Physician Induced Demand: The Empirical Evidence of Angiography for Suspected Coronary Artery Disease

Background

We aimed to investigate the existence of unnecessary demand for angiography and the factors affecting it to provide evidence for decision makers.

Methods

This longitudinal panel study was conducted in public hospitals in Tehran, Iran by using 2458 patients' records that were undergoing angiography for suspected coronary artery disease 2013-2015. To modeling the physicians' behavior based on physician-induced demand (PID), the patients were classified as appropriate, uncertain, and inappropriate and then Hierarchical Linear Modeling (HLM) model besides the physician ethic index was developed and finally the existence of PID showed based on three scenarios.

Results

Angiographies were performed inappropriately in 23.8% of 2458 patients as well 46.7% were uncertain, and 29.5% were appropriate. According to the HLM model, the physician-to-population ratio (δ0= -0.161) and the interaction variable coefficient are higher than zero and significant (δ1 = 253). The results of the physician ethic index showed that most physicians were at a moderate rate, meaning that their utility was a combination of both pecuniary and non-pecuniary profits (0 < | ɛpδ |<1). Considering the HLM model and the medical ethics index together has almost shown the condition of PID (the necessary condition δ1> 0 and the sufficient condition (1 ≤ |ɛpδ|)) existed for about 26% of all studied physicians who had pure profit maximizer.

Conclusion

To reduce induced demand and improve medical ethics adherence in cardiologist, policy makers should develop native guidelines, rules, and instructions besides policies related to education, and increasing patients' awareness.

Nurses' job preferences for working in deprived areas in Tehran: a discrete choice experiment

BACKGROUND

In Iran, the issue of the nursing shortage and unequal distribution exist simultaneously. The shortage of healthcare workers is one of the most important concerns of the health systems. In addition, the disparity in the distribution of healthcare workers between large metropolises and remote or non-capital areas has become a serious concern and a top priority to address. We conducted this study to identify and create a sufficient understanding of the different financial and non-financial preferences of nurses for working in deprived areas.

METHODS

This research was carried out in June and April 2022. It was carried out in three major phases. The factors influencing the nurses' job preferences were first discovered using qualitative methods. The second phase was conducting a pilot study and determining the best design for discrete choice experiment scenarios. The last phase involved publishing the questionnaire to gather information. Data were analyzed (discrete choice analysis) using JMP Pro 16 software.

RESULTS

A desirable job for the participants (nurses) in this study would have a higher salary, work in a city, the Rasmi employment contract, a low workload, adequate workplace facilities, an appropriate work schedule, and 1 to 3 years spent on the assigned job to promote to a higher position. Willingness to pay (WTP) and the probability of selecting different attribute levels were also calculated and reported. For example, the highest amount of money that a nurse expected to be paid was for changing the geographical location of the workplace from a city to a deprived area. In this case, a nurse tends to receive 91.87 million IRR more to move from a city to a deprived area to work. This amount of money was by far the most among other WTPs.

CONCLUSION

The results of this study indicated that nurses are willing to forego net income in exchange for other favorable characteristics of their working environment and conditions. This shows that a variety of actions are accessible to policymakers that can greatly enhance the working conditions for nurses. The WTP and the probability of selecting various attributes may help policymakers plan more effectively.

Impact of Targeted Subsidies Reform on Household Nutrition: Lessons Learned from Iran

Background

In 2010, Iran became the first major oil-exporting country to reduce substantially implicit energy subsidies by increasing domestic energy and agricultural prices by up to 20 times. The current research aims to evaluate the profound impact of the countywide implementation of this targeted subsidy reform (TSR) on the consumption patterns of households in Iran, specifically in relation to the consumption of healthy food commodities.

Methods

This study employed a robust approach to examine the impact of the TSR on household food consumption, as a natural experiment, using pooled cross-section data from the Household Income and Expenditure Survey (HIES) spanning the years 1992 to 2019. The analysis was based on a comprehensive interpretation of survey data, which served as the primary source for analysis. The estimation procedure utilized an interrupted time series (ITS) model to capture the parameters associated with food consumption.

