Medical Overuse in the Iranian Healthcare System: A Systematic Scoping Review and Practical Recommendations for Decreasing Medical Overuse During Unexpected COVID-19 Pandemic Opportunity.

PURPOSE: To perform an inclusive search for original studies that report medical overuse in the Iranian healthcare system and discovering the area of overuse. PATIENTS AND METHODS: A systematic search of the literature is conducted in bibliographic databases including PubMed, Embase, Scopus, Web of Sciences, Cochrane and Scientific Information Database using a comprehensive search strategy without time limit until the end of 2018, updated by 1 July 2020, accomplished by reference tracking, author contacting and expert consultation to identify studies on the overuse of medical care. RESULTS: We reviewed 4124 published articles based on predetermined inclusion criteria. The author's consensus included a total of 41 articles. Of these, 32 were in English and 9 in Farsi, published between 1975-2019. The result categorized into two distinct clinical areas: treatment (18 articles) and diagnostic (23 articles) services. Almost all of the studies only described the magnitude of unnecessary overuse. Unnecessary overuse of antibiotics, MRI, and CT-scan were the most reported topics. The ranges of their overuse proportion were as follows: antibiotic (31 to 97%); MRI (33 to 88%), and CT-scan (19 to 50%). CONCLUSION: Our review showed, even so, the magnitude of unnecessary overuse of medical services is high but there are only a few interventional studies in clinical and administrative level for finding effective methods for decreasing these unnecessary services. Researchers should be encouraged to conducting interventional studies. We suggest the ministry of health to use the golden opportunity of COVID-19 epidemic for designing Iran national policy and action plan for controlling and preventing unnecessary healthcare services and including a section for "Interventional Research" in the action plan.

Iranian Study on Social Determinants of Self-management in Patients with Hypertension Referring to Tabriz Health Care Centers in 2017-2018.

AIM: The present study aims to evaluate self-management status in Iranian patients with hypertension and its relationship with social determinants. SETTING AND DESIGN: This study was carried out in 2017-2018 in health care centers affiliated with Tabriz University of Medical Sciences in Iran. METHODS: A total of 240 patients with hypertension, who referred to health care centers of Tabriz, were invited to fill out the self-management (researcher made) and social determinants of health questionnaires. STATISTICAL ANALYSIS: Spearman correlation was used to determine the relationship between self-management score and its items with items of social determinants of health questionnaire. Also, Pearson correlation Student t-test was used. RESULTS: In this research 197 patients were studied. Mean age of the participants was 56.6 ± 10.1 years. The mean ± SD (standard deviation) of self-management score was 81.51 ± 13.16. The correlation coefficient of self -management with financial ability of securing the education expenses, nutrition and fruits, and health care expenses were 0.228 (P = 0.001), 0.149 (P value <0.05), and 0.28 (P < 0.001) respectively. Also, the correlation coefficient of age with self-management was - 0.206 (P value = 0.004). Item level analysis showed strong significant associations between social determinants and three items related to lifestyle and two items related to monitoring of blood pressure (BP) at home. CONCLUSION: Overall self -management status of the patients was very good. Health centers that plan self -management support programs for patients should consider the social determinants of life style modification and monitoring of BP at home by hypertensive patients.

Country-level interventions for the prevention and management of hypertension through the modification of social determinants of health: a systematic review protocol.

BACKGROUND: Hypertension is one of the public health challenges. Various risk factors are associated with hypertension, including social demographics, geographical location, health behaviours, and social stress. Interventions in the social determinants of health can improve hypertension and health promotion. Accordingly, different sectors such as agriculture, housing, education, and transportation should cooperate. This systematic review examines policies as a set of activities and actions/interventions aimed at the modification of the social determinants of health to prevent hypertension. METHODS: A systematic search will be conducted in Medline (via Ovid), PubMed, EMBASE, Cochrane Library, ProQuest Dissertations & Theses, and scientific Persian databases including SID and Magiran. There will be no time restriction. The quality of selected studies will be assessed using an appropriate Joanna Briggs Institute (JBI) Critical Appraisal Checklists according to the type of studies. Two independent researchers will carry out screening and quality assessment. Disagreement between two researchers will be resolved by a third party. DISCUSSION: Recommendations will be made for policymakers in order to make better evidence-based decisions about the prevention and management of hypertension with regard to the social determinants of health. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020152298.

