Association Between Plant-based Diet and Kidney Function in Adults.

OBJECTIVE: A plant-based diet has both antioxidant and anti-inflammatory properties. Therefore, it is hypothesized that adherence to a plant-based diet may have a positive effect on kidney function. The study aimed to determine the association between the plant-based diet index (PDI) and chronic kidney disease (CKD). METHODS: This cross-sectional analysis used information from the Ravansar noncommunicable diseases cohort study, which included 9,746 participants between the ages of 35 and 65. By measuring the estimation glomerular filtration rate (eGFR) with the modification of diet in the renal disease equation, CKD was determined. Using a food frequency questionnaire, the PDI was computed based on food intake. To determine odds ratios (ORs), multivariable logistic regression models were utilized. RESULTS: 1,058 (10.86%) participants had CKD (eGFR<60 mL/min/1.73 m2), and the mean PDI was 54.22 ± 6.68. The mean eGFR in the group with a high PDI score was significantly higher than the group with a low PDI score (fourth quartile: 79.20 ± 0.36 vs. first quartile: 72.95 ± 0.31, P < .001). Adherence to a plant-based diet was more prevalent in those with a higher socioeconomic status (P < .001). After adjusting for potential confounders, the odds of CKD in the third and fourth quartiles of PDI were 25% (OR: 0.75; 95% confidence interval: 0.62-0.91) and 39% (OR: 0.61; 95% confidence interval: 0.48-0.78, P trend<.001) lower than the first quartile, respectively. CONCLUSIONS: The findings of this study suggest that having a plant-based diet may prevent the prevalent CDK. However, further studies with a cohort design are recommended.

Adapting the Donabedian model in undergraduate nursing education: a modified Delphi study.

BACKGROUND: Donabedian conceptual and multidimensional framework has been used in several studies in an educational context. In this study, we aimed to adapt the Donabedian three-component model (structure, process, and outcome) in undergraduate nursing education. This conceptual framework provides a comprehensive image of nursing education institutions and can help to evaluate institutions by measuring different aspects of their performance. A comprehensive understanding of the various elements of an educational institution helps to develop a complete, appropriate relevant set of performance indicators. METHODS: This was a modified Delphi study. It had three rounds. The expert panel consisted of nursing faculty members and nursing Ph.D. students. In the first round, a questionnaire was designed based on interviews, focus groups, and a literature review. Experts rated their agreement with each element on a 5-point Likert scale in rounds two and three. The consensus level was set as 75%. The stability between rounds was also determined by calculating kappa coefficients. One Sample T-Test was also calculated for new items in round three. RESULTS: All 55 items of the questionnaire were confirmed in the second round based on the consensus percentage of 75. Five new items were added to the third round based on comments in round two. Eventually, all elements except one were confirmed according to the consensus level, kappa values, means, and One-Sample T-Test in round three. The structure's key elements include staff (academic and non-academic); equipment; guidelines; resources and facilities; and students' demographics and characteristics. Process key elements include communication; education; evaluation; cooperation; and consultation. Outcome key elements include knowledge development; nursing image; alumni's outcome; students' outcome; related medical centers' performance; accreditation and evaluation results; and satisfaction. CONCLUSIONS: Different elements of a nursing education institution at the bachelor's level were determined. The results of this study can help related bodies to develop and implement a comprehensive and systematic evaluation. These results can also be a basis for making this model useful in other nursing courses or education in other fields.

Non-hospital healthcare center's preparedness assessment toolbar for providing basic emergency care: a sequential exploratory mixed-method study.

