Estimation of a Neonatal Health Production Function for Iran: Secondary Analysis of Iran's Multiple Indicator Demographic and Health Survey 2010

BACKGROUND

Despite constant decrease in rate of neonatal mortality, the rate is still higher than that of other under-five children. One of the first steps towards reduction of neonatal mortality is to identify its determinants using health production function. The aim of the present study was to estimate neonatal health production function for Iran.

METHODS

In this cross-sectional study, Iranian Multiple Indicator Demographic and Health Survey (Ir-MIDHS) 2010 was used. Four categories of socioeconomic, mother, neonatal demographic and healthcare system factors were entered into the Binomial Logistic Regression model to estimate neonate health production function. Households' economic status was constructed using principal component analysis.

RESULTS

History of abortion/stillbirth had the highest significant positive impact on odds of neonatal mortality (odds ratio=1.98; 95 % CI=1.55-2.75), indicating that neonates of mothers with such a history had 1.98 times higher chance of death compared to other neonates. Moreover, odds ratio of neonatal death for the poorest quintiles was 1.70 (95 % CI=1.08-2.74), indicating that by moving from the poorest quintile to the richest one, the odds of being alive for neonates increased up to 70%. However, skilled birth attendant decreased the chance of death up to 58% (odds ratio=0.58; 95 % CI=0.36-0.93).

CONCLUSION

Considering the most significant inputs of neonatal health production function in Iran, improvement of economic status of households, provision of appropriate care services for mothers, and improvement of delivery care provided by trained personnel, could be priorities for health policymakers to act and reduce neonatal mortality in Iran.

Out of Pocket Payment and Affordability of Medication for Geriatric Patients in Tehran, Iran

BACKGROUND

Considering the importance of high out-of-pocket (OOP) payment (OOPP), as a marker of health system performance, and affordability of medications in the elderly, this study was conducted to determine these issues.

METHODS

In this cross-sectional study, prescriptions of patients aged 65 yr or older from 5 university-affiliated pharmacies in Tehran, Iran were evaluated from Jan to Mar 2014. Prescriptions were selected from four insurance organizations. We used the prescriptions data regarding patients' demographics and the prescribers as well as the sales data for OOP. Affordability was calculated by considering the daily salary of an unskilled worker.

RESULTS

Totally, 1467 prescriptions were analyzed. Mean age of patients was 73.89(6.66) yr. Mean (SE) of reimbursable and OOPP of the prescriptions were 203820 (10831) and 230252 (10634) IRR (Iranian Rials) respectively (equivalent to 81.6 (4.33) and 92.17 (4.33) US$ respectively). Subspecialists imposed higher expenditures for patients and insurance organizations. Patients referred to the ophthalmologists paid less OOP. Nearly 50% of the total prescription costs was paid as OOP. The mean OOPP was averagely equal to 1.41(0.065) daily salary. These prescriptions were unaffordable for 36.2% of patients.

CONCLUSION

The OOPP was higher than the insurance goal of 30% for outpatients in Iran. More than one-third of elderly patients could not afford their single prescription. Due to the health consequences of the unaffordability of medications, corrective actions are needed by the insurance organizations and the health system.

Comparison of the Thresholds of Households' Exposure to Catastrophic Health Expenditure in Iran and Brazil, and Selection of the Most Appropriate Threshold

BACKGROUND

Different definitions are nowadays adopted to estimate the threshold of exposure of households to catastrophic health expenditures and different thresholds are used in various studies. This study was conducted to compare these thresholds and select the most appropriate threshold for defining catastrophic health expenditure in Iran and Brazil.

METHODS

In this cross-sectional study, data were collected from 592 households from District 17 of Tehran, Iran, and 869 households from Porto Alegre, Brazil in 2013. Firstly, catastrophic health expenditures were calculated using two common proportions, i.e. out-of-pocket health payments, as a proportion of total cost and as a proportion of ability to pay. These proportions were analysed using the ROC curve and Kappa coefficient.

