Strategies for utilisation management of hospital services: a systematic review of interventions.

BACKGROUND: To achieve efficiency and high quality in health systems, the appropriate use of hospital services is essential. We identified the initiatives intended to manage adult hospital services and reduce unnecessary hospital use among the general adult population. METHODS: We systematically reviewed studies published in English using five databases (PubMed, ProQuest, Scopus, Web of Science, and MEDLINE via Ovid). We only included studies that evaluated interventions aiming to reduce the use of hospital services or emergency department, frequency of hospital admissions, length of hospital stay, or the use of diagnostic tests in a general adult population. Studies reporting no relevant outcomes or focusing on a specific patient population or children were excluded. RESULTS: In total, 64 articles were included in the systematic review. Nine utilisation management methods were identified: care plan, case management, care coordination, utilisation review, clinical information system, physician profiling, consultation, education, and discharge planning. Primary case management was shown to effectively reduce emergency department use. Care coordination reduced 30-day post-discharge hospital readmission or emergency department visit rates. The pre-admission review program decreased elective admissions. The physician profiling, concurrent review, and discharge planning effectively reduced the length of hospital stay. Twenty three studies that evaluated costs, reported cost savings in the hospitals. CONCLUSIONS: Utilisation management interventions can decrease hospital use by improving the use of community-based health services and improving the quality of care by providing appropriate care at the right time and at the right level of care.

End-of-life Care: Beliefs, Attitudes, and Experiences of Iranian Physicians.

CONTEXT: Most of the patients suffering from cancer are diagnosed at late stages of cancer, which curative interventions are unable to improve their quality of life. AIM: To survey Iranian physicians' attitudes and practices toward end-of-life (EOL) care. SUBJECTS AND METHODS: We conducted a cross-sectional survey among physicians participating in a national annually conducted educational seminar. RESULTS: The survey results show that 80% of physicians had between 1 and 3 EOL patients. About 72% of patients received medical care in hospitals. The difference in best setting for care of terminally ill patients was statically significant after controlling for the length of practice and physician belief. The results also showed that that the participants believed that that the level of physicians' knowledge in this field was unacceptable. CONCLUSION: Physicians of our study were interested to participating in continuing education programs focused on EOL patients.

Attitudes and Knowledge of Iranian Nurses about Hospice Care.

CONTEXT: Due to expansion of chronic diseases and increase of health care costs, there is a need for planning and delivering hospice care for patients in their final stages of life in Iran. The aim of the present study is to investigate the knowledge and attitudes of nurses about delivering hospice care for End of Life (EOL) patients. MATERIALS AND METHODS: This cross-sectional study was conducted in 2012 with a sample size of 200 nurses that were selected by convenient (available) sampling. The data collection instrument was a self-administered questionnaire whose validity was approved by experts' opinions and its reliability was approved by test-retest method. RESULTS: Among all participants of this study, 87% were female. The mean age of nurses was 32.00 ± 6.72. From all respondents 62% stated that they have no knowledge about hospice care and 80% declared that need for hospice care is increasing. Most of the participants felt that, appropriate services are not presented to patients in the final stages of their lives. About 80% believed that hospice care leads to reduction of health care costs, improvement of physical, mental and social health of patients and finally improvement of the quality of health care services. There was a significant relationship between age, employment history and level of education of nurses and their attitude and knowledge about how this service is provided. CONCLUSION: In view of the increase in chronic illnesses and the costs of caring, the need for provision of hospice care is felt more and more every day. However the awareness level of nurses about these services is low. Therefore the need for including these issues in nursing curriculum and holding scientific courses and seminars in this field is needed.

Relationship between job satisfaction and performance of primary care physicians after the family physician reform of east Azerbaijan province in Northwest Iran.

BACKGROUND: Following the implementation of family physician program in 2004 in Iranian healthcare system, the understanding in changes in physicians' practice has become important. OBJECTIVE: The objective of this study was to determine the level of family physicians' job satisfaction and its relationship with their performance level. MATERIALS AND METHODS: A cross-sectional study was conducted among all 367 family physicians of East Azerbaijan province in during December 2009 to May 2011 using a self-administered, anonymous questionnaire for job satisfaction. The performance scores of primary care physicians were obtained from health deputy of Tabriz Medical University. RESULTS: In this study, overall response rate was 64.5%. The average score of job satisfaction was 42.10 (±18.46), and performance score was 87.52 (±5.74) out of 100. There was significant relationships between working history and job satisfaction (P = 0.014), marital status (P = 0.014), and sex (P = 0.018) with performance among different personal and organizational variables. However, there was no significant relationship between job satisfaction and performance, but satisfied people had about three times better performance than their counterparts (all P < 0.05). CONCLUSIONS: The low scores of family physicians in performance and job satisfaction are obvious indications for more extensive research in identifying causes and finding mechanisms to improve the situation, especially in payment methods and work condition, in existing health system.