Results

The findings revealed a substantial increase in household expenditures on food immediately following the policy intervention, with an impressive rise of 823 thousand Rials (equivalent to approximately $6.36 based on the floating exchange rate in 2019). Furthermore, the results strongly indicate a significant annual upward trend in total monthly food expenditures per adult person, surpassing the pre-intervention trend by 441 thousand Rials (approximately $3.40) (P=0.044, CI=[12.86, 1016.81]). Moreover, the implementation of the policy led to an annual per capita increase in fruit consumption by 1.02 grams per day (P=0.225, CI=[-0.68; 2.72]).

Conclusion

This study shows that the initial positive effects of the TSR have gradually been eroded by inflation in subsequent years. This experience can serve as a lesson for all countries that TSR should be accompanied by other measures, such as poverty alleviation interventions, in order to achieve desired long-term results.

The Effect of Human Development Index on Obesity Prevalence at the Global Level: A Spatial Analysis

Background

Obesity is one of the major public health concerns, and its prevalence is increasing worldwide. This study aimed to investigate the effect of human development index on the prevalence of obesity across 152 countries.

Methods

Country-level data on obesity prevalence and its influencing variables related to 152 countries were obtained during 2000-2019 from several sources. A Spatial Bayesian Hierarchical model was employed in this research, and the analyses were performed using R statistical software (version 3.6.1).

Results

We found a positive relation between HDI and obesity prevalence, in such a way if low HDI countries advance to high HDI countries, the obesity rate is expected to increase significantly by 7.45%. Moreover, the association between obesity prevalence and the percentage of people aged 40-59 (β=0.07), urbanization rate (β=0.11), percentage of internet users (β=0.01), percentage of alcohol users (β=0.16), milk consumption per capita (β=0.15) and Percentage of depression (β=0.58) was significantly positive. Conversely, per capita consumption of fruits and vegetables (β=-0.15), and smoking rate (β=-0.02) was negatively associated with obesity prevalence.

Conclusion

The prevalence of obesity is growing across all countries, especially in the countries with high and very high HDI. Therefore, policymakers must also pay attention to the negative effects of development when trying to improve the welfare of society.

The influencing factors of health-related quality of life of the general population of Iran during the COVID-19 Pandemic

COVID-19 is a global challenge that negatively affects the health-related quality of life (HRQoL) of the general population. The current study aimed to evaluate HRQoL and its associated factors among the Iranian general population during the COVID-19 pandemic. The data were collected in 2021 using the EuroQol 5-Dimension 3-Level (EQ-5D-3L) and EQ-5D Visual Analog Scale (EQ VAS) questionnaires through an online survey. Participants were recruited via social media from the Fars province. The multiple binary logistic regression model was used to identify factors influencing participants' HRQoL. Kolmogorov-Smirnov, the t-test, ANOVA, and the chi-square test were used. All tests were conducted at a significance level of 5% using Stata 14.2 and SPSS 16. A total of 1,198 participants were involved in this cross-sectional study. The mean age of participants was 33.3 (SD:10.2), and more than half were women (55.6%). The mean EQ-5D-3L index value and EQ-VAS of the respondents were 0.80 and 77.53, respectively. The maximum scores of the EQ-5D-3L and EQ-VAS in the present study were 1 and 100, respectively. The most frequently reported problems were anxiety/depression (A/D) (53.7%), followed by pain/discomfort (P/D) (44.2%). Logistic regression models showed that the odds of reporting problems on the A/D dimension increased significantly with supplementary insurance, including concern about getting COVID-19, hypertension, and asthma, by 35% (OR = 1.35; P = 0.03), 2% (OR = 1.02; P = 0.02), 83% (OR = 1.83; P = 0.02), and 6.52 times (OR = 6.52; P = 0.01), respectively. The odds of having problems on the A/D dimension were significantly lower among male respondents, those in the housewives + students category, and employed individuals by 54% (OR = 0.46; P = 0.04), 38% (OR = 0.62; P = 0.02) and 41% (OR = 0.59; P = 0.03), respectively. Moreover, the odds of reporting a problem on the P/D dimension decreased significantly in those belonging in a lower age group and with people who were not worried about getting COVID-19 by 71% (OR = 0.29; P = 0.03) and 65% (OR = 0.35; P = 0.01), respectively. The findings of this study could be helpful for policy-making and economic evaluations. A significant percentage of participants (53.7%) experienced psychological problems during the pandemic. Therefore, effective interventions to improve the quality of life of these vulnerable groups in society are essential.

