Economic burden of diabetic foot ulcer: a case of Iran.

BACKGROUND: Diabetic foot ulcer (DFU) is known as a serious complication of diabetes mellitus in patients with diabetes, imposing heavy medical costs on healthcare systems due to its chronic nature. patients with severe diabetic foot ulcer are often disabled to work, and some of them may even die, leading to associated productivity losses. Since no previous study has investigated the economic burden of DFU in Iran, this study is to estimate the economic burden of diabetic foot disease in Iran. METHODS: In this descriptive cross-sectional study, randomly selected samples consisted of 542 patients with DFU, hospitalized in the hospitals of Shahid Beheshti University of Medical Sciences. The demographic profile and cost data used in this analysis were derived from a researcher-designed checklist. Lost productivity was calculated based on Human Capital Approach, and the total economic cost of DFU was determined using patient-level data on costs and prevalence data from the global burden of diseases reports. All analyses were performed using SPSS software (Version 23), and Microsoft Excel (Version 19). RESULTS: The economic burden of DFU in Iran in two scenarios of discounting future costs and not discounting them was about $8.7 billion and $35 billion, respectively (about 0.59 and 2.41% of GDP). 79.25% of the estimated costs in this study were indirect costs and productivity losses, of which 99.34% (7,918.4 million Dollars) were productivity losses due to premature death. 20.75% (2,064.4 million dollars) of the estimated costs in this study were direct costs. The average length of stay (LOS) was 8.10 days (SD = 9.32), and 73.3% of patients recovered and were discharged after hospitalization and 7.6% died. The majority of the costs are imposed on the age group of 60-69 year (53.42% of the productivity lost due to hospital length of stay, 58.91% of the productivity lost due to premature death & 40.41% of direct costs). CONCLUSIONS: DFU represents a heavy burden to patients, Iran's health system, and the economy. Early prevention strategies need to be prioritized in making public health policies. These policies and decisions can be in the area of changing lifestyle, health education, changing people's behavior, and encouraging physical activity that targeted high-risk populations in order to reduce the prevalence of diabetic foot and resulting substantial economic burden.

Socioeconomic inequality in informal payments for health services among Iranian households: a national pooled study.

BACKGROUND: There is limited evidence on the prevalence and socioeconomic inequality in informal payments (IP) of households in the Iranian health system. This study was conducted to investigate the prevalence of IP and related socioeconomic inequalities among Iranian households in all provinces. METHOD: Data on Household Income and Expenditure Surveys (HIES) for 91,360 households were used to examine the prevalence and inequality in informal health sector payments in the years 2016 to 2018. The Normalized Concentration Index (NC) was used to examine inequality in these payments and the decomposition analysis by the Wagstaff approach was used to determine the share of variables affecting the measured inequality. RESULTS: Of the total households, 7,339 (7.9%) reported IP for using health services. Urban households had higher IP (10%) compared to rural ones (5.42%). Also, the proportion of households with IP in 2016 (11.69%) was higher than in 2017 (9.9%), and 2018 (4.60%). NC for the study population was 0.129, which shows that the prevalence of IP is significantly higher in well-off households. Also, NC was 0.213 (p < 0.0001) and -0.019 for urban and rural areas, respectively (p > 0.05). Decomposition analysis indicated that income, sex of head of household, and the province of residence have the highest positive contribution to measured inequality (with contributions of 156.2, 45.8, and 25.6%, respectively). CONCLUSION: There are a significant prevalence and inequality in IP in Iran's health system and important variables have shaped it. On the whole, inequality was pro-rich. This may lead to increasing inequality in access to quality services in the country. Our findings showed that previous health policies such as regulatory tools, and the health transformation plan (HTP) have not been able to control IP in the health sector in the desired way. It seems that consumer-side policies focusing on affluent households, and high-risk provinces can play an important role in controlling this phenomenon.

Inequality in Cosmetic Services and Surgery among Iranian Households in 2019: A Decomposition Analysis.

Background: The demand for cosmetic surgery is on the rise worldwide, making it the common form of surgery globally while the use of cosmetic surgery being exponentially high in Iran. The aim of this study was to investigate inequality in the use of cosmetic services and surgery (CSS) among Iranian households concerning demographic and socio-economic characteristics. Methods: This study used data of 38960 Iranian household from the income-expenditure survey of the statistical center of Iran (SCI) in 2019. Concentration index (C) was used to measure inequalities in the use of CSS. Microsoft Excel sheet 2019 was used to extract the data, and the analysis was performed using Stata statistical package version 14.2. Results: Households with female head, with single head, households with 3 - 4 people, headed with undergraduate education person, households with insurance coverage, with higher socio-economic quintiles, rural households and residents of northwestern Iran were accounted for the highest use of CSS. Also, according to the decomposition analysis, wealth and education level are the two main factors in creating inequality, with wealth, having the highest positive share (88.11%) and education level having the most negative share (-5.26%) in creating measured inequality. Conclusion: The use of CSS is more concentrated in well-off households in Iran. As the resources of health system are limited, the government and the policy makers should have defined plans with regards to CSS use especially taking factors like socioeconomic status and education status of target groups in to account.