Inappropriate Rate of Admission and Hospitalization in the Iranian Hospitals: A Systematic Review and Meta-Analysis.

BACKGROUND: Inappropriate admission and hospitalization are types of overuse that impose a financial burden on all health systems, especially in hospitals. OBJECTIVE: To analyze the evidence on the inappropriateness of admission and hospitalization in Iranian hospitals. METHODS: This study was conducted using PubMed, Embase, Scopus, and Web of Science, as well as Persian databases, including Magiran and Scientific Information Database up to May 2018. Two researchers extracted result of the included studies, independently. We used Cohen's κ statistic for measuring inter-rater agreement. The meta-analyses were conducted based on pooled effect estimates for the rate of admission and hospitalization using the DerSimonian-Laird random-effects model with 95% confidence intervals (CI). RESULTS: Seventeen articles met the inclusion criteria. The inter-rater agreement was very good for abstracts and full-texts screening (κ 0.86 and 98, respectively). The overall inappropriate rate was 12.3% (95% CI, 8.4-17.5) and 11.9% (95% CI, 7.7-18.1) for admission and hospitalization, respectively. The inappropriate rate of admission was significantly higher before the Health Sector Evolution Plan (HSEP) than after HSEP (14.6%, 95% CI, 8.6-23.6 before HSEP and 10%, 95% CI, 5.5-17.3 after HSEP), and the inappropriate rate of hospitalization was significantly higher after HSEP than before HESP (9.5%, 95% CI, 5.2-16.7 before HSEP and 16.9%, 95% CI, 8.2-31.7 after HSEP). CONCLUSIONS: Adoption standard measures of admission and hospitalization, treating patients in appropriate care centers, and establishing a referral system is essential to reduce the inappropriate admission and hospitalization in Iranian hospitals. Such interventions can lead to a reduction in personnel costs and workload and ultimately increase the productivity of the hospital.

Policy package for preventing overuse and underuse of health care services in the Iranian health care system: A study protocol.

Background: Overuse and underuse of health care services are progressively recognized in all health systems around the world. There is evidence of overuse and underuse of health care services in Iran. In this study, it was aimed to summarize the evidence of overuse and underuse of health care services in the Iranian health care system. Methods: This study will be conducted in 5 steps using a sequential explanatory multimethod design, literature review, systematic review, qualitative interview, expert panel, and policy Delphi method. This study was approved by Tabriz University of Medical Sciences (ethical confirmation number: IR.TBZMED.REC.1396.908). Conclusion: There is a strong evidence of worldwide overuse and underuse of health care services. Designing context-based prevention strategies by conducting comprehensive and systematic studies will improve the appropriate use of routine services and help patients, physicians, and providers make evidence-based decisions.

Readiness for weight change and its association with diet knowledge and skills, diet decision making and diet and exercise barriers in patients with type 2 diabetes.

AIMS: this study aimed to investigate stages of weight change in type 2 diabetics and its associations with diet knowledge and skills, diet decision making, diet and exercise barriers. MATERIALS AND METHODS: This was a cross-sectional study of 1139 patients with type 2 diabetes aged>18 years in East Azerbaijan, Iran. Data were collected using the Personal Diabetes Questionnaire (PDQ) and were analyzed using SPSS software (version 22) and descriptive statistics, Chi-square and one-way ANOVA tests. RESULTS: 48.1% of the patients were in the pre-contemplation stage. 7.5%, 14.6% and 29.8% of patients were in the stages of contemplation, preparation and action, respectively. Patients with a higher score in diet knowledge and skills and diet decision making were more likely to be involved in the action stage of weight loss process, while those who had more eating problems and exercise barriers were less likely to be involved in the action stage of weight loss. CONCLUSION: The results of this study showed that a substantial percentage of patients are at the pre-contemplation stage, so proper measures are needed to inform patients about the consequences of obesity and overweight. It is also necessary to focus on people with poor incomes and education status and those living in rural areas. Improve diet knowledge and skills and diet decision making and the reduction of barriers to exercise can help patients to take action to lose weight.