The role of taxation measures in the management of harmful products, services, and practices in Iran: a qualitative study

BACKGROUND AND AIM

Levying a tax on harmful products, services, and practices can affect consumer choices, effectively preventing diseases and reducing health care costs. The goal of this study was to investigate the role of taxation as a powerful financial tool in the management of harmful products, services, and practices to maintain and improve public health and preserve the financial sustainability of the health care system.

MATERIALS AND METHODS

This qualitative study was conducted in 2020-2021. In order to collect information for this study, semi-structured interviews were conducted. Using purposive and snowball sampling methods, 38 managers, policymakers, economists, and key experts were interviewed. Data were analyzed using the content analysis method. The transcribed interviews were further imported into MAXQDA for classification, and relevant codes were extracted.

FINDINGS

In this study, 6 main themes and 19 subthemes were labeled. The main themes included 1) objectives, effects, and requirements of the taxation of harmful products, services, and practices, 2) definition, instances, elasticity, and grading of harmful products, services, and practices, 3) Problems in controlling harmful products, services, and practices, 4) controlling harmful products, services, and practices, 5) traffic violations and accidents, and social harms, and 6) tax revenue use and the share of health care. The effects of taxing harmful products include reduced access to these products, reduced demand for harmful products, and the promotion of public health.

CONCLUSION

Harmful products, services, and practices have major health and financial implications for individuals, families, and society. To improve public health, the demand for these products and services can be controlled through taxation measures to push consumers toward less harmful alternatives.

Explaining specific taxes management and use in the health sector: a qualitative study

Background and aim

Being the major source of revenue and essential economic tool for policymakers to improve public health, taxes contribute to government spending on the development of health care facilities and services. Given the financial challenges facing the health sector together with the public health issues that affect each society, placing specific taxes on some goods, services, and activities can be effective in this regard. The study aims to explain the various dimensions of specific taxes in the health sector and management of these resources in order to achieve the health system goals.

Materials and methods

This study with a qualitative research design was conducted using semi-structured interviews with open-ended questions in 2020–2021. In total, 38 managers, policymakers, economists, key experts, and other individuals, as informants, were interviewed. Purposive and snowball with maximum variation was also employed. As well, content analysis was utilized to shed light on the data. The transcribed interviews were further imported into MAXQDA for extracting and classifying the relevant codes.

Findings

In this study, 5 main themes and 23 subthemes were labeled. The main themes accordingly included “Objectives and Conditions of Specific Health Taxes”, “Earmarked Taxes”, “Taxes on Goods and Measures of Harmful to Health”, “Value-Added Taxes”, and “Green Taxes”.

Discussion and conclusion

Considering the specific taxes in the health sector, i.e., taxes on goods and measures of harmful to health, value-added taxes, and green taxes, all taxation and pricing policies need to take account of the effects as well as the advantages and disadvantages of types of taxes, a country’s economic structure, the conditions of industries and manufacturing enterprises, cultural aspects in society, and peoples’ socioeconomic status.

Health-related quality of life among adult patients with visual impairments in Yazd, Iran

BACKGROUND

Visual impairment (VI) is one of the major public health problems that cause suffering, disability, loss of productivity, and reduced quality of life (QoL). This study aimed to evaluate the health-related QoL (HRQoL) among adults with visual problems in 2021.

MATERIALS AND METHODS

This analytical cross-sectional study was conducted on 300 patients with VIs referring to ophthalmology centers in Yazd, Iran. Data were collected through face-to-face interviews using EQ-5D, visual analog scale (VAS), and demographic information questionnaires. The results were analyzed using independent sample t-test, one-way analysis of variance, Pearson correlation coefficient, and adjusted limited dependent variable mixture model (ALDVMM) model by STATA, and SPSS.

RESULTS

The mean and standard deviation of EQ-5D-5 L index and EQ-VAS score in the studied patients were 0.68 ± 0.25 and 72.46 ± 19.36, respectively. Most problems at unable/extreme level were related to the mobility dimension (12%) and the usual activities dimension (9%). Factors related to HRQoL scores using ALDVMM model showed that divorced or widow marital status, age over 50, having strabismus, and acuter visual problems had significant negative effects on EQ-5D-5 L index values (P < 0.05).