RESULTS

The appropriate cut off point for the thresholds of 5%, 10%, 15%, and 20% of the total expenditure was 0.52, 0.34, 0.28, and 0.46 in Iran, and 0.44, 0.36, 0.28, and 0.23 in Brazil, respectively. The appropriate cut off point for the thresholds of 20%, 25%, 30%, 35%, and 40% of ability to pay was 0.31, 0.28, 0.25, 0.34, and 0.40 in Iran and 0.36, 0.34, 0.30, 0.38, and 0.46 in Brazil, respectively.

CONCLUSION

The appropriate cut off point for the proportion of out-of-pocket health payments to total expenditure and proportion of health expenditure to ability to pay was the threshold of 20% of total expenditure and 35% of ability to pay, respectively.

Measuring Socioeconomic Inequality Changes in Child Mortality in Iran: Two National Surveys Inequality Analysis

BACKGROUND

We aimed to measure changes in socioeconomic inequality in child mortality in Iran.

METHODS

A secondary data analysis of two Demographic and Health Surveys (DHS 2000 and 2010) was undertaken. Neonatal, infant and under-5 mortality rates were estimated directly from complete birth history. Economic quintiles were constructed using principal component analysis. Changes in inequality were measured using odds ratios, mortality rates, and concentration curves and indices.

RESULTS

Based on the compared measures, inequalities in neonatal, infant, and under-5 mortality declined between the two surveys. The poorest-to-richest neonatal, infant and under-5 mortality odds ratios in 2000 were 1.69 (95% CI= 1.3-2.07), 2.85 (95% CI= 1.96-4.1) and 1.98 (95% CI= 1.64-2.3), respectively. Whereas these mortality odds ratios in 2010 had fallen to 1.65 (95% CI= 0.95-2.9), 1.47 (95% CI=0.5-4) and 1.85 (95% CI=1.13-3), respectively. Moreover, mortality rates in all economic quintiles experienced a decreasing trend. Neonatal, infant, and under-5 mortality concentration indices in 2000 were -0.15, -0.26, and -0.17 respectively. Whereas concentration indices in 2010 had dropped to -0.13, -0.11, and -0.14, respectively. Concentration curves dominance test revealed that there was a statistically significant reduction in inequality in infant and under-5 mortalities.

CONCLUSION

Despite substantial reduction in child mortality rates and narrowing of the gap between poor and rich people, socioeconomic inequality in child mortalities disfavoring worse-off groups still exists. Combination of child health-related efforts that aim to reach to those children born in poor households alongside with pro-equity programs in other sectors of society may further reduce infant, under-5, and particularly neonatal mortality across economic quintiles in Iran.

Assessment of Orthographic Similarity of Drugs Names between Iran and Overseas Using the Solar Model

BACKGROUND

The recognition of patient safety is now occupying a prominent place on the health policy agenda since medical errors can result in adverse events. The existence of confusing drug names is one of the most common causes of medication errors. In Iran, the General Office of Trademarks Registry (GOTR), for four years (2010-2014) was responsible for approving drug proprietary names. This study aimed to investigate the performance of the GOTR in terms of drug names orthographic similarity using the SOLAR model.

METHODS

First, 100 names were randomly selected from the GOTR's database. Then, each name was searched through pharmaceutical websites including Martindale (the Complete Drug Reference published by Pharmaceutical Press), Drugs.com and Medicines Complete. Pair of drugs whose names look orthographically similar with different indications were identified. Then, the SOLAR model was utilized to determine orthographic similarity between all pair of drug names.

RESULTS

The mean of match values of these 100 pairs of drug was 77% indicating the high risk of similarity. The match value for most of the reviewed pairs (92%) was high (≥66%). This value was medium (≥ 33% and <66%) just for 8% of the pairs of drug. These results indicate high risk of confusion due to similarity of drug names.