Factors affecting hospital services overutilization and reductive strategies in Iran: a qualitative study to explore experts' views.

OBJECTIVES: This study aimed to investigate the viewpoints of the main stakeholders of the Iranian healthcare system about the overutilization of hospital services and strategies to eliminate or reduce it in Iran. METHODS: This is a qualitative study and thematic data analysis using face-to-face semi-structured interviews and Focus Group Discussions (FGDs). We conducted eight interviewers and two FGDs with hospital stakeholders including faculty members, insurance organizations' authorities, experienced hospital administrative staff, hospital managers, and health-care providers. RESULTS: The factors leading to the overutilization of hospital services were categorized into four main themes including site of service, quality, supplier push, and demand pull. Strategies for eliminating or reducing the overutilization of hospital services are also identified based on the influential factors. CONCLUSION: Addressing overutilization of hospital services in the health system and adherence to policies for reducing or eliminating overutilization is a way to make preventive strategies to overcome overutilization. Developing a national plan to integrate utilization management into health system programs is a strategy to combat overutilization in various levels of the health system including hospital setting.

Exposure assessment to dust and free silica for workers of Sangan iron ore mine in Khaf, Iran.

We aimed to conduct an exposure assessment to dust and free silica for workers of Sangan iron ore mine in Khaf, Iran. The maximum concentrations of total dust and free silica were measured in crusher machine station at 801 ± 155 and 26 ± 7 mg/m(3), respectively. Meanwhile, the minimum concentrations were measured in official and safeguarding station at 8.3 ± 2 and 0.012 ± 0.002 mg/m(3), respectively. Also, the maximum concentrations of respirable dust and free silica were measured in Tappeh Ghermez drilling no. 1 at 66 ± 13 and 1.5 ± 0.4 mg/m(3), respectively, while the minimum concentrations were measured in pneumatic hammer at 5.26 ± 3 and 0.01 ± 0.005 mg/m(3), respectively. Considerate to Iranian standard for respirable dust concentrations (0.11 mg/m(3)) and international standards (ACGIH = 0.1 and NIOSH = 0.05 mg/m(3)), it was found that dust and free silica amounts were much higher than national and international standard levels in this mine.

Organizing palliative care in the rural areas of Iran: are family physician-based approaches suitable?

INTRODUCTION: The provision of palliative end-of-life care (P/EOLc) for patients, wherever they live, is an increasingly important service, particularly given the increasing rates of cancer and other life-threatening diseases in Iran. However, unfortunately, those living in the rural areas of Iran are greatly disadvantaged with respect to this type of care. Therefore, the present study explored the feasibility of organizing P/EOLc in the rural areas of Iran. METHODS: In this qualitative study, two focus group (FG) discussions were held in Tabriz (Iran) with rural family physicians (FPs, n=23) and key P/EOLc stakeholders (n=13). The FG sessions were recorded, transcribed, and the transcriptions checked by participants before the data were subjected to content analysis. RESULTS: While most FPs indicated that they did not have sufficient involvement in providing P/EOLc, they emphasized the necessity of providing P/EOLc through four main themes and 25 subthemes. The four main themes were labeled as "structures and procedures," "health care provider teams," "obstacles," and "strategies or solutions." Furthermore, according to the main themes and subthemes identified here, the key stakeholders believed that the Iranian health system and the FPs' team have the potential to provide P/EOLc services in rural areas. CONCLUSION: The most feasible strategy for providing P/EOLc in Iranian rural areas would be to use the current health care framework and base the process around the FP.

Cytokine single nucleotide polymorphisms in Iranian patients with pulmonary tuberculosis.