CONCLUSIONS

The results showed that HRQoL was moderate in patients with VIs and reduced in patients with high disease severity, old age, lack of a spouse, retirement, and nonuniversity education. As a result, socioeconomic and demographic characteristics were required to be considered in visual health policies.

Investigation of robustness of hybrid artificial neural network with artificial bee colony and firefly algorithm in predicting COVID-19 new cases: case study of Iran

As an ongoing public health menace, the novel coronavirus pandemic has challenged the world. With several mutations and a high transmission rate, the virus is able to infect individuals in an exponential manner. At the same time, Iran is confronted with multiple wave peaks and the health care system is facing a major challenge. In consequence, developing a robust forecasting methodology can assist health authorities for effective planning. In that regard, with the help of Artificial Neural Network-Artificial Bee Colony (ANN-ABC) and Artificial Neural Network- Firefly Algorithm (ANN-FA) as two robust hybrid artificial intelligence-based models, the current study intends to select the optimal model with the maximum accuracy rate. To do so, first a sample of COVID-19 confirmed cases in Iran ranging from 19 February 2020 to 25 July 2021 is compiled. 75% (25%) of total observation is randomly allocated as training (testing) data. Afterwards, an ANN model is trained with Levenberg-Marquardt algorithm. Accordingly, based on R-squared and root-mean-square error criteria, the optimal number of hidden neurons is computed as 17. The proposed ANN model is employed to develop ANN-ABC and ANN-FA models for achieving the maximum accuracy rate. According to ANN-ABC, the R- squared values of the optimal model are 0.9884 and 0.9885 at train and test stages. In respect to ANN-FA, the R-squared ranged from 0.9954 to 0.9940 at the train and test phases, which indicates the outperformance of ANN-FA for predicting COVID-19 new cases in Iran. Finally, the proposed ANN-ABC and ANN-FA are applied for simulating the COVID-19 new cases data in different countries. The results revealed that both models can be used as a robust predictor of COVID-19 data and in a majority of cases ANN-FA outperforms the ANN-ABC.

Socioeconomic Determinants of Suicide in Iran: Panel Data Study

Background:

A set of experiences that leads to the destruction of individual’s self-esteem are the main causes of suicide. Socioeconomic factors can be reasons for this event. Therefore, we aimed to investigate the impact of socioeconomic variables on suicide.

Methods:

A panel data model was used to investigate the impact of socioeconomic indexes on the number of suicides in each province of Iran from 2001–2016. The data of socioeconomic variables were obtained from the statistical center of Iran, and data for the number of suicides in each province were obtained from the forensic science department. The analysis was conducted using estimated generalized least squares method by EViews version 8.

Results:

The lowest and highest number of suicides was in 2001 (4.97 per 100,000 populations) and 2004 (5.97 per 100,000 populations), respectively and the average rate of suicide from 2001 to 2013 was 1.01 also unemployment, divorce, and industrialization rates have high impact on suicides for both sexes in P<0.05.

Conclusion:

Living skills training should be provided to the members of the societies as a short-term plan and in the long-term, improving the economic condition of people should be conduct to reduce the number of suicides.

Distributional health and financial consequences of increased cigarette tax in Iran: extended cost-effectiveness analysis

BACKGROUND

To assess the potential impact of a tax-induced cigarette price increase on financial and health outcomes by different socioeconomic groups.

METHODS

In a modeled condition using pooled cross-section data from Household Income and Expenditure Survey (2002-2017) and Iran 2019 population data, a methodology of an extended cost effectiveness analysis (ECEA) was applied to model the impact on cigarette consumption of hypothetically increased cigarette tax. The methodology was employed to evaluate: [1] health benefits (premature deaths averted); [2] health expenditures regarding smoking-related disease treatment averted; [3] additional tax revenues raised; [4] change in household expenditures on cigarettes; and [5] financial risk protection among male Iranian smokers in a time span of 60 years following a one-time increase in cigarette price of 75%. The Stata version 15.1 (StataCorp., College Station, TX, USA) was used to perform the relevant analysis and estimate regression models.

RESULTS

A 75% increase in cigarettes price through taxation would reduce the number of smokers by more than half a million, 11% of them in the poorest quintile; save about 1.9 million years of life (11% of which would be gained in the lowest quintile compared to 20% in the highest one); eliminate a total of US$196.4 million of health expenditures (9% of which would benefit the bottom quintile). Such a policy could raise the additional annual tax revenues by roughly US$ 1 billion, where the top two quintiles bear around 46% of the total tax burden. We estimated that the tax increase would avert an estimated 56,287 cases of catastrophic expenditure that wholly concentrated among the bottom two expenditure quintiles.