Readiness for diet change and its association with diet knowledge and skills, diet decision making and diet barriers in type 2 diabetic patients.

AIMS: to investigate stages of change for dietary in type 2 diabetics and its associations with diet knowledge and skills, diet decision making and diet barriers. MATERIALS AND METHODS: This was a cross-sectional study which was conducted on 1139 diabetics aged>18 years in East Azerbaijan, Iran. Data were collected through a Personal Diabetes Questionnaire (PDQ) and analyzed through SPSS version 22 software using descriptive statistics, Chi-square and one-way ANOVA tests. Tukey's HSD post hoc tests were applied to illustrate ANOVA findings. RESULTS: 59.3% of patients do not follow a diet plan to control their blood glucose. 44.7%, 5.5%, 13%, and 36.8% of patients, respectively, were in the stages of pre-contemplation, contemplation, preparation and action. Patients who had shorter disease duration and those whose current treatment was lifestyle change were more likely within the action stage. Also, patients who had a higher score in diet knowledge and skills and diet decision making and those who had a lower score in diet barriers were more likely in the action stage of change. CONCLUSION: Based on the results of this study, a considerable proportion of diabetic patients were in the pre-contemplation stage. Diet knowledge and skills, diet decision making and diet barriers were factors contributing to diet readiness to change. Therefore, taking necessary measures to increase diet knowledge, skills and diet decision-making and a reduction in diet barriers can help people with type 2 diabetes to change diet.

Factors related to the non-adherence of medication and nonpharmacological recommendations in high blood pressure patients.

Introduction: Many studies have been conducted on non-adherence with the antihypertensive treatment regime in various countries, considering the burden of cardiovascular disease (CVD) on the public health system, it is essential to carry out studies in this regard. Methods: Patients with hypertension evaluated at the family medicine clinic of Tabriz University of Medical Sciences were enrolled using simple sampling. Data gathering tool was a questionnaire consisting of three sections including the Hill-Bone compliance questionnaire, the disease characteristics, and patients' socioeconomic. Results: Of 254 patients with hypertension, gender, income satisfaction, the occupation and the level of education did not correlate with the acceptance of the treatment. However, the number of antihypertensive medications had a significant effect on adherence with dietary orders and appointment keeping (P<0.01 and P=0.01, respectively). The number of antihypertensive drugs could statistically significantly predict overall score obtained from the questionnaire, F (1, 251) = 22.29, P<0.018. Conclusion: Factors related to the history of the disease and socioeconomic status had no effect patients adherence with treatment; however, the number of the prescribed antihypertensive drugs is in association with higher overall scores obtained through the Hill-Bone questionnaire.

Balancing Overuse and Underuse in the Iranian Healthcare System: A Force Field Theory Analysis.

BACKGROUND: Overuse and underuse of healthcare services occure within population, organizations and even patients around the world. Producing a balance between these two can increase efficiency, service quality and patient satisfaction. It also decrease extra costs. The aim of this study was to identify forces for change and forces against change for generating balance between overuse and underuse to achieve right care. METHODS: This study was conducted in five steps: 1) describe our plan or proposal for change; 2) identify forces for change; 3) identify forces against change; 4) assign forces; and 5) analyze and apply. We used purposive sampling strategy. The number of participants in the expert panel were eight. Each participant signed informed consent form before starting the study (Ethical code: IR.TBZMED.REC.1396.908). RESULTS: The driving factors for balancing overuse and underuse were education, preparing clinical guideline and standard protocols, resource allocation, using evidence-based medicine, evidence-based management and evidence-informed policy making approaches and social prescribing. The restraining factors for balancing overuse and underuse were conflict of interest issues, payment systems, paternalism and medicalization, patients and physicians' side problems and culture of consumerism in the community. The total scores for and against change were 14 and 17, respectively. CONCLUSION: It seems that the emphasis on education and training in this field is essential for physicians, patients and all people in the community. Also, making reforms in payment systems and changing the rules and regulations in this area could be major drivers.

