Iran Quality of Care in Medicine Program (IQCAMP): Design and Outcomes.

BACKGROUND: Assessment of quality and cost of medical care has become a core health policy concern. We conducted a nationwide survey to assess these measures in Iran as a developing country. To present the protocol for the Iran Quality of Care in Medicine Program (IQCAMP) study, which estimates the quality, cost, and utilization of health services for seven diseases in Iran. METHODS: We selected eight provinces for this nationally representative short longitudinal survey. Interviewers from each province were trained comprehensively. The standard definition of seven high-burden conditions (acute myocardial infarction [MI], heart failure [HF], diabetes mellitus [DM], stroke, chronic obstructive pulmonary (COPD) disease, major depression, and end-stage renal disease [ESRD]) helped customize a protocol for disease identification. With a 3-month follow-up window, the participants answered pre-specified questions four times. The expert panels developed a questionnaire in four modules (demographics, health status, utilization, cost, and quality). The expert panel chose an inclusive set of quality indicators from the current literature for each condition. The design team specified the necessary elements in the survey to calculate the cost of care for each condition. The utilization assessment included various services, including hospital admissions, outpatient visits, and medication. RESULTS: Totally, 156 specialists and 78 trained nurses assisted with patient identification, recruitment, and interviewing. A total of 1666 patients participated in the study, and 1291 patients completed all four visits. CONCLUSION: The IQCAMP study was the first healthcare utilization, cost, and quality survey in Iran with a longitudinal data collection to represent the pattern, quantity, and quality of medical care provided for high-burden conditions.

Patient experience with chronic obstructive pulmonary disease: a nationally representative demonstration study on quality and cost of healthcare services.

Introduction: Due to insufficient data on patient experience with healthcare system among patients with chronic obstructive pulmonary disease (COPD), particularly in developing countries, this study attempted to investigate the journey of patients with COPD in the healthcare system using nationally representative data in Iran. Methods: This nationally representative demonstration study was conducted from 2016 to 2018 using a novel machine-learning based sampling method based on different districts' healthcare structures and outcome data. Pulmonologists confirmed eligible participants and nurses recruited and followed them up for 3 months/in 4 visits. Utilization of various healthcare services, direct and indirect costs (including non-health, absenteeism, loss of productivity, and time waste), and quality of healthcare services (using quality indicators) were assessed. Results: This study constituted of a final sample of 235 patients with COPD, among whom 154 (65.5%) were male. Pharmacy and outpatient services were mostly utilized healthcare services, however, participants utilized outpatient services less than four times a year. The annual average direct cost of a patient with COPD was 1,605.5 USDs. Some 855, 359, 2,680, and 933 USDs were imposed annually on patients with COPD due to non-medical costs, absenteeism, loss of productivity, and time waste, respectively. Based on the quality indicators assessed during the study, the focus of healthcare providers has been the management of the acute phases of COPD as the blood oxygen levels of more than 80% of participants were documented by pulse oximetry devices. However, chronic phase management was mainly missed as less than a third of participants were referred to smoking and tobacco quit centers and got vaccinated. In addition, less than 10% of participants were considered for rehabilitation services, and only 2% completed four-session rehabilitation services. Conclusion: COPD services have focused on inpatient care, where patients experience exacerbation of the condition. Upon discharge, patients do not receive appropriate follow-up services targeting on preventive care for optimal controlling of pulmonary function and preventing exacerbation.

Quality and cost of healthcare services in patients with diabetes in Iran: Results of a nationwide short-term longitudinal survey.

Aims: To investigate the journey of patients with diabetes in the healthcare system using nationally-representative patient-reported data. Methods: Participants were recruited using a machine-learning-based sampling method based on healthcare structures and medical outcome data and were followed up for three months. We assessed the resource utilization, direct/indirect costs, and quality of healthcare services. Results: One hundred fifty-eight patients with diabetes participated. The most utilized services were medication purchases (276 times monthly) and outpatient visits (231 times monthly). During the previous year, 90% of respondents had a laboratory fasting blood glucose assessment; however, less than 70% reported a quarterly follow-up physician visit. Only 43% had been asked about any hypoglycemia episodes by their physician. Less than 45% of respondents had been trained for hypoglycemia self-management. The annual average health-related direct cost of a patient with diabetes was 769 USD. The average out-of-pocket share of direct costs was 601 USD (78.15%). Medication purchases, inpatient services, and outpatient services summed up 79.77% of direct costs with a mean of 613 USD. Conclusion: Healthcare services focused solely on glycemic control and the continuity of services for diabetes control was insufficient. Medication purchases, and inpatient and outpatient services imposed the most out-of-pocket costs.

Distribution of Dietary Risk Factors in Iran: National and Sub-National Burden of Disease.