CONCLUSION

Increasing cigarette tax can provide health and financial benefits, and would be pro-poor in terms of health gains, Out-of-Pocket (OOP) savings, and financial risk protection against smoking-related diseases.

The Effects of the Re-imposition of US Sanctions on Food Security in Iran

BACKGROUND

Following the re-imposition of US sanctions against Iran in 2018, unprecedented inflation has occurred in Iran's food market that will undoubtedly affect the food security of the Iranian people. The present study aims to determine the effects of the sanctions on food prices and food security of Iranian households.

METHODS

Interrupted time series (ITS) analysis was applied to assess the effects of sanctions on the average retail price of food products in Iran. Household food security was estimated by calculating the share of household food expenditure. Costs of following a healthy diet based on the food pyramid were estimated.

RESULTS

The import dependency ratio of Iran's food market was about 25%. After sanctions due to the limitations in international financial exchanges a significant increase in the prices of all food groups occurred in 2018, the year after the re-imposition of sanctions. The highest inflation rate was observed in vegetable, meat, and fruit groups. The percentage of urban and rural households in Iran that were prone to food insecurity increased from 8.84% and 25.17% to 11.2% and 29.2%, respectively, from 2017 to 2019. The annual average cost of a healthy diet for a sample Iranian family of 3.3, based on the current prices, is 341 866 008 IRR (US$2849) which is 3.6 times greater than the average amount Iranian families spent on food last year (94 505 000 IRR or US$788).

CONCLUSION

After the re-imposition of US sanctions against Iran, food insecurity as a result of economic vulnerability, has increased and due to the current status of food prices and incomes, following a healthy diet has become more difficult for most Iranians. This makes the Iranian population more prone to chronic diseases in the near future and if this trend persists, it places the country in danger of food crisis and political instability.

The Effects of the Re-imposition of US Sanctions on Food Security in Iran

Background: Following the re-imposition of US sanctions against Iran in 2018, unprecedented inflation has occurred in Iran’s food market that will undoubtedly affect the food security of the Iranian people. The present study aims to determine the effects of the sanctions on food prices and food security of Iranian households.

Methods: Interrupted time series (ITS) analysis was applied to assess the effects of sanctions on the average retail price of food products in Iran. Household food security was estimated by calculating the share of household food expenditure. Costs of following a healthy diet based on the food pyramid were estimated.

Results: The import dependency ratio of Iran’s food market was about 25%. After sanctions due to the limitations in international financial exchanges a significant increase in the prices of all food groups occurred in 2018, the year after the re-imposition of sanctions. The highest inflation rate was observed in vegetable, meat, and fruit groups. The percentage of urban and rural households in Iran that were prone to food insecurity increased from 8.84% and 25.17% to 11.2% and 29.2%, respectively, from 2017 to 2019. The annual average cost of a healthy diet for a sample Iranian family of 3.3, based on the current prices, is 341 866 008 IRR (US$2849) which is 3.6 times greater than the average amount Iranian families spent on food last year (94 505 000 IRR or US$788).

Conclusion: After the re-imposition of US sanctions against Iran, food insecurity as a result of economic vulnerability, has increased and due to the current status of food prices and incomes, following a healthy diet has become more difficult for most Iranians. This makes the Iranian population more prone to chronic diseases in the near future and if this trend persists, it places the country in danger of food crisis and political instability.

Impact of simulated cigarette excise tax increase on its consumption in Iran

OBJECTIVES

To assess the impact of a simulated tax-induced cigarette price increase on its consumption by different expenditure clusters in Iran.

METHODS

Employing consecutive cross sections for cigarette consumption, a two-part model was applied for different expenditure groups.

RESULTS

A 75% price increase in cigarettes noticeably— as is common in some countries with strong tobacco control policies—reduces current consumption in all five social classes, causing nearly 8% of current male smokers to quit or not to start.

CONCLUSIONS

Findings of the current study suggest that Iranian policy makers go through to implement tobacco taxation policies to control smoking prevalence, which in turn might lead to a reduction in national healthcare expenditures as well as enhance the global community’s capacity to meet Sustainable Development Goals.