Evaluation of the health promotion standards in governmental and non-governmental hospitals in East-Azerbaijan.

Background: Considering the importance of assessing the program of health promotion hospitals (HPH) for elucidating the compliance with the standards, the present study aimed to evaluate the health promotion standards in governmental and nongovernmental hospitals of East-Azerbaijan. Methods: In the present cross-sectional study, all hospitals in East-Azerbaijan province in 2018 were recruited. The Persian validated World Health Organization (WHO) a self-assessment questionnaire was sent to the director of each hospital and invited to corporate with the study. Self-assessment questionnaire consists of 40 measurable elements that assess management policy, patient's assessment, patient information and intervention, promoting health work placed and continuity and cooperation. Independent sample ttest was conducted to compare the mean score of each standard across hospitals type, location, and size. A significance level of 0.05 was used. Results: Hospitals total HPH score was 56.06±21.27 (out of 100). Among five standards, Standard 3 had the highest score (66.85±18.80), and Standard 4 had the lowest score (47.79±19.12). The capital cities' hospitals had a significantly higher score in Standard 5 (p=0.02). Non-governmental hospitals had a significantly higher score in standard 4 (p=0.02). There were no significant differences in all five standards of HPH between hospitals with ≤200 and >200 beds (p>0.05). Conclusion: The hospitals in East-Azerbaijan-Iran had moderate compliance with HPH program, and they need to improve their performance especially in the field of providing healthy workplace and offering proper education and health-promoting services to patients after discharge.

Balancing overuse and underuse in the Iranian healthcare system: a force field theory analysis

BACKGROUND: Overuse and underuse of healthcare services occure within population, organizations and even patients around the world. Producing a balance between these two can increase efficiency, service quality and patient satisfaction. It also decrease extra costs. The aim of this study was to identify forces for change and forces against change for generating balance between overuse and underuse to achieve right care. METHODS: This study was conducted in five steps: 1) describe our plan or proposal for change; 2) identify forces for change; 3) identify forces against change; 4) assign forces; and 5) analyze and apply. We used purposive sampling strategy. The number of participants in the expert panel were eight. Each participant signed informed consent form before starting the study (Ethical code: IR.TBZMED.REC.1396.908). RESULTS: The driving factors for balancing overuse and underuse were education, preparing clinical guideline and standard protocols, resource allocation, using evidence-based medicine, evidence-based management and evidence-informed policy making approaches and social prescribing. The restraining factors for balancing overuse and underuse were conflict of interest issues, payment systems, paternalism and medicalization, patients and physicians' side problems and culture of consumerism in the community. The total scores for and against change were 14 and 17, respectively. CONCLUSION: It seems that the emphasis on education and training in this field is essential for physicians, patients and all people in the community. Also, making reforms in payment systems and changing the rules and regulations in this area could be major drivers

Medical overuse in the Iranian healthcare system: a systematic review protocol.

INTRODUCTION: Lack of resources is one of the main problems of all healthcare systems. Recent studies have shown that reducing the overuse of medical services plays an important role in reducing healthcare system costs. Overuse of medical services is a major problem in the healthcare system, and it threatens the quality of the services, can harm patients and create excess costs for patients. So far, few studies have been conducted in this regard in Iran. The main objective of this systematic review is to perform an inclusive search for studies that report overuse of medical services in the Iranian healthcare system. METHOD AND ANALYSIS: An extensive search of the literature will be conducted in six databases including PubMed, Embase, Scopus, Web of Science, Cochrane and Scientific Information Database using a comprehensive search strategy to identify studies on overuse of medical care. The search will be done without time limit until the end of 2017, completed by reference tracking, author tracking and expert consultation. The search will be conducted on 1 February 2018. Any study that reports an overuse in a service based on a specific standard will be included in the study. Two reviewers will screen the articles based on the title, abstract and full text, and extract data about type of service, clinical area and overuse rate. Quality appraisal will be assessed using the Joanna Briggs Institute checklist. Potential discrepancies will be resolved by consulting a third author. ETHICS AND DISSEMINATION: Recommendations will be made to the Iranian MOHME (Ministry of Health and Medical Education) in order to make better evidence-based decisions about medical services in the future. PROSPERO REGISTRATION NUMBER: CRD42017075481.

