and passive educational intervention groups, respectively. Among those, 39 and 30 participants were included in the final analysis. The participants of the active group received 12 h of EBP-structured presentation. The passive educational group received EBP education through their daily rounds, evidence-based journal clubs, and morning reports. Participants were evaluated with EBP-KABQ and ACE tools questionnaires. The active and passive intervention groups were not significantly different from each other at the baseline in the EBP-KABQ questionnaire and ACE tools score (p > 0.05). However, most questions in the EBP-KABQ questionnaire were significantly different from the pre-intervention measurement and the passive intervention group after the educational intervention. Educational intervention in both groups led to a significant difference in ACE tools score between groups (8.86 ± 2.62 vs. 7.31 ± 2.92, p = 0.029, in the active and passive groups, respectively). Paired t-test analysis revealed that our intervention led to a significant increase in ACE tool scores in both groups (p < 0.000, in both groups).

Prevalence and Predictive Factors for Nosocomial Infection in the Military Hospitals: A Systematic Review and Meta-Analysis.

BACKGROUND: To assess prevalence and predictive factors for Nosocomial Infection (NI) in the military hospitals. METHODS: PubMed, Scopus, Cochrane and PreQuest databases were systematically searched for studies published between Jan 1991 and Oct 2017 that reported the prevalence of NI and predictive factors among military hospitals. We performed the meta-analysis using a random effects model. Subgroup analysis was done for heterogeneity and the Egger test to funnel plots was used to assess publication bias. RESULTS: Twenty-eight studies with 250,374 patients were evaluated in meta-analysis. The overall pooled estimate of the prevalence of NI was 8% (95% 6.0-9.0). The pooled prevalence was 2% (95% CI: 2.0-3.0) when we did sensitivity analysis and excluding a study. The prevalence was highest in burn unit (32%) and ICU (15%). Reported risk factors for NI included gender (male vs female, OR: 1.45), age (Age≥65, OR: 2.4), diabetes mellitus (OR: 2.32), inappropriate use of antibiotics (OR: 2.35), received mechanical support (OR: 2.81), co-morbidities (OR: 2.97), admitted into the ICU (OR: 2.26), smoking (OR: 1.36) and BMI (OR: 1.09). CONCLUSION: The review revealed a difference of prevalence in military hospitals with other hospitals and shows a high prevalence of NI in burn units. Therefore careful disinfection and strict procedures of infection control are necessary in places that serve immunosuppressed individuals such as burn patient. Moreover, a vision for the improvement of reports and studies in military hospitals to report the rate of these infections are necessary.

Universal health coverage under the Joint Comprehensive Plan of Action's sanctions: strategic purchasing approach in the Iranian health system.

Due to the sanctions imposed by the USA government upon the Iranian health system, achieving the UHC might face some financial problems. This study aimed to make the best solution for the Iran health care system to overcome not only the temporary sanctions but also a program to reach the UHC goals through the strategic purchasing approach. This was a qualitative study carried out from 2015 to 2017 containing two phases: a comparative analysis and a three-step Delphi technique. In the first phase, the Garden model was applied to select the countries. In the second phase, 20 experts who specialised in health management, health economics, and health insurance science were asked. Data were analyzed with SPSS (version 20.0) and STATA (version 15.0) In the threat of trade and economic sanctions imposed on the Iranian health care system, the experts identified and emphasized that the vulnerable groups to receive financial assistance can be the retired, fecund women, teenagers and people with lower wages. The experts thought that, in the context of resource constraints, different payment systems are proposed for cities and villages based on the different needs of local population. Considering the difficult situation, this study focused on how Iran can cope well in a dangerous situation and economies the health expenditure applying strategic purchasing as one of the key tools in controlling costs to achieve universal health coverage. Economic evaluation, payment system, and priority population are the linchpins of the UHC. Universal health coverage, if it is to be considered, not only is applicable, but it could also be a solution for future generations. Therefore, the proposed policy proposals can provide both a short-term and long-term basis for the health care system of countries that are facing budget constraints or are basically low-income.

Non-urgent visits to emergency departments: a qualitative study in Iran exploring causes, consequences and solutions.

OBJECTIVE: To explore the causes and consequences of non-urgent visits to emergency departments in Iran and then suggest solutions from the healthcare providers' viewpoint. DESIGN: Qualitative descriptive study with in-depth, open-ended, and semistructured interviews, which were inductively analysed using qualitative content analysis. SETTING: A territorial, educational and military hospital in Iran. PARTICIPANTS: Eleven healthcare providers including eight nurses, two emergency medicine specialists and one emergency medicine resident. RESULTS: Three overarching themes of causes and consequences of non-urgent visits to the emergency department in addition to four suggested solutions were identified. The causes have encompassed the specialised services in emergency department, demand-side factors, and supply-side factors. The consequences have been categorised into three overarching themes including the negative consequences on patients, healthcare providers and emergency departments as well as the health system in general. The possible solutions for limiting and controlling non-urgent visits also involved regulatory plans, awareness-raising plans, reforms in payment mechanisms, and organisational arrangements. CONCLUSION: We highlighted the need for special attention to the appropriate use of emergency departments in Iran as a middle-income country. According to the complex nature of emergency departments and in order to control and prevent non-urgent visits, it can be suggested that policy-makers should design and implement a combination of the possible solutions.