BACKGROUND: Basic emergency management in urban and rural areas is a critical challenge, which can affect the pre-hospital mortality rate. Therefore, Non-hospital Healthcare Center (NHHC) must be prepared to manage such emergency cases that may occur in the geographic area where these centers act. The main aim of the study was to develop and validate an toolbar for NHHCs' preparedness to provide initial emergency care. METHODS: This study was designed based on a sequential exploratory mixed- method in two phases, in each of which there are three steps. In the phase I, the literature systematic review and qualitative methods (Focus Group Discussions (FGDs) and Semi-Structured Interviews (SSIs)) were applied to identify the domains and items. In the phase II, content validity, feasibility, and reliability of the toolbar were performed. Content validity was assessed using a modified Kappa coefficient based on clarity and relevance criteria. Feasibility of the toolbar was randomly assessed through its implementation in 10 centers in Tabriz. Reliability was randomly assessed in a pilot on 30 centers. Reliability was assessed by measuring internal consistency, test-retest reliability, and inter-rater agreement. The main statistical methods for assessing reliability include Cronbach's alpha, Intra-class Correlation Coefficient, and Kendal's Tau-b. All the statistical analyses were performed using Stata 14. RESULTS: In the phase I, primary version of the toolbar containing 134 items related to assessing the preparedness of NHHCs was generated. In the phase II, item reduction was applied and the final version of the toolbar was developed containing 126 items, respectively. These items were classified in 9 domains which include: "Environmental Infrastructures of Centers", "Protocols, Guidelines and Policies", "Medical Supplies and Equipment", "Emergency Medicines", "Human Resources", "Clinical Interventions", "Maintenance of equipment", "Medicine Storage Capability", and "Management Process". The toolbar had acceptable validity and reliability. CONCLUSIONS: This study provided a standard and valid toolbar that can be used to assess the preparedness of NHHCs to deliver initial emergency care.

Baccalaureate nursing education institutions' key performance indicators: a review of the existing indicators and qualitative analysis of expert interviews.

BACKGROUND: Improvements in nurses' and midwives' education will increase workforce quantity and quality. Continual improvement of organization performance is based on continual measuring; Appropriate indicators must be selected to measure and appraise the performances. This study aimed to recognize and categorize key performance indicators (KPIs) for baccalaureate nursing education institutions' performance measurement. METHODS: This study had two phases: (1) Interview: Seven semi-structured interviews were conducted with faculty members and nurses. (2) Narrative Literature review: schools' and universities' reports and web pages were assessed to recognize KPIs. The data analysis method was directed content analysis. The Donabedian Model components were used to guide the data analysis. RESULTS: The total number of indicators retrieved was 468; 75 were from interviews with faculty members and nurses and 393 were from the literature review. Indicators were categorized into: Structure (staff; equipment, resources, and facilities; guidelines), Process (education; communication and collaboration; evaluation), and Outcome (survey and accreditation; national and international recognition; satisfaction; sustainability and financial efficiency; students; alumni; knowledge related to the field). CONCLUSIONS: A number of indicators were identified that were categorized into various groups related to the performance of nursing schools. Further investigations are needed with different groups of stakeholders including students, professional associations, healthcare institutions, alumni, and clients. As well in some areas, new or composite indicators may need to be developed. Also, each institution needs to select appropriate indicators based on its context, policy goals, and infrastructure.

Designing and conducting initial application of a performance assessment model for in-hospital trauma care.

BACKGROUND: Trauma is a major cause of death worldwide, especially in Low and Middle-Income Countries (LMIC). The increase in health care costs and the differences in the quality of provided services indicates the need for trauma care evaluation. This study was done to develop and use a performance assessment model for in-hospital trauma care focusing on traffic injures. METHODS: This multi-method study was conducted in three main phases of determining indicators, model development, and model application. Trauma care performance indicators were extracted through literature review and confirmed using a two-round Delphi survey and experts' perspectives. Two focus group discussions and 16 semi-structured interviews were conducted to design the prototype. In the next step, components and the final form of the model were confirmed following pre-determined factors, including importance and necessity, simplicity, clarity, and relevance. Finally, the model was tested by applying it in a trauma center. RESULTS: A total of 50 trauma care indicators were approved after reviewing the literature and obtaining the experts' views. The final model consisted of six components of assessment level, teams, methods, scheduling, frequency, and data source. The model application revealed problems of a selected trauma center in terms of information recording, patient deposition, some clinical services, waiting time for deposit, recording medical errors and complications, patient follow-up, and patient satisfaction. CONCLUSION: Performance assessment with an appropriate model can identify deficiencies and failures of services provided in trauma centers. Understanding the current situation is one of the main requirements for designing any quality improvement programs.