Validity and Reliability of the Questionnaire for Assessing Women's Reproductive History in Azar Cohort Study.

This study was done to evaluate the validity and reliability of women's reproductive history questionnaire which will be used in Azar Cohort study; a cohort that is conducted by Tabriz University of Medical Science in Shabestar county for identifying risk factors of no communicable diseases. Content and face validity were evaluated by ten experts in the field and quantified as content validity index (CVI) and content validity ratio (CVR). To assess the reliability, using test-retest approach, kappa statistic was calculated for categorical variables and intra-class correlation coefficient (ICC) was used for the quantitative items. The calculated CVI and CVR were 0.91and 0.94, respectively. Reliability for all items was high. The ICC was 0.99 and kappa statistic was equal to 1. The final version of questionnaire was redesigned in 26 items with 7 subscales.

Association of the type of trauma, occurrence of bone bruise, fracture and joint effusion with the injury to the menisci and ligaments in MRI of knee trauma.

BACKGROUND: magnetic resonance imaging (MRI) as a noninvasive diagnostic tool may help clinicians in the evaluation of injuries to menisci and ligaments. PURPOSE: this study assessed the associations between type of trauma to knee joint, bone bruise, fracture and pathological joint effusion with injuries to menisci and ligaments of knee joint. METHODS: we reviewed knee joint MRI of 175 patients aged less than 45 years old who were referred to MRI center of our University. RESULTS: statistical analysis showed that tearing of medial meniscus (MM) is significantly more common in sport related trauma (p= 0.045) but tearing of medial collateral ligament (MCL) is significantly more common in non-sport related trauma (p= 0.005). Existence of bone bruise in knee MRI is negatively associated with tearing of medial meniscus (MM) (p=0.004) and positively associated with tearing of anterior cruciate ligament (ACL) (p=0.00047) and medial collateral ligament (MCL) (p = 0.0001). Existence of fracture is associated with decreased risk of the tearing of ACL and MM (p=0.04, p=0.001 respectively). Pathologic joint effusion is significantly more common in ACL and MCL tearing (p=0.0001, p=0.004 respectively). CONCLUSIONS: as diagnostic clues, bone bruise, fracture and joint effusion may help radiologists for better assessment of injury to menisci and ligaments in MRI of patients with knee trauma.

Unnecessary Overtreatment Index: a useful tool in family practice / Índice de Sobretratamento Desnecessário: uma ferramenta útil para a medicina de família / Índice de Sobretratamiento Innecesario: una herramienta útil para la medicina familiar

One of the most important aspects of quaternary prevention is avoiding the exposure of the patients to unnecessary overtreatment. In this commentary we explain how a valid and reliable double blinded randomized controlled clinical trial (RCT) with a good external validity may help a physician to estimate the magnitude of unnecessary overtreatment.

Migration patterns of herniated disc fragments: a study on 1,020 patients with extruded lumbar disc herniation.