BACKGROUND: Non-communicable diseases (NCDs) are one of the greatest threats to public health, and have been related to poor quality dietary patterns. This study was conducted to determine the distribution of dietary risk factors in Iran. METHODS: Cross-sectional data was gathered between April and November 2016 from 30,541 eligible adults (out of 31 050 individuals who were selected through systematic proportional to size cluster random sampling) living in urban and rural areas, using the WHO-based STEPs risk factor questionnaire. Low intakes of fruits, vegetables, dairy products, and fish, and high intakes of salty processed food (SPF), as well as daily intake of hydrogenated fat (HF) were considered as nutritional risk factors. RESULTS: At the national level, 82.8% (95% CI: 82.4-83.2), 57.8% (95% CI: 57.2-58.4), 80.6% (95% CI: 80.1-81) and 90.3% (95% CI: 90-90.6) of participants of all age groups had sub-optimal intakes of fruits, vegetables, dairy products and fish, respectively. Furthermore, 12.8% (95% CI: 12.4-13.1), and 29.4% (95% CI: 28.9-29.9) of respondents had high SPF intakes and HF use, respectively. At the sub-national level, the highest distribution of suboptimal intake of fruits (97.2%; 95% CI:96-98.3), vegetables (79.2%; 95% CI: 76.3-82.1) and dairy products (92.9%; 95% CI: 91-94.7) was observed in Sistan and Baluchistan. Except for Boushehr and Hormozgan, the majority of the population of other provinces consumed fish less than twice a week. Similarly, the high intake of SPF was found mostly in the population of Yazd (23.7; 95% CI: 20.2-27.2). HF consumption was the highest in North Khorasan (64.2%; 95% CI: 60.3-68.1). CONCLUSION: These findings highlight the widespread distribution of dietary risk factors in Iran, which should be a priority for the people and the politicians in order to prevent NCDs.

Mortality Attributable to Nutritional Deficiencies among Iranian Children under the Age of Five at National and Subnational Level: 1995-2015.

BACKGROUND: Under-five mortality is considered an indicator of population well-being and health equality in societies. Under-five mortality caused by nutritional deficiencies is a public health concern in developing countries. In this study, we aimed to report the trend and mortality rate of nutritional deficiencies from 1995 to 2015 in children aged under five years. METHODS: In this study, we used the death registration system (DRS) data to estimate age- and sex-specific nutritional deficiency mortality rates at national and sub-national levels in Iran from 1995 to 2015. The Iranian DRS used the 10th revision of International Classification of Diseases (ICD-10) but we report our results based on Global Burden of Diseases (GBD) study codes. We used the average annual percent change (AAPC) to quantify trend in under-five mortality rate attributable to nutritional deficiencies from 1995 to 2015. RESULTS: At national level, mortality rates in both sexes were 8.53 (95% uncertainty interval [UI]: 7.69-9.47), 1.04 (0.86-1.36), and 0.37 (95% UI: 0.28-0.57) per 100,000 in 1995, 2005, and 2015, respectively. AAPC was estimated between 1995 and 2015. At sub-national level, the highest and lowest mortality rates across provinces ranged from 17.7 per 100000 in 1995 to 1.1 per 100000 in 2015. In the latest years, protein-energy malnutrition (PEM) was the most frequent cause of mortality among other nutritional deficiencies. CONCLUSION: The results show a substantial reduction in terms of mortality caused by nutritional deficiencies at national, as well as provincial, level among children under-five years of age.

Effect of the herbal medicines in obesity and metabolic syndrome: A systematic review and meta-analysis of clinical trials.

Obesity is a medical situation in which excess body fat has gathered because of imbalance between energy intake and energy expenditure. In spite of the fact that the variety of studies are available for obesity treatment and management, its "globesity" still remains a big challenge all over the world. The current systematic review and meta-analysis aimed to evaluate the efficacy, safety, and mechanisms of effective herbal medicines in the management and treatment of obesity and metabolic syndrome in human. We systematically searched all relevant clinical trials via Web of Science, Scopus, PubMed, and the Cochrane database to assess the effects of raw or refined products derived from plants or parts of plants on obesity and metabolic syndrome in overweight and obesity adult subjects. All studies conducted by the end of May 2019 were considered in the systematic review. Data were extracted independently by two experts. The quality assessment was assessed using Consolidated Standards of Reporting Trials checklist. The main outcomes were anthropometric indices and metabolic syndrome components. Pooled effect of herbal medicines on obesity and metabolic syndrome were presented as standardized mean difference (SMD) and 95% confidence interval (CI). A total of 279 relevant clinical trials were included. Herbals containing green tea, Phaseolus vulgaris, Garcinia cambogia, Nigella sativa, puerh tea, Irvingia gabonensis, and Caralluma fimbriata and their active ingredients were found to be effective in the management of obesity and metabolic syndrome. In addition, C. fimbriata, flaxseed, spinach, and fenugreek were able to reduce appetite. Meta-analysis showed that intake of green tea resulted in a significant improvement in weight ([SMD]: -0.75 [-1.18, -0.319]), body mass index ([SMD]: -1.2 [-1.82, -0.57]), waist circumference ([SMD]: -1.71 [-2.66, -0.77]), hip circumference ([SMD]: -0.42 [-1.02, -0.19]), and total cholesterol, ([SMD]: -0.43 [-0.77, -0.09]). In addition, the intake of P. vulgaris and N. sativa resulted in a significant improvement in weight ([SMD]: -0.88, 95 % CI: [-1.13, -0.63]) and triglyceride ([SMD]: -1.67, 95 % CI: [-2.54, -0.79]), respectively. High quality trials are still needed to firmly establish the clinical efficacy of the plants in obesity and metabolic syndrome.

