Avoidable hospitalization after family physician and rural health insurance: interrupted time series and regression analyses, Tehran province, Iran.

BACKGROUND: Studying the effect of primary health care development when simultaneously implemented with health insurance schemes assesses effectiveness and use of health care services and gives us insight on how to develop such interventions in different countries. AIM: To analyze the impact of health insurance and the family physician program on total hospitalizations, and the relation between avoidable hospitalizations and access to family physicians among the rural population in Iran. METHODS: We conducted an interrupted time series (ITS) analysis of monthly hospitalization rates between the years of 2003 and 2014 to assess the immediate and gradual effects of these reforms on total hospitalization rates in the rural areas of Tehran province. In addition, we used a sample of 22 570 hospitalizations between 2006 and 2013 to develop a logistic regression model to measure the association between access to a family physician and avoidable hospitalizations. FINDINGS: ITS analysis showed that there was an immediate increase of about 1.96 hospitalizations per 1000 inhabitants (P<0.0001, CI=1.58, 2.34) hospitalization rates after the reforms. This was followed by a significant increase of about 0.089 per 1000 inhabitants (P<0.0001, CI=0.07, 0.1). Hospitalization increase continued up to four years after the policy implementation. Following that, hospitalization rates decreased among the rural population (a decrease of 0.066 per 1000, P<0.0001, CI=-0.084, -0.048). Studying the hospitalizations that occurred between 2006 and 2013 showed that there were 4106 avoidable hospitalizations from among a sample of 22 570 hospitalizations. Results of logistic regression models including gender, age and access to family physician variables showed that there was no statistical relation between access to a family physician and avoidable hospitalizations. CONCLUSION: Reforms had access effect and caused increased hospital services uses in people with unmet needs. Also the reforms did not decrease avoidable hospitalizations, and therefore had no efficiency effect.

The Effect of Access to Primary Care Physicians on Avoidable Hospitalizations: A Time Series Study in Rural Areas of Tehran Province, Iran.

BACKGROUND: Avoidable hospitalizations (AHs) are defined as hospitalizations that could have been prevented through timely and effective services. AHs are, therefore, an indicator used to evaluate the access and effectiveness of primary health care services. METHODS: A retrospective time-series study spanning 8 years (2006-2013) was conducted to determine the relationship between AHs and gender, age, and access to primary health care physicians in rural areas in Tehran province, the capital of Iran. The total number of avoidable hospitalizations was 22,570; logistic regression was estimated for each year separately. RESULTS: Total hospitalizations and AHs increased during the study period, especially during the first 3 years of the study. AHs, as a percentage of total hospitalizations, did not change significantly throughout the study years. This value was 22.3% during the first year of study and varied between 17% and 19.6% from 2007 to 2013. No statistically significant relationship was seen between AH occurrence and access to a physician during the study years. CONCLUSION: Increasing access to primary health care physicians cannot necessarily result in decreased AHs. Considering the factors influencing AHs while designing and implementing the family physicians program is important to achieve the expected results regarding the effectiveness of primary health care services.

National Women's Health Plan, Selected Countries Experiences and Necessity of Developing It in Iran: A Narrative Review Article.

BACKGROUND: National plans have an important role in defining vision, goals, priorities, and action plans. The present paper examined the international experience in developing upstream documents concerning women's health; it regards the necessity of developing Iranian women's health plan. METHODS: This review, conducted with search in electronic databases and literature of no limitation in terms of years conducted. The phrases such as "woman health policy", "woman health promotion", "woman health strategy" and "woman health plan" were searched. The criteria based on which the countries were chosen were the degree to which they were developed in health system, health indexes, the accessibility of required information, and the possibility of benchmarking the new methods. RESULTS: Emphasize on gender as a determinant of health, increasing the economic activities of women, decreasing the violence against women, gender-based researches, and inter-sectorial approach are some common items in the women's health plans in selected countries. The main upstream documents about women health in Iran such as 'Research policies and principles of women issues', "Women Charter of Rights in Iran" were not developed and implemented in form of a comprehensive plan so we need to formulate a full women health national plan that summarizes all previous policies with addition of new needed strategies inclusion. CONCLUSION: Developing a national plan for Iranian women's health regarding with selected countries experiences makes a long-term vision for health and obtains the institutional and organizational efforts and resources necessary for women health promotion in Iran.

Does rural health system reform aimed at improving access to primary health care affect hospitalization rates? An interrupted time series analysis of national policy reforms in Iran.