CONCLUSION

The stewardship of the GOTR in patient safety considerations is fundamentally problematic. Thus, as a best practice, we recommend that proprietary names of drugs be evaluated by an entity within the health system. While an entity within the health system should address patient safety considerations, the GOTR is responsible for intellectual property rights.

Willingness to Pay for Complementary Health Care Insurance in Iran

BACKGROUND

Complementary health insurance is increasingly used to remedy the limitations and shortcomings of the basic health insurance benefit packages. Hence, it is essential to gather reliable information about the amount of Willingness to Pay (WTP) for health insurance. We assessed the WTP for health insurance in Iran in order to suggest an affordable complementary health insurance.

METHODS

The study sample consisted of 300 household heads all over provinces of Iran in 2013. The method applied was double bounded dichotomous choice and open-ended question approach of contingent valuation.

RESULTS

The average WTP for complementary health insurance per person per month by double bounded dichotomous choice and open-ended question method respectively was 199000 and 115300 Rials (8 and 4.6 USD, respectively). Household's heads with higher levels of income and those who worked had more WTP for the health insurance. Besides, the WTP increased in direct proportion to the number of insured members of each household and in inverse proportion to the family size.

CONCLUSION

The WTP value can be used as a premium in a society. As an important finding, the study indicated that the households were willing to pay higher premiums than currently collected for the complementary health insurance coverage in Iran. This offers the policy makers the opportunity to increase the premium and provide good benefits package for insured people of country then better risk pooling.

Comparison the effects of poor health and low income on early retirement: a systematic review and meta-analysis

The main aim of this study was to estimate the effects of poor health and low income on early retirement. For this purpose systematic review and meta-analysis were conducted. Web of Science, PUBMED and Scopus databases were searched systematically. Finally 17 surveys were added in meta-analysis. These studies were conducted in 13 countries. At the end a Meta regression was done to show the effects of welfare system type on effect sizes of poor health and low income. The results of this study showed that poor health had effect on the risk of early retirement. (Poor health pooled effect sizes: 1.279 CI: (1.15 1.41), low income pooled effect sizes: 1.042 CI: (0.92 1.17), (poor health pooled marginal effects: 0.046 CI: (-0.03 0.12), low income pooled marginal effects: -0.002 CI: (-0.003 0.000). The results of this study showed that association between poor health and early retirement was stronger in comparison with low income and early retirement.

Conceptual Models of Social Determinants of Health: A Narrative Review

BACKGROUND

There are several conflicting conceptual models to explain social determinants of health (SDH) as responsible for most health inequalities. This study aimed to present these models in historical perspective and provide main component of SDH models as an SES indicators.

METHODS

This was a narrative study using international databases to retrieve literature dealing with conceptual models of SDH. All publication in English language until Mar 2015 was included. The CASP and PRISMA were used to summarize the literature.

RESULTS

Overall, 248 publications were retrieved and screened. After exclusion of irrelevant and duplicates, 94 citations were found to be relevant and 21 publications included in this review. In general, 21 models of SDH were found: some models presented before year 1995(n=4), some models presented between 1995 and 2005 (n=13) and some models presented after 2005 (n=4). However, we found three categories of indicators that contribute to SDH models and that were classic factors, fixed and demographic factors and proxy factors.

CONCLUSION

Reduction of socioeconomic inequalities in health requires understanding of mechanisms and causal pathways; therefore, every country needs to design the specific model. As the available models are for developed countries, lack of a specific model for developing ones is tangible. As there is no gold standard related to SES indicators, therefore, it is proposed to use the various indicators based on life course approach, which leads to understanding and adopting effective policy interventions.

Implications of Dual Practice among Health Workers: A Systematic Review

BACKGROUND

Mixed health care systems to work simultaneously on both public and private facilities, is common today. This phenomenon referred to as dual practice (DP), has potential implications for access, quality, cost and equity of health services. This paper aimed to review systematically studies that assess the implications of DP among health workers.