A foresight study of factors affecting the health system research and technology.

CONTEXT: The success of the health system research and technology management in the 21st century can play an important role in advancing the country toward becoming a scientific power. AIMS: The study aimed to increase knowledge and identify factors affecting the health system research and technology, as well as to provide solutions for improving the status of health science and technology. MATERIALS AND METHODS: This was an applied and descriptive study conducted in 2018 using cross-impact analysis. The factors affecting the Iranian Health System Research and Technology Management and their influences on each other were identified using an expert panel. The key-driven factors were determined using the MICMAC software. RESULTS: The input, stake, target, resultant, excluded, and regulating factors were identified. The degree of fill rate the matrix was 58.9%. Financial annex of the health scientific map (S = 206), roadmap (S = 206), governmental laws and regulations (S = 198), and sufficient governmental budget allocation (S = 194) earned the highest potential influence scores by 2025. Furthermore, scientific authority (S = 216), international communication (187), university relationship with industries (S = 187), and competitive infrastructure (S = 178) obtained the highest potential dependence scores by 2025. CONCLUSIONS: The success of the Iranian Health System Research and Technology Management by 2025 requires the development of the financial annex of the comprehensive scientific health map, the development of the road map, and the allocation of sufficient governmental budget for health research. Policy-making in health system research and technology management requires more attention to these factors and the dynamics of relationships among factors in the model.

Emergency department visits for non-urgent conditions in Iran: a cross-sectional study.

OBJECTIVES: To determine the percentage of non-urgent (NU) visits in an Iranian emergency department (ED), to explore why patients with NU conditions refer to EDs and also to assess the association between patients' characteristics and their visits. DESIGN: A cross sectional study based on face to face survey. SETTING: A territorial, teaching and military hospital in Tehran province, Iran. PARTICIPANTS AND DATA COLLECTION: All patients who visited the ED during the 2-week period were recruited. Data were collected using a validated questionnaire. RESULTS: Of 1884 patients who visited the ED, 1217 (64.6%) patients were triaged as NU while 667 (35.4%) were urgent and semiurgent visits cases. The most important reasons for NU visits were seeking prompt (36.6%) and less costly care (35.9%). We found that NU visits have increased with younger patients, during weekends and night shifts, and with patients suffering from recurrent symptoms lasting in 1 week or less. CONCLUSIONS: EDs are a common source of care for NU problems in Iran. The most invaluable solution is building up special clinics for providing healthcare services to NU patients during the weekends and, in the busy and night shifts. Receiving higher fees from NU patients could also be adopted with caution. Promoting awareness and knowledge of both healthcare providers and patients about the main role of EDs will contribute in improving their performance. As a long-term solution, adopting the family physician programme and ameliorating the referral system are recommended.

Challenges of Iranian national health scientific map.

CONTEXT: Iranian National Health Scientific Map is a national plan the implementation of which remarkably influences the progress of the country, though it is facing challenges in its implementation phase. AIMS: The present study has been conducted with the main aim of identifying the challenges facing the comprehensive scientific health map of Iran. SETTING AND DESIGN: This is an applied and qualitative study. SUBJECTS AND METHODS: The study was done in 2017 with the content analysis approach among experts of research and technology management. Some 18 people were selected and were deeply interviewed, meanwhile observing the credibility of research. STATISTICAL ANALYSIS USED: Data analysis was performed based on content analysis and using ATLAS.ti software. RESULTS: Data analysis resulted in the identification of 427 codes, 84 subthemes, and 12 themes. Twelve themes were specified including policy-making, management, university autonomy, quantitative development, consideration of science production chain, designing and monitoring of science map, finance, qualitative assessment, human resources, research ethics, as well as allocating attention to the infrastructure and communication. CONCLUSION: The scientific map of health challenges are indicative of the need for modification of the scientific map and adhering to solutions in line with the removal of the identified challenges. Today, paying attention to the solutions capable of meeting such challenges is a must.

Innovation capability in medical sciences universities: A qualitative study of Iran.