Association of Anthropometric Indices With Metabolic Phenotypes of Obesity in Children and Adolescents: The CASPIAN-V Study.

Background: Obesity, particularly in the upper part of the body, is a major health problem. Measuring the neck circumference (NC) and wrist circumference (WrC) is a relatively new method of differentiating between normal and abnormal fat distributions. This study aimed to evaluate the association of NC, hip circumference (HC), and WrC with different phenotypes of obesity and their metabolic status. Methods: In this multi-centric cross-sectional study, 4,200 students aged 7-18 years were selected from 30 provinces in Iran in 2014 by using a multistage cluster random sampling method. Metabolic syndrome (MetS) was defined based on the ATP III criteria modified for the pediatric age group. The subjects were classified into four groups according to their weight and metabolic status: metabolically healthy obese (MHO), metabolically non-healthy non-obese (MNHNO), metabolically non-healthy obese (MNHO), and metabolically healthy non-obese (MHNO). Results: Significant but different associations of NC, HC, and WrC with obesity phenotypes were documented in the entire population. Significant but different associations of NC, HC, and WrC with metabolic phenotypes were also found in the entire population. In the multinomial logistic regression, the association of the different obesity phenotypes with the study anthropometric indices increased significantly with increasing NC, WrC, and HC. Also, per one unit increment in NC, HC, and WrC, the odds of MHO, MNHNO, and MNHO increased compared to that of the MHNO phenotype. Conclusion: In children and adolescents, HC, NC, and WrC are significantly associated with obesity phenotypes and their metabolic status, and these metrics are suggested to be innovative, low-cost, and alternative tools for assessing them in different age and sex pediatric age groups.

Physical activity profile of the Iranian population: STEPS survey, 2016.

BACKGROUND: Insufficient physical activity (IPA) is one of the leading causes of premature mortality through the increased burden of non-communicable diseases. From 1990 to 2017, the percentage of low physical activity attributable disability-adjusted life years (DALY) increased globally by 1.5 times and 2-fold in Iran, causing more than 1.2 million deaths worldwide and 18,000 deaths in Iran in 2017. Reports suggest that Iran, a developing middle-income country, suffers from a high level of IPA. Socioeconomic and cultural alterations along with the country's developments expose the population to IPA risk. We aimed to describe IPA prevalence in Iran's adult population, categorized by demographics, geographical region, and activity domains to assess the present pattern of physical inactivity and its domains in the country. METHODS: In 2016, in order to represent Iran's adult population, adult participants (n: 30541) from 30 provinces were selected using systematic proportional to size cluster sampling. Physical activity (PA) was assessed via the Global Physical Activity Questionnaire, calculating the Metabolic Equivalent of Task (MET) value in minutes per week for work, recreation, and transport domains. Insufficient physical activity (IPA) was defined according to WHO's recommendation (less than 600 METs per week). Adjusted odds ratios of IPA associates for sociodemographic, lifestyle related variables, and metabolic risk factors were reported. RESULTS: A high prevalence of IPA was seen in the total population (54.7%, 95%CI: 54.0-55.3) with a considerable difference between the two genders (males: 45.3% (95%CI: 44.3-46.3); females: 61.9% (95%CI: 61.0-62.7)). Work-related activity was the domain with the greatest percentage of total PA, whereas, both genders lacked recreational activities. In our findings, being female, a housekeeper, younger and living in urban areas were significantly associated with higher levels of IPA. Moreover, insufficient fruit and vegetable consumption, lack of alcohol consumption, having a personal vehicle, and finally, having a medical history of diabetes were significantly associated with the presence of IPA in our population. Among the study population, 33.6% (95%CI: 33.0-34.2) had at least 4 h of sedentary behavior in a typical day. CONCLUSIONS: Widespread IPA among the Iranian adult population is of major concern. In our findings, we observed a considerable gap in the prevalence and pattern of IPA between the two genders. Additionally, IPA was associated with living in urban areas, unhealthy lifestyle habits and a history of other metabolic risk factors. Thus, a prompt initiative for population-specific actions should be taken.