How healthy are children at the beginning of primary school in Iran?

Background:

Childhood is the most important life stages where personality is built and formed. Since children are as a treasured capital for each society, assessment of their health status is so vital. This study assessed the health indices of children starting the primary school and considered parental factors influencing kid's health.

Methods:

An analytical descriptive cross-sectional study applied to measure the health status of children at the beginning primary school. The data extracted from 7768 primary school children with an average value of age 7 years and their parents, who were referred to Children Health Testing centers in the school year of 2016, in all provinces of Iran.

Results:

From 7768 kids, 52.3% were boys and 47.7% were girls. The mean of weight and height of children was 20.65 kg, and 115.84 cm, respectively. The mean body mass index (BMI, kg/m2) for age ratio of children in the country was 16.26. In addition, 4.9% of boys and 3.7% of girls were short stature, 0.5% of boys and 1.8% of girls were tall and 94.5% of kids had normal growth. About 5.3% of boys and 6.8% of girls were underweight, 9.2% of boys and 7.7% of girls were overweight, and 4.7% of boys and 3.4% of girls were obese.

Conclusions:

The overweight and severe short stature problems in children were more dominant than underweight and severe tall. Although underweight is more common in girls than boys, it is reversed in the case of overweight and obesity. In addition, the ratio of health problems among children in different provinces was dissimilar, thus considering the health status of children in each province to find a solution was crucial.

Determining the structure of pharmaceutical industry in Iran

Purpose

As the pharmaceutical industry is one of the key sectors of the health-care system, the identification of its structure is of particular importance. This paper aims to determine the structure of the pharmaceutical industry in Iran to provide appropriate solutions for pricing and regulation by policymakers. Iran is a growing pharmaceutical market with over $4bn in sales, so the supply side needs to be examined to meet the domestic consumption.

Design/methodology/approach

This research is a descriptive and retrospective analytical study which examines the Iranian pharmaceutical industry through library studies and using pharmaceutical data of the country’s Food and Drug Administration during 1992-2016. Due to data availability in firm level, the concentration ratio of N leading firms and the Herfindahl–Hirschman index are used to measure the concentration of the pharmaceutical market in 2014 and 2016.

Findings

The results show that pharmaceutical manufacturing, importing companies and distributing companies play roles in monopolistic competition market, loose oligopoly market and oligopoly market, respectively. For all companies, the magnitudes of Herfindahl–Hirschman indices indicate non-competitive settings. As a result, these companies set their own prices, and market demand affects their sales. In addition, demand for medicines is shaped in the form of supply-induced demand.

Research limitations/implications

This research was accomplished with no computational limitation. However, it was confined to only one country, one industry and the mentioned period of study.

Practical implications

The pharmaceutical manufacturers have no influence on medicine prices, and government pricing regulations lessen the market power of such market agents. However, the easy entry to and exit from market stimulate producers to participate in manufacturing activities. The pharmaceutical importers may expand their imports in response to entry new actors; however, the new entrants weaken the coordination on pricing decisions.

Social implications

As pharmaceutical distributers act in an oligopoly market, they can collude, reduce competition and lower the welfare of pharmaceutical consumers. In such conditions, high investment requirements and economies of scale may discourage the entry of new firms.

Originality/value

Although there are various studies on market structure in non-pharmaceutical industries, this study is a new effort to measure concentration in the Iranian pharmaceutical market and to determine its structure.

Is distribution of health expenditure in Iran pro-poor?

BACKGROUND

The size and distribution of households' health care expenditure indicate the financial burden on different income groups. Since the distribution of health expenditure evaluates the performance of health systems, this study aims to examine the health expenditure distribution among urban and rural households in Iran.

METHODS

This research was conducted on the distribution of health expenditure among urban and rural households in 2014. The effects of households' health expenditure on distribution of personal incomes were measured by using Kakwani and Reynolds-Smolensky indices. In addition, Theil T index was used to classify provinces based on inequality in health expenditure distribution. The calculations were made by using EXCEL.

RESULTS

The Kakwani indices for urban and rural households were calculated around -0.572 and -0.485, respectively. Reynolds-Smolensky indices for urban and rural households were measured as much as -0.038 and -0.031, respectively. Regardless of income distribution, Theil T index shows that urban households face with the most unequal distribution in health expenditure.