BACKGROUND: Innovation is a competitive advantage, with its preservation and continuity dependent on the organizational innovation capability. This study was conducted with the aim of determining the innovation capability dimensions and components in medical sciences universities of Iran. METHODS: The present study is a qualitative study with content analysis approach, undertaken in 2016-2017. The data processing included 10 deep interviews with the experts of the health innovation domain in top management of the three types of the medicine sciences universities of Iran with >5 years of experience. Targeted data sampling was performed using snowball method and continued until the saturation of the data. Data analysis was performed using conventional content analysis method using Maxqda 12 software. RESULTS: Data analysis resulted in the extraction of 28 categories and 8 main themes including communications and interactions, innovation climate, university setting, policy factors (policy-making, rules and regulations), organizational culture, organizational resources, management and leadership, and organizational learning in two university internal and external dimensions. CONCLUSION: To accelerate innovation in medical sciences universities, recognizing the potential of innovation capability is essential.

Accreditation in one teaching hospital: a phenomenology study among Iranian nurses.

PURPOSE: Accreditation helps to ensure safe and high-quality services in hospitals. Different occupational groups have various hospital accreditation experiences. The purpose of this paper is to investigate nurses' accreditation experience and its effects on Iranian teaching hospital service quality. DESIGN/METHODOLOGY/APPROACH: This was a qualitative study involving a phenomenological approach to studying nurses' hospital accreditation experience and understanding the effects on Iranian teaching hospital service quality. Data were collected using two focus groups in which nurses were selected using purposive sampling. Transcripts were analyzed using content analysis. FINDINGS: Nurses' experiences showed that hospital administrators and nurses had greater role in implementing accreditation than other occupational groups. Accreditation improved patient-centeredness, patient safety, logistics and managerial processes and decision making. However, a weak incentive system, extra documentation and work stress were negative experiences. PRACTICAL IMPLICATIONS: Nurse experience, as the most important care team member, reveals accreditation's strengths and weaknesses and its effects on service quality. ORIGINALITY/VALUE: The author used a phenomenology approach to measure accreditation effects on service quality - a valuable tool for understanding a phenomenon among those that experience hospital accreditation processes.

Accreditation effects on health service quality: nurse viewpoints.

PURPOSE: The purpose of this paper is to determine accreditation effects on Iranian military hospital health service quality through nurses' viewpoints. DESIGN/METHODOLOGY/APPROACH: The paper is a cross-sectional questionnaire-based study. Sampling drew from a hospital nurse census ( n=160). Descriptive statistics were used to analyze participant demographics and nurses' views. Linear regression analysis determined the independent variables' overall effect on the accreditation quality results dimension (dependent variable). FINDINGS: From the nurses' viewpoints, accreditation effects on services quality mean score was 3.60±0.61. Linear regression analysis showed that leadership and quality management were identified as the most important accreditation quality predictors. The R2 value (0.698) showed that nearly 70 percent of the dependent variable changes were affected by the independent variables. PRACTICAL IMPLICATIONS: This study gives hospital managers a deeper insight into accreditation and its effects on military hospital service quality. Military hospitals benefit from military organization such as hierarchy and command chain, so managers should employ these characteristics to adopt appropriate policies to promote human resource management as a competitive advantage. Furthermore, results will guide public and private hospital managers on how to manage organizational variables that benefit from accreditation. ORIGINALITY/VALUE: Accreditation was introduced as a hospital quality improvement program. However, implementing accreditation programs should be cost-effective. Hospital managers and employees should feel that accreditation can improve service quality. Nurses had positive viewpoints about accreditation and its effects on military hospital service quality.

Factors affecting strategic plan implementation using interpretive structural modeling (ISM).

Purpose Strategic planning is the best tool for managers seeking an informed presence and participation in the market without surrendering to changes. Strategic planning enables managers to achieve their organizational goals and objectives. Hospital goals, such as improving service quality and increasing patient satisfaction cannot be achieved if agreed strategies are not implemented. The purpose of this paper is to investigate the factors affecting strategic plan implementation in one teaching hospital using interpretive structural modeling (ISM). Design/methodology/approach The authors used a descriptive study involving experts and senior managers; 16 were selected as the study sample using a purposive sampling method. Data were collected using a questionnaire designed and prepared based on previous studies. Data were analyzed using ISM. Findings Five main factors affected strategic plan implementation. Although all five variables and factors are top level, "senior manager awareness and participation in the strategic planning process" and "creating and maintaining team participation in the strategic planning process" had maximum drive power. "Organizational structure effects on the strategic planning process" and "Organizational culture effects on the strategic planning process" had maximum dependence power. Practical implications Identifying factors affecting strategic plan implementation is a basis for healthcare quality improvement by analyzing the relationship among factors and overcoming the barriers. Originality/value The authors used ISM to analyze the relationship between factors affecting strategic plan implementation.

A Model for the Development of Hospital Beds Using Fuzzy Analytical Hierarchy Process (Fuzzy AHP).