Direct medical cost and cost analysis of COVID-19 in Iran: A multicenter cross-sectional study.

Background: Although our daily life and economics were severely affected by COVID-19, cost analysis of the disease has not been conducted in Iran. Hence, we aimed to perform a cost analysis study and then estimate direct medical costs of COVID-19. Methods: A cross-sectional study was performed in Tehran and recorded medical files from March 1, 2020, to September 1, 2020, were examined. A predefined electronic form was developed and all required variables were included. All people whose both first and final diagnoses were COVID-19 positive and were admitted in governmental hospitals were considered for inclusion. Using stratified random sampling method, 400 medical records were evaluated to gather all data. STATA 14 was used for data analysis. Results: We evaluated 400 medical records and the age of patients ranged from 22 to 71 years. The mean cost of COVID-19 was 1434 USD. Of 400 patients, 129 of them had underlying disease and statistical significance was observed in people who had underlying diseases than people who did not have underlying disease. Conclusion: Beds and medications were the most important factors that added to the costs. COVID-19 has undoubtedly imposed a high financial burden on the health system. It is highly recommended that patients with positive test result be strictly encouraged to stay at home and adhere to safety protocols.

QALY league table of Iran: a practical method for better resource allocation.

BACKGROUND: The limited health care resources cannot meet all the demands of the society. Thus, decision makers have to choose feasible interventions and reject the others. We aimed to collect and summarize the results of all cost utility analysis studies that were conducted in Iran and develop a Quality Adjusted Life Year (QALY) league table. METHODS: A systematic mapping review was conducted to identify all cost utility analysis studies done in Iran and then map them in a table. PubMed, Embase, Cochrane library, Web of Science, as well as Iranian databases like Iran Medex, SID, Magiran, and Barakat Knowledge Network System were all searched for articles published from the inception of the databases to January 2020. Additionally, Cost per QALY or Incremental Cost Utility Ratio (ICUR) were collected from all studies. The Joanna Briggs checklist was used to assess quality appraisal. RESULTS: In total, 51 cost-utility studies were included in the final analysis, out of which 14 studies were on cancer, six studies on coronary heart diseases. Two studies, each on hemophilia, multiple sclerosis and rheumatoid arthritis. The rest were on various other diseases. Markov model was the commonest one which has been applied to in 45% of the reviewed studies. Discount rates ranged from zero to 7.2%. The cost per QALY ranged from $ 0.144 in radiography costs for patients with some orthopedic problems to $ 4,551,521 for immune tolerance induction (ITI) therapy in hemophilia patients. High heterogeneity was revealed; therefore, it would be biased to rank interventions based on reported cost per QALY or ICUR. CONCLUSIONS: However, it is instructive and informative to collect all economic evaluation studies and summarize them in a table. The information on the table would in turn be used to redirect resources for efficient allocation. in general, it was revealed that preventive programs are cost effective interventions from different perspectives in Iran.

World one-hundred days after COVID-19 outbreak: Incidence, case fatality rate, and trend.

BACKGROUND: The prevalence of viral diseases is on the rise and has caused many problems for public health. COVID-19 is a new viral outbreak in the world. This study aimed to investigate the trends of incidence and case fatality rate (CFR) of COVID-19 in the world by April 30, 2020. METHODS: This was a descriptive-analytical study. We investigated the number of cases and deaths in 35 selected countries and regions of the WHO that had at least 10,000 cases by the time of the study. In addition, the incidence and CFR of COVID-19 were investigated. Finally, time trends of the number of cases, deaths, and CFR were investigated using ordinary least squares regression models. RESULTS: The total number of confirmed cases of COVID-19 was 3,090,184. The European region had the highest number of COVID-19 patients (1,434,649 [46.43%]). Ukraine with 10,406 and the USA with 1,003,974 cases have reported the lowest and highest confirmed cases, respectively. In addition, the European region and the African region with 157.13 and 2.50 patients per 100,000 population had the highest and the lowest incidence rate, respectively. India (2.44) and Spain (455.69) had the lowest and the highest incidence rate per 100,000 population, respectively. In the world, 217,759 deaths have happened, of which 135,961 (62.44%) were reported in the European region. Furthermore, the USA had the highest number of deaths (52,428) due to COVID-19. CFR was 7.05% in the world, which ranged from 3.74% in the African region and 9.48% in the European region. The number of patients and deaths due to COVID-19 had increasing trends in all countries, and the trend of CFR just for Iran and Ukraine was negative. CONCLUSION: The countries had different trends in the morbidity and mortality of COVID-19. However, regarding the increasing trend of the disease in the world, it will be more important to rely on public prevention strategies. It is necessary to apply and continue public health policies at national and global levels till the control of the disease.