BACKGROUND CONTEXT: Herniated disc fragments are known to migrate in various directions within the spinal canal. To date, no comprehensive studies have been undertaken to examine the migration patterns of herniated disc material using a standard nomenclature and classification system. PURPOSE: To report migration patterns of extruded lumbar disc fragments. STUDY DESIGN: A review of magnetic resonance (MR) images. PATIENT SAMPLE: A total of 1,020 consecutive Azeri patients with symptomatic extruded lumbar intervertebral disc herniation. OUTCOME MEASURES: Migration patterns of extruded lumbar disc fragments in vertical and horizontal planes and their association with age, gender, body mass index (BMI), and the level of herniation. METHODS: High-quality axial and sagittal MR images of the lumbar spine were used. Disc material that was displaced away from the site of extrusion, regardless of continuity, was considered "migrated." The migration patterns observed were rostral or caudal in the vertical plane and central, paracentral, subarticular, foraminal, or extraforaminal in the horizontal plane. RESULTS: In the vertical plane, rostral and caudal migrations were observed in 27.8% and 72.2% of the patients, respectively. The number of rostral migrations increased significantly with increasing age and in higher levels in the lumbar spine (p<.001 for both). Radiculopathy was significantly more frequent in caudal migrations than in rostral migrations (78.9% vs. 65.1%, p<.001). There was no significant association between gender or BMI and migration patterns in the vertical plane. In the horizontal plane, central, paracentral, subarticular, foraminal, and extraforaminal migrations were reported in 17.3%, 74.2%, 4.3%, 2.5%, and 1.8% of the patients, respectively. The youngest (median age 39 years, interquartile range [IQR] 13 years) and the oldest (median age 55 years, IQR 15 years) groups of patients (p<.001) had the most formainal and extraforaminal migrations, respectively. Radiculopathy was present in 66.5%, 76.8%, 88.6%, 96%, and 27.8% of the patients with central, paracentral, subarticular, foraminal, and extraforaminal migrations, respectively (p<.001). No significant association was found between gender, BMI, or the level of herniation and migration pattern in the horizontal plane. CONCLUSIONS: Caudal and paracentral migrations are the most common patterns of migration in patients with extruded lumbar disc herniation in the vertical and horizontal planes, respectively. Age and the level of herniation may affect the migration patterns of herniated lumbar disc material.

Validity and reliability of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and its correlation with urodynamic findings.

PURPOSE: To validate the Persian version of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) as a standard questionnaire for assessment of urinary incontinence (UI). MATERIALS AND METHODS: After translation and back translation of the questionnaire, the harmonized translation was pre-tested in a pilot study on 28 patients. The final Persian version of the ICIQ-UI SF was administered to 123 consecutive patients aged ≥ 16 years complaining of UI. The psychometric aspects of the questionnaire, such as reliability and construct validity, were assessed and compared with full urodynamics study's findings as the gold standard diagnostic test. RESULTS: Mean age of the participants was 46.30 ± 13.14 years (range, 16 to 72 years). Based on ICIQ-UI SF, the prevalence of mixed urinary incontinence, stress urinary incontinence and urgency urinary incontinence was 35%, 34.1%, and 30.9%, respectively. Cronbach's alpha coefficient was calculated 0.75, which indicates the high reliability of this questionnaire in determination of UI. The obtained Weighted Kappa Index in determining the value of the test-retest was 0.70, and Pearson Correlation Coefficient was calculated 0.93 and intra-class correlation coefficient was 0.84. CONCLUSION: Persian version of ICIQ-UI SF is a simple, valid, and reliable method for evaluation of patients with UI. Significant correlation exists between ICIQ-UI SF score and urodynamics parameters.

Diagnostic value of ultrasonography and magnetic resonance imaging in ulnar neuropathy at the elbow.

Aim. To evaluate the diagnostic value of ultrasonography and magnetic resonance imaging (MRI) in patients with ulnar neuropathy at the elbow (UNE). Methods. We prospectively performed electrodiagnostic, ultrasonographic, and MRI studies in UNE patients and healthy controls. Three cross-sectional area (CSA) measurements of the ulnar nerve at multiple levels along the arm and maximum CSA(-max) were recorded. Results. The ulnar nerve CSA measurements were different between the UNE severity grades (P < 0.05). CSA-max had the greatest sensitivity (93%) and specificity (68%). Moreover, CSA-max ≥10 mm(2) defined the severe UNE cases (sensitivity/specificity: 82%/72%). In MRI, ulnar nerve hyperintensity had the greatest sensitivity (90%) and specificity (80%). Conclusion. Ultrasonography using CSA-max is sensitive and specific in UNE diagnosis and discriminating the severe UNE cases. Furthermore, MRI particularly targeting at increased signal of the ulnar nerve can be a useful diagnostic test of UNE.