BACKGROUND: Several genes coding for different cytokines may affect host susceptibility to tuberculosis. METHODS: In the present study, the allele and genotype frequencies of a number polymorphic genes coding for cytokines or cytokine receptors were investigated in Iranian patients with pulmonary tuberculosis (PTB). RESULTS: From the IL-1 cluster, a positive, significant difference was found at position -889, where the T/T genotype was over represented in PTB patients (p = 0.01); a positive, significant increase was found in the IL1R PstI 1970 C/C genotype, where the C allele was over represented in the PTB patients (p = 0.01). A significant negative association at codon 10 TGF-beta, T allele, was shown in our patients and the C allele and C/C genotype were over represented in the PTB patients (P<0.005). For TNF-alpha at position -238, we found a negative association for the G/A genotype and a positive association for the G/G genotype (p = 0.0009). Significant negative associations at position -590 IL-4, T allele and the T/T genotype were shown in our patients (p = 0.0007); also, the C allele and T/C genotype were significantly increased in our patients (P<0.05). With IL-6 at -174, G/G increased and G/C decreased significantly in the patients (P<0.005). CONCLUSION: Pro-inflammatory cytokines such as TNF-alpha and TGF-beta seem to be decreased, and IL-6 increased in PTB patients.

Hospital Care for Newborn Babies: Quality Assessment, A Systematic Review.

CONTEXT: Neonatal mortality rate is declining globally. The aim of the present study is to identify relevant indicators for assessing newborn care in hospitals by a systematic review. EVIDENCE ACQUISITION: A search on electronic data base and manual searches of personal files for studies on quality indicators of newborn care were carried out. Searching 9 bibliographic databases, we found 85 articles of which 22 exactly related ones were selected and studied. Hand search yielded 1 record were also searched and 2 records were included. RESULTS: A list of 87 structure, process and outcome indicators was formulated from the articles. Also 26 excess measures were identified in gray literature. After removing duplicates, and categorizing in 3 domains, 18 measures were input, 41 process and 34 outcome measures. CONCLUSIONS: These 93 indicators provide a framework for assessing how well the hospitals are providing neonatal care. These measures should be discussed in each context expert panels to address nationally applicable indices of neonatal care and may be adapted for local health settings.

Effectiveness of presence of physician and midwife in quantity and quality of family planning services in health care centers.

BACKGROUND AND AIM: Iran's health sector has been engaging the services of physicians and midwives in healthcare centers since 2005, with the hope of improving the quantity and quality of family planning services. The aim of this study was to assess the effect of serving physicians and midwives on the quantity and quality of family planning services in the healthcare centers of Iran. MATERIALS AND METHODS: The present cross-sectional study (Jan 2010 until Sep 2011) was carried out on 600 eligible families who were clients of healthcare centers of Tabriz, Azarshahr and Osku, cities of Northwest Iran from 2006 until 2011, in two groups (before and after). Some of the characteristics of the participants and the data on the quality and quantity of family planning services provided were grouped in a checklist of 16 variables by comparing the patients' past medical histories. RESULTS: In comparison with 3 years prior to engaging physician and midwife services in health care centers, the Couple Year Protection (CYP) and the quantity of family planning service indexes significantly increased among eligible families. The family size of participants declined significantly after family physicians and midwives became available in the healthcare centers (P < 0.005). CONCLUSION: Our findings showed some improvement in the quantity of services without any noticeable changes in the quality of services provided as a consequence of this huge intervention. Therefore, it is suggested that there should be proper oversight of the duties of the health team in order to keep a close watch on primary healthcare, design of proper mechanisms for collecting and maintaining performance reports and statistics, and continuously monitor and control the quality of services.

Antenatal Micronutrient Supplementation Relationship with Children's Weight and Height from Birth up to the Age of 18 Months.

BACKGROUND: Maternal nutritional is the most important environmental factor influencing pregnancy outcome. While studies showed association between maternal iron-micronutrient deficiencies with pregnancy outcome, data examining impact of micronutrient supplementation on growth rate beyond birth are sparse. Present study examined the relationship between iron and multivitamins supplementation on growth rate of babies up to age of 18 month. METHODS: This study was a statistical analysis on data recorded through a routine procedure in health houses from 1994 to 2007. Subjects were selected by a two-stage randomization method and required data extracted from the records. Analyses were performed using STATA 10 software. RESULTS: Data was collected for 3835 pairs of mother-baby. Mothers received 61.7±5.4 and 115.6±53.8 multivitamins and iron tablets, respectively. Analyses showed significant relationship between children's weight and height at birth with iron supplementation and children's height at 6, 12 and 18 month with multivitamins supplementation. CONCLUSIONS: Mechanisms of these effects are unclear but it is safe to suggest supplementation during pregnancy is necessary.