Basic Management of Life-Threatening Emergencies: The Importance of Developing the Instrument to Assess Nonhospital Health Centers' Preparedness.

We presented a commentary on published studies on the "preparedness of non-hospital centers in dealing with life-threatening emergencies" to emphasize the importance of developing, validating, and piloting an instrument to assess the preparedness of these centers when life-threatening emergencies occur in their geographic area.

Epidemiology of multimorbidity in Iran: An investigation of a large pharmacy claims database.

PURPOSE: Multimorbidity (MM) (presence of more than one chronic condition within a same patient) imposes a heavy burden on patients and health care systems. In contrast to high-income countries, the epidemiology of this phenomenon is unclear in low- and middle-income countries, particularly among Iranian population. METHODS: This was a retrospective cohort study using Iranian Health Insurance Organization claims database. A framework was developed for identifying a set of 18 chronic conditions from the pharmacy claims data in Iran. All 2013 outpatient utilizers (aged 18 years or older) were included. Data were analyzed according to number of chronic conditions, gender, and age. The association between MM and utilizations of health services was examined for 2013 to 2016. RESULTS: In total, 481 733 people were included. Cardiovascular diseases (including hypertension) (19.1%), depression/anxiety/sleep disorders (13.7%), and acid-related disorders (10.3%) were the three most prevalent conditions. MM was present in 21.1%. Although prevalence of MM is higher in older age groups and was present in 40% of individuals aged 65 and older, the absolute number of multimorbid patients was higher in those younger than 65 years (66 271 vs 35 386). MM was more prevalent among women (22.1%) compared with men (19.5). After multivariate adjustment for age group and sex, each additional chronic condition was associated with an increase of 2.23 physician visits, 2.86 drugs dispensed, 2.32 laboratory tests, and 1.6 medical imaging. CONCLUSIONS: Our findings challenge the current single-disease-based assumption implicit in Iranian health care system. To take account of MM, complementary strategies should be designed and implement in health care system.

Preparedness of non-hospital health centers to manage patients with life-threatening emergency conditions: findings from a qualitative study.

BACKGROUND: Management of Life-threatening Emergency (LTE) patients in urban and rural areas is an important challenge, which can affect pre-hospital mortality rate. Therefore, Non-hospital Health Center (NHHC) must be prepared to manage such emergency cases that may occur in the geographic area where these centers act. The aim of this study was to explore domains related to the preparedness of NHHCs to manage LTE patients through resorting to healthcare providers' and experts' perspectives. METHODS: A qualitative exploratory study was applied using Semi-Structured Interviews (SSIs) and Focus Group Discussions (FGDs). Prior to beginning data collection, the study and its objectives were explained to the participants and their informed consents were obtained. Then, SSIs and FGDs were conducted by two trained researchers using an interview guide, which was developed through literature review and consulting experts. In total, 12 SSIs were done with the providers at different NHHCs in Tabriz. In addition, 2 FGDs were conducted with the specialists in Emergency Medicine (EM) and Primary Health Care (PHC), and the executives of health centers, with over 5 years of work experience, and Emergency Medical Services (EMS) experts. Purposive sampling method was used in this study. All SSIs and FGDs were audio recorded and subsequently transcribed. Framework Analysis was employed to manually analyze the interview transcripts from all the SSIs and FGDs. RESULTS: The interview transcripts analysis resulted in the emergence of 3 themes and 11 sub-themes, categorized according to Donabedian's triple model. 5 sub-themes were related to input, including medical equipment and supplies, environmental infrastructures of the centers, emergency medicines, human resource, and protocols, guidelines and policies. 4 sub-themes were related to process, including providing clinical services, medicine storage capacity, maintenance of equipment, and management process. Finally, 2 sub-themes were related to outcome, which were patients' satisfaction with the quality of care and improved survival of LTE patients. CONCLUSIONS: The results of this study can provide a new perspective for health managers and policy makers on how to evaluate the preparedness of NHHCs in managing LTE patients. In addition, it will be used to develop instruments to measure the preparedness of these centers.