CONCLUSION

Based on calculations, the distribution of health expenditure is against the poor households. In addition, this distribution is more regressive in urban than rural households. As well, Reynolds-Smolensky indices indicate more uneven income distribution after paying for health care, and inequality is larger among urban than rural households. To this research, the health policymaking priorities should be given to the provinces with the highest inequality, and the expenditure burden of low-income households should be reduced through expanding insurance coverage.

The impact of rural health insurance and the family physician program on hospitalizations, a beforeafter study at the county level conducted in Tehran province, Iran

Background: The health insurance and family physician reform in Iran were implemented in 2005. This study was conducted to assess the effect of these reforms on avoidable hospitalizations among the rural population of Eslam-shahr County, Iran. Methods: We conducted a before-after study in Eslam-shahr County's single existing hospital. This county is a part of the Tehran Province of Iran. The demographic characteristics and diagnostic codes of the rural population that were hospitalized during the 2 years leading to, and after the reforms were extracted from the hospital's electronic information system. A list of 61 three-character and 131 four-character AHs codes were developed based on the literature review. We estimated a logistic regression model which included gender and age as independent variables to assess changes in the probability of avoidable hospitalizations following reform implementation. Analyses were carried out using STATA version 13. Results: We recorded 817 rural hospitalizations before and 967 hospitalizations after reform implementation, suggesting that hospitalization growth after the reforms was almost 18.4%. The logistic regression results show that the probability of avoidable hospitalizations after the interventions had decreased compared to before the interventions were put into place (OR: 0.46; 95% CI: 0.24-0.88). Also, the probability of AHs among the 60< year-old age group was considerably higher compared to other age groups. No statistical relationship was found between avoidable hospitalizations and gender. Conclusion: The reforms may have had a mixed effect on hospitalization. They may result in increased hospitalizations due to responding to the unmet needs of the population, and simultaneously they may lead to a decrease in avoidable hospitalizations and eliminate the costs imposed by them upon the health system.

General practitioners' views on key factors affecting their desired income: A principal component analysis approach

Background: Based on the target income hypothesis, the economic behavior of physicians is mainly affected by their target income. This study aimed at designing an instrument to explain how general practitioners (GPs) set their desired income. Methods: A self-administered questionnaire of affecting factors on GPs' target income was extracted from literature reviews and a small qualitative study. Respondents were 666 GPs who completed the questionnaire (response rate= 52%) during 2 seasonal congresses of Iranian GPs. The principal component analysis (PCA) with varimax rotation was used to classify the variables and data reduction. Sample adequacy test, sphericity test, eigenvalues of components, and scree plot were evaluated for PCA. Cronbach's alpha was also checked to assess the internal consistency of the principal components. Results: The results of the KMO measure of sampling adequacy (0.657) and Bartlett's test of sphericity (809.05, p<0.001) revealed that the collected data were suitable for PCA. Based on the scree plot pattern and eigenvalues greater than 1, 6 components including perceived comparative income, importance of responsiveness to patients, perceived socioeconomic status, economic expectations, socioeconomic status of paternal family, and provision of luxury services were selected, which explained 65.19% of the total variance. Finally, only those with a Cronbach's alpha value higher than 0.6 were considered reliable (the first 4 components). Conclusion: Based on the target income hypothesis, a physician's desired level of income affects their behavior. Our developed instrument and its mentioned components can be used in future studies related to GPs' behavior, especially those studies related to the economic aspects of GPs' behavior. It also helps formulate a better payment mechanism for primary care providers.

CTRP1 in Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease occurs in significant percentage of general population. NAFLD is closely associated with entire spectrum of metabolic-related disorders including diabetes, obesity, and cardiovascular diseases. Considering several similar pathways underpinning metabolic disorders, presence of common molecular mediators contributing to pathomechanism of these disorders is expected. Mounting evidence has demonstrated important role of adipokines in the context of NAFLD. Adipokines produced by different tissues, mainly adipose, modulate numerous pathways including glucose and fatty acid metabolism and inflammation. CTRPs (C1q/TNF-related proteins) are a recently identified family of adipokines in which adiponectin is the most well-known ones. CTRP1 is a member of this family which has captured attention in recent years. CTRP1 enhances glucose and fatty acid oxidation, improves insulin sensitivity, attenuates plaque formation, and increases aldosterone production. Hence, various roles in metabolic pathways can link CTRP1 to NAFLD pathogenesis.