METHODS

MEDLINE, EMBASE, and The Cochrane library were searched for obtaining published literature between Feb 1990 and May 2014. Google and Google Scholars, organizational websites, and reference lists of relevant papers searched to get grey literature. Only studies concentrated on consequences and impacts of DP among health professionals and conducted using "randomized controlled trials", "non-randomized controlled trials", "controlled before and after studies", or "interrupted time series" were eligible for inclusion.

RESULTS

From 3242 records, we focused on 19 studies, which aimed to assess effects and impacts of dual practice. After that, the current understanding of DP positive and negative implications was categorized and discussed based on two perspectives.

CONCLUSION

There has been a propensity to over-reliance on theoretical methods in predicting the implications of this phenomenon. Almost all of the mentioned implications are based on theoretical predictions undermined in the broader literature. Furthermore, assessing the current literature showed positive and negative impacts of DP on different parts of the health system and various dimensions of service delivery. These implications are contexted specific and may vary from system to system.

Impact of Diabetic Retinopathy on Health-related Quality of Life in Iranian Diabetics

BACKGROUND

To extract utility values of diabetic retinopathy on a perfect health and perfect vision scales for Iranians with both types diabetes.

METHODS

In this investigation, 150 untreated patients with diabetic retinopathy consecutively were examined and interviewed in Farabi Eye Hospital, Tehran, Iran, a tertiary referral center in the Iranian health care system. Utility values based on patients-reported outcome measures, standard gamble, time trade off and visual analogue scale approaches, were estimated.

RESULTS

Considering all three utility elicitation methods were valid, diabetic retinopathy patients, on average reported the 0.95 (±0.03), 0.85 (±0.15) and 0.80 (±0.30) standard policy scale utility according to standard gamble, TTO and VAT respectively. In all three-studied approach, diabetic retinopathy had more disutility in higher levels of disease and had more disutility in the presence of both maculopathy and vasculopathy compared with one of them. Evidence show that share of macular edema in imposing disutility was maximum in early stage and exponentially decreased with advancing the severity of diabetic retinopathy.

CONCLUSION

Study indicated utility scores in DR-experienced Iranian patients were highest with the SG and lowest with the VAT method. The proffered utility-elicitation method in Iranian patient populations could be the TTO approach. The novel model we employed for DR takes the effects of diabetic macular edema and vascularization into account separately, and can provide a better estimate of the QoL for these patients.

Bed Capacity Planning Using Stochastic Simulation Approach in Cardiac-surgery Department of Teaching Hospitals, Tehran, Iran

BACKGROUND

To determine the hospital required beds using stochastic simulation approach in cardiac surgery departments.

METHODS

This study was performed from Mar 2011 to Jul 2012 in three phases: First, collection data from 649 patients in cardiac surgery departments of two large teaching hospitals (in Tehran, Iran). Second, statistical analysis and formulate a multivariate linier regression model to determine factors that affect patient's length of stay. Third, develop a stochastic simulation system (from admission to discharge) based on key parameters to estimate required bed capacity.

RESULTS

Current cardiac surgery department with 33 beds can only admit patients in 90.7% of days. (4535 d) and will be required to over the 33 beds only in 9.3% of days (efficient cut off point). According to simulation method, studied cardiac surgery department will requires 41-52 beds for admission of all patients in the 12 next years. Finally, one-day reduction of length of stay lead to decrease need for two hospital beds annually.

CONCLUSION

Variation of length of stay and its affecting factors can affect required beds. Statistic and stochastic simulation model are applied and useful methods to estimate and manage hospital beds based on key hospital parameters.

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

BACKGROUND

Performance is a multi-dimensional and dynamic concept. During the past 2 decades, considerable studies were performed in developing the hospital performance concept. To know literature key concepts on hospital performance, the knowledge visualization based on co-word analysis and social network analysis has been used.