The impact of patient safety culture and the leader coaching behaviour of nurses on the intention to report errors: a cross-sectional survey.

BACKGROUND: There is growing interest in examining the factors affecting the reporting of errors by nurses. However, little research has been conducted into the effects of perceived patient safety culture and leader coaching of nurses on the intention to report errors. METHODS: This cross-sectional study was conducted amongst 256 nurses in the emergency departments of 18 public and private hospitals in Tabriz, northwest Iran. Participants completed the Hospital Survey on Patient Safety Culture (HSOPSC), Coaching Behavior Scale and Intention to Report Errors' questionnaires and the data was analyzed using multiple linear regression analysis. RESULTS: Overall, 43% of nurses had an intention to report errors; 50% of respondents reported that their nursing managers demonstrated high levels of coaching. With regard to patient safety culture, areas of strength and weakness were "teamwork within units" (PRR = 66.8%) and "non-punitive response errors" (PRR = 19.7%). Regression analysis findings highlighted a significant association between an intention to report errors and patient safety culture (B = 0.2, CI 95%: 0.1 to 0.3, P < 0.05), leader coaching behavior (B = 0.2, CI 95%: 0.1 to 0.3, P < 0.01) and nurses' educational status (B = 0.8, 95% CI: - 0.1 to 1.6, P < 0.05). CONCLUSIONS: Further research is needed to assess how interventions addressing patient safety culture and leader coaching behaviours might increase the intention to report errors.

The role of patients in the delivery of safe care in hospital: Study protocol.

AIM: This paper outlines the protocol for a study aimed at exploring perspectives about the role of patients' in the delivery of safe care in hospital. DESIGN: Qualitative exploratory study. METHODS: Research Ethics Committee approval for this study was obtained in October 2018. The study will be conducted between February-April 2019 with data collected through focus group discussions and semi-structured interviews and will involve patients and healthcare professionals from hospitals in Tabriz. A descriptive qualitative approach will be adopted, and the data will be managed and analysed using MAXQDA 10 software. DISCUSSION: The role of patients in furthering their own safety whilst in hospital cannot be underestimated and the results from this study can be used to support the development of practical strategies that address the delivery of safe hospital care and which involve patients and their caregivers.

Nursing Managers' Perspectives on the Facilitators and Barriers to Implementation of Evidence-Based Management.

BACKGROUND: Evidence-based health management is defined as a new approach to improve the quality of hospital decisions by systematic application of the best available evidence. To use that, facilitators and barriers to implementation of evidence-based management (EBMgt) in the decision-making process need to be identified. AIM: The purpose of this study was to assess nursing managers' perspectives on the facilitators and barriers to implementation of EBMgt in Tabriz hospitals, northwest Iran. METHODS: A cross-sectional study design was used in 2017. The study was conducted in one state in Iran (Tabriz). A total of 276 nursing managers (e.g., matrons, supervisors, & head nurses [HNs]) were invited to participate from the Tabriz hospitals (N = 20); 212 completed and returned the survey, yielding a response rate of 76.81%. The EBMgt assessment questionnaire was used to collect data. The questionnaire consists of two parts. The first part includes barriers to EBMgt (five main domains and 46 questions). The second part includes the facilitators of EBMgt (five main domains and 42 questions). Data entry and analysis were carried out using SPSS-21 software. RESULTS: Highest mean scores of barriers were observed for "training and research systems" (64.65 ± 12.42). "Lack of communication between knowledge producers and hospital decision-makers" (68.19 ± 17.32) had highest mean scores among all 46 barriers. Also, the results showed that mean scores for all the barriers were higher than 55. The highest mean scores were observed for "social/interpersonal factors" (65.84 ± 17.07). "Interest and willingness to scientific management principles" (68.62 ± 20.17) had highest mean scores among all 42 facilitators. LINKING EVIDENCE TO ACTION: The aim of EBMgt is to provide the most effective healthcare outcomes. Identifying barriers and facilitators is essential for implementing EBMgt in hospitals. Building the facilitators and eliminating barriers are foundation of EBMgt. Filling the gap between knowledge producers and nursing managers can be a starting point for improvement of the decision-making process in nursing care.