BACKGROUND: This study aimed to identify and prioritize factors affecting the development of military hospital beds and provide a model using fuzzy analytical hierarchy process (Fuzzy AHP). METHODS: This applied study was conducted in 2016 in Iran using a mixed method. The sample included experts in the field of military health care system. The MAXQDA 10.0 and Expert Choice 10.0 software were used for analyzing the collected data. RESULTS: Geographic situation, demographic status, economic status, health status, health care centers and organizations, financial and human resources, laws and regulations and by-laws, and the military nature of service recipients had effects on the development of military hospital beds. The military nature of service recipients (S=0.249) and economic status (S=0.040) received the highest and lowest priorities, respectively. CONCLUSION: Providing direct health care services to the military forces in order to maintain their dignity, and according to its effects in the crisis, as well as the necessity for maintaining the security of the armed forces, and the hospital beds per capita based on the existing laws, regulations and bylaws are of utmost importance.

Key success factors of health research centers: A mixed method study.

BACKGROUND: In order to achieve success in future goals and activities, health research centers are required to identify their key success factors. OBJECTIVE: This study aimed to extract and rank the factors affecting the success of research centers at one of the medical universities in Iran. METHODS: This study is a mixed method (qualitative-quantitative) study, which was conducted between May to October in 2016. The study setting was 22 health research centers. In qualitative phase, we extracted the factors affecting the success in research centers through purposeful interviews with 10 experts of centers, and classified them into themes and sub-themes. In the quantitative phase, we prepared a questionnaire and scored and ranked the factors recognized by 54 of the study samples by Friedman test. RESULTS: Nine themes and 42 sub-themes were identified. Themes included: strategic orientation, management, human capital, support, projects, infrastructure, communications and collaboration, paradigm and innovation and they were rated respectively as components of success in research centers. Among the 42 identified factors, 10 factors were ranked respectively as the key factors of success, and included: science and technology road map, strategic plan, evaluation indexes, committed human resources, scientific evaluation of members and centers, innovation in research and implementation, financial support, capable researchers, equipment infrastructure and teamwork. CONCLUSION: According to the results, the strategic orientation was the most important component in the success of research centers. Therefore, managers and authorities of research centers should pay more attention to strategic areas in future planning, including the science and technology road map and strategic plan.

Factors affecting the overcrowding in outpatient healthcare.

BACKGROUND: The expansion of outpatient services and the desire to provide more outpatient care than inpatient care create some problems such as the overcrowding in the outpatient clinics. Given the importance of overcrowding in the outpatient clinics, this qualitative study aimed to determine the factors influencing the overcrowding in the specialty and subspecialty clinic of a teaching hospital. MATERIALS AND METHODS: This was a qualitative study conducted in the specialty and subspecialty clinic of a hospital using content analysis method in the period of January to March 2014. The study population was all managers and heads of the outpatient wards. The studied sample consisted of 22 managers of the clinic wards who were selected using the purposive sampling method. The required data was collected using semi-structured interviews. The collected data was analyzed using conventional content analysis and the MAXQDA 10.0 software. RESULTS: Three themes were identified as the main factors affecting the overcrowding including the internal positive factors, internal negative factors, and external factors. CONCLUSIONS: Despite the efforts made to eliminate overcrowding, and reduce waiting times and increase access to the services for patients, the problem of overcrowding still has remained unresolved. In addition, the use of some strategies such as clarifying the working processes of the clinic for staff and patients and the relationships between the clinic and other wards especially emergency department, as well as using a simple triage system on the patients' arrival at the clinic are recommended.

Factors Affecting Quality of Emergency Service in Iran's Military Hospitals: A Qualitative Study.

INTRODUCTION: Quality is a key factor for the success of any organization. Moreover, accessing quality in the emergency department is highly significant due to the sensitive and complex role of this department in hospitals as well as the healthcare and medical treatment system. This study aimed to identify, from the perspective of medical experts and nurses serving in the military health and medical treatment system, the factors that affect the quality of emergency service provided in selected military hospitals in Iran. METHODS: This qualitative research was performed in Valiaser Hospital of Tehran (Iran) in 2015, using the framework analysis method. The purposive sampling technique was used for data collection. A total of 14 participants included two emergency medicine specialists, four general physicians, two senior nurses (holding M.Sc. degrees), and six nurses (holding B.Sc. degree). Data were collected through semistructured interviews. Sampling continued until data saturation occurred. The Atlas/Ti software was employed for data analysis. RESULTS: Four basic themes emerged as the effective factors on the quality of emergency services, namely, structural themes, process/performance themes, outcome themes, and environmental/contextual themes. Moreover, through a framework analysis, 47 subthemes were specified and summarized as indicators of the different aspects of the main themes. CONCLUSION: The factors affecting the quality of emergency services in Iran's selected military hospitals are especially complicated due to the diversity of the missions involved; thus, different factors can influence this quality. Therefore, an effort should be made to tackle the existing obstacles, facilitate the identification of these effective factors, and promotion of the quality of healthcare services.