Cost-effectiveness analysis of enzyme replacement therapy (ERT) for treatment of infantile-onset Pompe disease (IOPD) in the Iranian pharmaceutical market.

Infantile-onset Pompe disease (IOPD) or acid maltase deficiency is a rare metabolic disorder. It is caused by a deficiency in functioning of the enzyme acid alpha-glucosidase and leads to the accumulation of glycogen in the liver, heart, muscle, and other tissues. Myozyme is an effective drug, but it imposes a heavy financial burden on societies and healthcare systems. Therefore, this study was conducted to analyze the cost-effectiveness of Myozyme compared to conventional therapy for the treatment of IOPD. PubMed, Scopus, Web of Science, and Cochrane library databases were searched on December 2018 to identify the effectiveness of Myozyme versus conventional therapy. Then, a cost-effectiveness and a cost utility study were conducted in patients suffering from IOPD. In this cost effectiveness and cost utility analysis, Markov and decision tree models were used for modeling. Model parameters were obtained from international data, and the perspective of the payer was considered. Every cycle was one year; the model was run for 22 cycles. TreeAge pro 2011 was used for analysis. Finally, one-way and probabilistic sensitivity analyses were performed. Two papers were included and 39 patients were evaluated as the treatment group in both studies. Results revealed the effectiveness of Myozyme. Results also revealed a wide range of adverse reactions. Enzyme replacement therapy (ERT) resulted in 4.21038 quality-adjusted life years (QALY) per $381,852. The incremental cost per QALY was $96,809 and the incremental cost per life years gained (LYG) was 74,429 over a 22-year time horizon. Sensitivity analysis indicated the robustness of the results. Myozyme is effective for IOPD and could increase the life expectancy of patients significantly. However, since the calculated incremental cost per QALY was 17 times higher than the GDP per capita of Iran, Myozyme is not cost effective in Iran.

Prevalence and determinants of inappropriate admission and hospitalization in Iran: A systematic review and meta-analysis.

Background: A huge portion of health expenditure is attributed to hospital services. Thus, it is important to use the resources appropriately. Many studies have measured inappropriate admissions and hospitalizations. The aim of this study was to review them systematically and determine the pooled quantity as well as the reasons behind such admissions and hospitalizations. Methods: PubMed, Scopus, Web of Science, Google scholar, and internal databases such as Sid, Magiran, and Barkat were searched in January 2018. Moreover, the grey literature was also performed. All studies which had assessed the appropriateness and inappropriateness of services were included. Newcastle-Ottawa scale was used for quality appraisal. I2 test, subgroup analysis, metaregression, and sensitivity analysis were performed. STATA was used for analysis. There was neither time limitation nor language limitation. The registration number in PROSPERO is CRD42019123401. Results: Of 1576 studies, 15 met the inclusion criteria. The number of medical files ranged from 198 to 1815. Most of the studies (14) were performed in teaching hospitals. AEP was the most frequent tool for assessing inappropriateness of the services. The pooled inappropriate admission and hospitalization were 11% (95% CI= 8% - 14%)) and 13 % (95% CI= 10%-16%)), respectively. The most important determinants for inappropriate hospitalizations were attributed to physicians. Conclusion: A huge portion of health care services is inappropriate. Thus, it is highly recommended to monitor physicians more than before, as the more they are monitored, the less inappropriate the delivered services will be.

Cost Analysis of Accidents according to Demographic Factors in Iran.

BACKGROUND: The first cause of death and disability constituting to the burden of disease in Iran has been accident and injury incidents. Young people are more at risk, these accidents have a negative effect on the national gross domestic product (GDP), on the one hand, and they increase the costs of the health system on the other hand. Therefore, this study aimed to analyze the costs and epidemiological pattern of accidents. METHODS: The study variables in the first 8 months of 2016 included from Tehran Province, Iran; age, sex, how to transfer to the hospital, consequences of an accident, the injured area, and costs. Overall, 400 cases were investigated by referring to the patients' files and deriving the intended data. SPSS software used to analyze the data and statistical tests of t-test and ANOVA were applied. RESULTS: Most accidents have happened in summer months of Jun, Jul and Aug. Most of the files (48%) were related to the age group of 16-30. The mean cost was 9024.82 dollar. In total, 39% of the road accidents had occurred by motorcycle and 90.8% of the patients discharged from the hospital. CONCLUSION: Since about half of the traffic accidents were related to the age of 16 to 30 who were the active population of a community, therefore, any disability or death in these groups could cause an economic burden on the community and increase DALY. Thus, it appears essential to develop proper programs such as education for appropriate driving and strict rules for giving driving license to these ages.