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

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

Evidence-based management - healthcare manager viewpoints.

Purpose Hospital manager decisions can have a significant impact on service effectiveness and hospital success, so using an evidence-based approach can improve hospital management. The purpose of this paper is to identify evidence-based management (EBMgt) components and challenges. Consequently, the authors provide an improving evidence-based decision-making framework. Design/methodology/approach A total of 45 semi-structured interviews were conducted in 2016. The authors also established three focus group discussions with health service managers. Data analysis followed deductive qualitative analysis guidelines. Findings Four basic themes emerged from the interviews, including EBMgt evidence sources (including sub-themes: scientific and research evidence, facts and information, political-social development plans, managers' professional expertise and ethical-moral evidence); predictors (sub-themes: stakeholder values and expectations, functional behavior, knowledge, key competencies and skill, evidence sources, evidence levels, uses and benefits and government programs); EBMgt barriers (sub-themes: managers' personal characteristics, decision-making environment, training and research system and organizational issues); and evidence-based hospital management processes (sub-themes: asking, acquiring, appraising, aggregating, applying and assessing). Originality/value Findings suggest that most participants have positive EBMgt attitudes. A full evidence-based hospital manager is a person who uses all evidence sources in a six-step decision-making process. EBMgt frameworks are a good tool to manage healthcare organizations. The authors found factors affecting hospital EBMgt and identified six evidence sources that healthcare managers can use in evidence-based decision-making processes.

Compensation based on work relative value unit for cardiovascular surgeons in Iran: A mixed method study.

BACKGROUND: Work relative value unit (wRVU) is a tool for assessing surgeons' performance, compensation, and productivity. It appears that wRVU for cardiovascular procedures does not consider complexity and its value for lengthy operations is low. The aim of the study is to determine wRVU for cardiovascular procedures in Iran according to the proposed approach. MATTERIALS AND METHODS: This study was conducted as a mixed method in teaching hospitals in Tabriz in the period of September 2020 to December 2021. According to Hospital Information System and expert opinions, six procedures in cardiovascular surgery were included in the study. They were compared with 18 procedures in neurosurgery, orthopedics, and otorhinolaryngology in terms of the operation time and wRVU/min. Then, we calculated new wRVUs for the selected procedures based on surgeons' opinions, time measurements, and anesthetists' points of view by content analysis in qualitative and statistical analysis in quantitative parts. RESULTS: Among the six cardiac procedures, the wRVU for five was under-estimated. The wRVU/min value ranged from 0/28 to 1/15 in the studied procedures. Findings demonstrate no significant relationship between the length of operations and the wRVU announced by the Ministry of Health and Medical Education (P value >0/05). Compared to studied procedures in four specialties, thoracoabdominal aortic aneurysm repair has the longest surgery time at 417 minutes. According to anesthesiologists, cardiovascular; orthopedics; ear, nose, and tongue; and neurosurgery specialties obtained 4/2, 2/9, 2/8, and 4, respectively, in terms of surgery duration, complexity, risk, and physical effort. CONCLUSION: Despite policymakers' attempts to bring justice to payments, it seems that there has been little progress in paying cardiovascular surgeons. Improper payment to cardiovascular surgeons will affect the future of the workforce in this specialty. Today, the need to reconsider the wRVUs in heart specialty is felt more than before.

Gastrointestinal Cancer Prevention Policies: A Qualitative Systematic Review and Meta-Synthesis.

This qualitative systematic review was conducted to summarize the policies for prevention of common gastrointestinal cancers worldwide. This study was conducted using PubMed, Web of Science, SCOPUS, and ProQuest databases. Two independent reviewers assessed included studies for methodological quality and extracted data by using standardized tools from Joanna Briggs Institute (JBI). Primary study findings were read and reread to identify the strategies or policies used in the studies for prevention of gastrointestinal cancers. The extracted findings were categorized on the basis of their similarity in meaning. These categories were then subjected to a meta-synthesis. The final synthesized findings were graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis. From the nine included studies in this review, 39 findings were extracted and based on their relevance in meaning were aggregated into 12 categories. Four synthesized findings were developed from these categories. We used World Health Organization report on 2000 for synthesizing the findings. The four synthesized findings were "service provision", "resource generation", "financing", and "stewardship". In order to reach a comprehensive evidence informed policy package for the prevention of gastrointestinal cancers, there should be a great communication among the interventions conducted directly on patients, health system infrastructures, and resources.