The mRNA Expression and Circulating Levels of Visfatin and Their Correlation with Coronary Artery Disease Severity and 25-Hydroxyvitamin D

It is evident that coronary artery disease (CAD) is closely associated with abnormal glucose and lipid metabolism. Notably, dysregulation of inflammatory pathways and immune system also contribute to CAD development. Recently, it has been suggested that visfatin, a proinflammatory adipocytokine, may be involved in several inflammatory and metabolic diseases. In this study, we evaluated the serum visfatin levels and its mRNA expression in peripheral blood mononuclear cells (PBMCs) from CAD patients compared with control subjects. We also studied the correlation between visfatin gene expression and serum levels with clinical and metabolic parameters. This study was conducted on 56 male patients with CAD confirmed by angiography and 30 healthy men as controls. CAD severity was determined based on the number of vessels. Study of gene expression in PBMCs was performed using real time-PCR, and serum levels of visfatin and 25-hydroxyvitamin D were measured by ELISA. We found that serum visfatin levels and its gene expression in PBMCs were increased in patients with CAD compared with the control group (p=0.027 and p=0.016, respectively). Also, visfatin gene expression was positively correlated with visfatin levels and both these variables had a strong positive correlation with the severity of CAD. It appears that elevated mRNA expression and circulating level of visfatin might be of relevance to the pathogenesis and severity of CAD. However, further studies are necessary to better clarify the associations between visfatin and CAD.

Effect of Governance Indicators on Under-Five Mortality in OECD Nations: Generalized Method of Moments

Introduction

Today, it is recognized that factors other than health services are involved in health improvement and decreased inequality so identifying them is the main concern of policy makers and health authorities. The aim of this study was to investigate the effect of governance indicators on health outcomes.

Methods

A panel data study was conducted to investigate the effect of governance indicators on child mortality rate in 27 OECD countries from 1996 to 2012 using the Generalized Method of Moments (GMM) model and EVIEWS.8 software.

Results

According to the results obtained, under-five mortality rate was significantly related to all of the research variables (p < 0.05). One percent increase in under-five mortality in the previous period resulted in a 0.83% increase in the mortality rate in the next period, and a 1% increase in total fertility rate, increased the under-five mortality rate by 0.09%. In addition, a 1% increase in GDP per capita decreased the under-five mortality rate by 0.07%, and a 1% improvement in control of corruption and rule of law indicators decreased child mortality rate by 0.05 and 0.08%, respectively. Furthermore, 1% increase in public health expenditure per capita resulted in a 0.03% decrease in under-five mortality rate.

Conclusion

The results of the study suggest that considering control variables, including GDP per capita, public health expenditure per capita, total fertility rate, and improvement of governance indicators (control of corruption and rule of law) would decrease the child mortality rate.

A polymorphism in the resistin gene promoter and the risk of multiple sclerosis

AIM

Multiple sclerosis (MS) is an inflammatory neurodegenerative disorder that inflammatory cytokines have been implicated in its immunopathogenesis. Resistin, a member of cysteine-rich secretory proteins family, identified with inflammatory properties in humans. To elucidate whether different genotypes of resistin are involved in MS pathogenesis, we compared serum levels of TNF-α, IL-1β, hs-CRP, and resistin levels in different genotypes of MS patients with relapsing remitting type and healthy subjects.

METHODS

IN a case-control study, 86 MS patients and 86 age- and sex-matched healthy subjects were enrolled. The age, gender distribution, and BMI of MS patientsand control group were similar. The serum levels of TNF-α, IL-1β, and Resistin were measured by ELISA. hs-CRP was measured by imunoturbidimetric method. After DNA extraction, the analysis of -420C/G SNP (rs1862513) was performed via PCR-RFLP method.

RESULTS

The resistin, TNF-α, IL1β, and hs-CRP levels were significantly higher in MS patients compared with control group. The distribution of "rs1862513" genotypes were not significant between MS and control groups. Although resistin and TNFα levels were higher in GG genotype carriers of both groups, but the difference was significant only in MS patient.

CONCLUSION

Resistin gene polymorphisms may modify the being susceptible to MS disease, which may cause through various levels of cytokines between genotypes.