METHODS

Documents were identified through "PubMed" searching from 1945 to 2014 and 2350 papers entered the study after omitting unrelated articles, the duplicates, and articles without abstract. After pre-processing and preparing articles, the key words were extracted and terms were weighted by TF-IDF weighting schema. Support as an interestingness measure, which considers the co-occurrence of the extracted keywords and "hospital performance" phrase was calculated. Keywords having high support with "hospital performance" are selected. Term-term matrix of these selected keywords is calculated and the graph is extracted.

RESULTS

The most high frequency words after "Hospital Performance" were "mortality" and "efficiency". The major knowledge structure of hospital performance literature during these years shows that the keyword "mortality" had the highest support with hospital performance followed by "quality of care", "quality improvement", "discharge", "length of stay" and "clinical outcome". The strongest relationship is seen between "electronic medical record" and "readmission rate".

CONCLUSION

Some dimensions of hospital performance are more important such as "efficiency", "effectiveness", "quality" and "safety" and some indicators are more highlighted such as "mortality", "length of stay", "readmission rate" and "patient satisfaction". In the last decade, some concepts became more significant in hospital performance literature such as "mortality", "quality of care" and "quality improvement".

Physician Dual Practice: A Descriptive Mapping Review of Literature

BACKGROUND

Physician dual practice is a common phenomenon in almost all countries throughout the world, which could potential impacts on access, equity and quality of services. This paper aims to review studies in physician dual practice and categorize them in order to their main objectives and purposes.

METHODS

Comprehensive literature searches were undertaken in order to obtain main papers and documents in the field of physician dual practice. Systematic searches in Medline and Embase from 1960 to 2013, and general searches in some popular search engines were carried out in this way. After that, descriptive mapping review methods were utilized to categorize eligible studies in this area.

RESULTS

The searches obtained 404 titles, of which 81 full texts were assessed. Finally, 24 studies were eligible for inclusion in our review. These studies were categorized into four groups - "motivation and forces behind dual practice", "consequences of dual practice", "dual practice Policies and their impacts", and "other studies" - based on their main objectives. Our findings showed a dearth of scientifically reliable literature in some areas of dual practice, like the prevalence of the phenomenon, the real consequences of it, and the impacts of the implemented policy measures.

CONCLUSION

Rigorous empirical and evaluative studies should be designed to detect the real consequences of DP and assess the effects of interventions and regulations, which governments have implemented in this field.

Cost-effectiveness analysis of health care waste treatment facilities in iran hospitals; a provider perspective

BACKGROUND

Our aim was to make right and informative decision about choosing the most cost-effectiveness heterogeneous infectious waste treatment methods and devices.

METHODS

In this descriptive study, decision tree analysis, with 10-yr time horizon in bottom-up approach was used to estimate the costs and effectiveness criteria of the employed devices at provider perspective in Iranian hospitals. We used the one-way and scenario sensitivity analysis to measure the effects of variables with uncertainty. The resources of data were national Environmental and Occupational Health Center Survey (EOHCS) in 2012, field observation and completing questionnaire by relevant authorities in mentioned centers.

RESULTS

Devices called Saray 2, Autoclave based, and Newster 10, Hydroclave based, with 92032.4 (±12005) and 6786322.9 (±826453) Dollars had the lowest and highest costs respectively in studied time period and given the 5-10% discount rate. Depending on effectiveness factor type, Newster 10 with Ecodas products and Saray products respectively had the highest and lowest effectiveness. In most considered scenarios, Caspian-Alborz device was the most cost-effectiveness alternative, so for the treatment of each adjusted unit of volume and weight of infectious waste in a 10 year period and in different conditions, between 39.4 (±5.1) to 915 (±111.4) dollars must be spent.

CONCLUSION

The findings indicate the inefficiency and waste of resources, so in order to efficient resource allocation and to encourage further cost containment in infectious waste management we introduce policy recommendation that be taken in three levels.