OBJECTIVES: To evaluate the effects of rural health insurance and family physician reforms on hospitalization rates in Iran. METHODS: An interrupted time series analysis of national monthly hospitalization rates in Iran (2003-2014), starting from two years before the intervention. Segmented regression analysis was used to assess the effects of the reforms on hospitalization rates. RESULTS: The analyses showed that hospitalization rates increased one year after the initiation of the reforms: 1.55 (95% CI: 1.24-1.86) additional hospitalizations per 1000 rural inhabitants per month ('immediate effect'). This increase was followed by a further gradual increase of 0.034 per 1000 inhabitants per month (95% CI: 0.02-0.04). The gradual monthly increase continued for two years after the reforms. The higher hospitalization rates were maintained in the following years. We observed a significant increase in hospitalization rates at a national level in rural areas that continued for over 10 years after the policy implementation. CONCLUSION: Primary health care reforms are often proposed for their efficiency outcomes (i.e. reduction in costs and use of hospitals) as well as their impact on improving health outcomes. We demonstrated that in populations with unmet needs, such reforms are likely to substantially increase hospitalization rates. This is an important consideration for successful design and implementation of interventions aimed at achieving universal health coverage in low- and middle-income countries.

The burden of preventable hospitalizations before and after implementation of the health transformation plan in a hospital in west of Iran.

BACKGROUND: Increased number of preventable hospitalizations (PHs) for ambulatory care sensitive conditions (ACSCs) represents less efficiency and low access to outpatient and primary health care, leading to waste of health system resources. AIM: The purpose of this study is to assess the quality of outpatient and primary health care using the rate of PHs for ACSCs and to estimate the economic burden of ASCS before and after the implementation of the health transformation plan (HTP) in Iran. METHODS: This research was a before-after quasi-experimental study. The study population included all patients hospitalized in the largest general hospital of Kurdistan province with five diseases such as asthma, diabetes, hypertension, congestive heart failure, and chronic obstructive pulmonary disease in 2014 (before the implementation of the HTP) and 2015 (after the implementation of the HTP). Data were analyzed by SPSS v.20 using Chi-square test. FINDINGS: Total number of hospitalizations before and after the implementation of the HTP was 1501 and 1405, respectively. Moreover, the proportion of PHs in all types of the hospital admissions before and after the implementation of the HTP was 47% and 49%, respectively. There was no statistically significant difference between the number of PHs before and after the HTP. In total, PHs imposed 885 798 US$ and 9920 bed-days on health system before and after the implementation of the HTP. CONCLUSION: Despite the previous expectations of policy makers for improving quality, efficiency, and access to primary health care through implementation of the HTP, proportion of PHs is considerable and it imposes a lot of costs and bed-days on the health system both before and after the HTP.

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.

Strategic thinking and its related factors in a medical science university in Iran.

BACKGROUND: Having strategic thinking is necessary in order to anticipate future changes and make strategic decisions. This study was carried out to assess the strategic thinking level in managers and personnel of Ahvaz Jundishapour University of Medical Science (AJUMS) - a public university in Iran. METHODS: It was a cross-sectional and analytical study and all managers (50) as well as a sample of personnel (200) from AJUMS participated in it. A researcher-made questionnaire was used in order to measure four dimensions of strategic thinking, including system thinking, futurism, conceptual thinking, and intelligent opportunism along with demographic and organizational characteristics of respondents. Statistical analysis was done by Freedman ranking test, one-way ANOVA, and Independent-samples t-test in SPSS software version 16. RESULTS: Strategic thinking in managers (5.62±0.51) and personnel (5.22±0.4), was evaluated at a somewhat high level. The maximum score among strategic thinking dimensions in managers (5.62±0.42) and personnel (5.52±0.43) was related to conceptual thinking that was in "good" level. A significant relationship was seen between intelligent opportunism dimension with job location in managers and education degree in personnel (p≤0.005). Also, there was a significant relationship between future dimension in managers and personnel with education degrees (p≤0.005). There was a significant difference between managers and employees in future dimension (p=0.018). CONCLUSION: It seems that the participants have acceptable strategic thinking levels, although there is still room for improvement. Therefore, considering the factors such as educational development of managers and personnel can be very useful in this regard.

Cost-utility analysis of oral deferasirox versus infusional deferoxamine in transfusion-dependent ß-thalassemia patients.

BACKGROUND: Deferasirox (DFX) is a novel iron chelator that has been shown to have similar efficacy and safety compared with deferoxamine (DFO) in patients with ß-thalassemia. The aim of this study was to determine the cost utility of DFX versus DFO in ß-thalassemia major patients from Iran's society perspective. STUDY DESIGN AND METHODS: A Markov model has been developed to determine lifetime cost and quality-adjusted life-years (QALYs) of patients. To estimate the annual cost of each method, a cross-sectional study was conducted among two groups of patients who received DFO and DFX (n = 100 and n = 45, respectively). Also a time trade-off method was used to estimate the utility of two strategies. Finally a one-way and probabilistic sensitivity analysis was conducted to examine the strength of the results. RESULTS: Our base-case analysis showed that estimated total lifetime costs per patient for DFX and DFO were 47,029 international dollar ($Int) and $Int143,522, respectively, while the estimated total discounted QALYs per person were 12.28 and 7.76, respectively. Calculated incremental cost-effectiveness ratio showed that DSX is a dominant therapy and its estimated lifetime net monetary benefit was $Int273,528. CONCLUSION: We conclude that the use of DFX instead of DFO represents a cost-effective use of resources for treatment of iron overload in patients with ß-thalassemia from Iran's society perspective.