Polypharmacy Pattern in Iran: A Comprehensive Analysis of a Large Prescription Database.

Background: Polypharmacy is a significant patient safety concern. Objectives: This study aims to estimate the prevalence of polypharmacy, its continuity and associated factors, and common medication classes among a large outpatient population in East Azerbaijan province, Iran. Methods: A retrospective prescription data analysis was performed. The cohort included all ≥ 20 years old subjects with at least one prescription filled during the main three-month study period (2020 March 1 - 2020 May 31). Polypharmacy was defined as being exposed to more than four different medications during the main study period, and continuous polypharmacy was defined as being exposed to more than four medications during both the main study period and follow-up period (2020 October 1 - 2020 December 31). The frequency and prevalence of polypharmacy, along with predictive factors, were estimated. We performed multivariate logistic regression and estimated odds ratios (ORs) to investigate the risk factors for polypharmacy. Results: 307,820 patients included (mean age 49.8 years, 62.9% female, mean drug use 3.7 (SD = 2.6). Polypharmacy was observed in 28.3% (CI: 28.1 - 28.4), of which 36.6% experienced continuous polypharmacy. The odds of being exposed to polypharmacy increased with being female, increasing age, and exposure to chronic conditions. The groups of medications most utilized by polypharmacy patients were those indicated for gastro-esophageal reflux diseases, beta-blocking agents, antidepressants, blood glucose-lowering drugs, and antithrombotic agents. Conclusions: Strategies should be formulated to inform healthcare policymakers and providers about the magnitude of the polypharmacy phenomenon, associated factors, and the common medication classes involved.

Incremental Healthcare Resource Utilization and Expenditures Associated with Cardiovascular Diseases in Patients with Diabetes: A Cross-Sectional Study.

BACKGROUND: Cardiovascular disease (CVD) is the most prevalent comorbid condition among patients with diabetes. The objective of this study is to determine the incremental healthcare resource utilization and expenditures (HRUE) associated with CVD comorbidity in diabetic patients. METHODS: In a cross-sectional study, patients receiving antidiabetic drugs were identified using the 2014 database of the Iran Health Insurance Organization of East Azerbaijan province (Iran). The frequency of HRUE was the main outcome. Outcome measures were compared between diabetic patients with and without CVD comorbidity during 2014-2016. The generalized regression model was used to adjust for cofounders because of a highly skewed distribution of data. Negative binomial regression and gamma distribution model were applied for the count and expenditure data, respectively. RESULTS: A total of 34,716 diabetic patients were identified, of which 21,659 (63%) had CVD comorbidity. The incremental healthcare resource utilization associated with CVD compared to non-CVD diabetic patients for physician services, prescription drugs, laboratory tests, and medical imaging was 5.9±0.34 (28% increase), 46±1.9 (46%), 12.9±0.66 (27%), and 0.16±0.40 (7%), respectively (all P<0.001). Similarly, extra health care costs associated with CVD comorbidity for physician services, prescription drugs, laboratory tests, and medical imaging were 10.6±0.67 million IRR (294.4±18.6 USD) (50% increase), 1.44±0.06 million IRR (40±1.6 USD) (32%), 8.36±0.57 million IRR (232.2±15.8 USD) (58%), 0.51±0.02 million IRR (14.1±0.5 USD) (24%), and 0.29±0.02 million IRR (8±0.5 USD) (22%), respectively (all P<0.001). CONCLUSION: CVD comorbidity substantially increases HRUE in patients with diabetes. Our findings draw the attention of healthcare decision-makers to proactively prevent CVD comorbidity in diabetic patients.