Healthcare reform and productivity of Hospital: a DEA-based analysis from South West of Iran.

BACKGROUND: Different healthcare reforms could affect the productivity of hospitals. The aim of this study was to track hospital productivity before and after the recent Iranian healthcare reform in Khuzestan province, South West of Iran. METHODS: Hospital productivity was evaluated through data envelopment analysis (DEA) and Malmquist productivity index (MPI) from 2011 to 2015 for 17 Iranian public hospitals before and after the health sector transformation plan. We assumed an output-oriented model with variable returns to scale (VRS) to estimate the productivity and efficiency of each hospital. The DEAP V.2.1 software was used for data analysis. RESULTS: After the transformation plan, the averages of technical efficiency, managerial efficiency and scale efficiency in the studied hospitals had negative changes, but technology efficiency had positive changes.44.4% of general hospitals, 25% of multi-specialized hospitals, and 100% of specialized hospitals had positive productivity changes after implementing the health sector evolution plan. The Malmquist productivity index (MPI) had low positive changes from 2013 to 2016 (MPI = 0.13 out of 1) but the mean productivity score had no change after the health sector evolution plan. CONCLUSIONS: The total productivity before and after the health sector evolution plan had no change in Khuzestan province. This and the increase in the utilization of impatient services seemed to be a sign of good performance. But apart from technology efficiency, other efficiency indices had negative changes. It is suggested that in health reforms in Iran, more attention should be paid to the allocation of resources in the hospital.

Socioeconomic determinants of unmet need for outpatient healthcare services in Iran: a national cross-sectional study.

BACKGROUND: Unmet need is a critical indicator of access to healthcare services. Despite concrete evidence about unmet need in Iran's health system, no recent evidence of this negative outcome is available. This study aimed to measure the subjective unmet need (SUN), the factors associated with it and various reasons behind it in Iran. METHODS: We used the data of 13,005 respondents over the age of 15 from the Iranian Utilization of Healthcare Services Survey in 2016. SUN was defined as citizens whose needs were not sought through formal healthcare services, while they did not show a history of self-medication. The reasons for SUN were categorized into availability, accessibility, responsibility and acceptability of the health system. The multivariable logistic regression was used to determine significant predictors of SUN and associated major reasons. RESULTS: About 17% of the respondents (N = 2217) had unmet need for outpatient services. Nearly 40% of the respondents chose only accessibility, 4% selected only availability, 78% chose only responsibility, and 13% selected only acceptability as the main reasons for their unmet need. Higher outpatient needs was the only factor that significantly increased SUN, responsibility-related SUN and acceptability-related SUN. Low education was associated with higher SUN and responsibility-related SUN, while it could also reduce acceptability-related SUN. While SUN and responsibility-related SUN were prevalent among lower economic quintiles, having a complementary insurance was associated with decreased SUN and responsibility-related SUN. The people with basic insurance had lower chances to face with responsibility-related SUN, while employed individuals were at risk to experience SUN. Although the middle-aged group had higher odds to experience SUN, the responsibility-related SUN were prevalent among elderly, while higher age groups had significant chance to be exposed to acceptability-related SUN. CONCLUSION: It seems that Iran is still suffering from unmet need for outpatient services, most of which emerges from its health system performance. The majority of the unmet health needs could be addressed through improving financial as well as organizational policies. Special attention is needed to address the unmet need among individuals with poor health status.

A Successful implementation of an idea to a nationally approved plan: Analyzing Iran's National Health Roadmap using the Kingdon model of policymaking.

Introduction: Hospital beds, human resources, and medical equipment are the costliest elements in the health system and play an essential role at the time of treatment. In this paper, different phases of the NEDA 2026 project and its methodological approach were presented and its formulation process was analysed using the Kingdon model of policymaking. Methods: Iran Health Roadmap (NEDA 2026) project started in March 2016 and ended in March 2017. The main components of this project were hospital beds, clinical human resources, specialist personnel, capital medical equipment, laboratory facilities, emergency services, and service delivery model. Kingdon model of policymaking was used to evaluate NEDA 2026 development and implementation. In this study, all activities to accomplish each step in the Kingdon model was described. Results: The followings were done to accomplish the goals of each step: collecting experts' viewpoint (problem identification and definition), systematic review of the literature, analysis of previous experiences, stakeholder analysis, economic analysis, and feasibility study (solution appropriateness analysis), three-round Delphi survey (policy survey and scrutinization), and intersectoral and interasectoral agreement (policy legislation). Conclusion: In the provision of an efficient health service, various components affect each other and the desired outcome, so they need to be considered as parts of an integrated system in developing a roadmap for the health system. Thus, this study demonstrated the cooperation process at different levels of Iran's health system to formulate a roadmap to provide the necessary resources for the health sector for the next 10 years and to ensure its feasibility using the Kingdon policy framework.

A Scoping Review of Possible Solutions for Decreasing Socioeconomic Inequalities in Type 2 Diabetes Mellitus.

Background: As socioeconomic inequalities are key factors in access and utilization of type 2 diabetes (T2D) services, the purpose of this scoping review was to identify solutions for decreasing socioeconomic inequalities in T2D. Methods: A scoping review of scientific articles from 2000 and later was conducted using PubMed, Web of Science (WOS), Scopus, Embase, and ProQuest databases. Using the Arksey and O'Malley framework for scoping review, articles were extracted, meticulously read, and thematically analyzed. Results: A total of 7204 articles were identified from the reviewed databases. After removing duplicate and nonrelevant articles, 117 articles were finally included and analyzed. A number of solutions and passways were extracted from the final articles. Solutions for decreasing socioeconomic inequalities in T2D were categorized into 12 main solutions and 63 passways. Conclusions: Applying identified solutions in diabetes policies and interventions would be recommended for decreasing socioeconomic inequalities in T2D. Also, the passways could be addressed as entry points to help better implementation of diabetic policies.

The Quality of Services of Iran University Hospitals Based on SERVQUAL's Evaluation Model: A Systematic Review and Meta-Analysis.

Introduction: Systematic evaluation of the quality of services provided in hospitals and healthcare centers is the first step toward standardization and improving their quality. Methods: In this systematic review (meta-analysis) study, the information was collected by searching for the articles published in well-known Iranian and international and through searching for the keywords of SERVQUAL, services quality, gap, hospital, patients, Iran, and without language and time restrictions. Results: A total of 18 articles were reviewed and opinions of 4,714 people who referred to hospitals and healthcare centers affiliated to Iran University of Medical Sciences during the past 10 years from 2010 to 2019 were examined in this study. The results showed that there was a quality gap in all 5 dimensions between the current status and desirable status of patients and based on a maximum score of 5, responsiveness (1.04), and assurance (0.99), empathy (0.95), reliability (0.91), and physical or tangible factors (0.86) were ranked first to fifth, respectively. According to the random effect model, the mean score of patients' perceptions and expectations and the gap between them was 3.59 (CI 95%: 3.73, 3.46), 4.66 (CI 95%: 4.33 and 4.66), and 0.86 (CI 95%: 1.00, 0.72), respectively. Conclusion: The patients' expectations in university hospitals were higher than their perceptions. Therefore, it is recommended for Ministry of Health and Medical Education of Iran to monitor periodically the quality of hospitals while focusing on students' and patients' satisfaction and pay attention to dimensions that have the highest quality gap. Systematic Review Registration: https://ethics.research.ac.ir/ProposalCertificateEn.php?id=167856&Print=true&NoPrintHeader=true&NoPrintFooter=true&NoPrintPageBorder=true&LetterPrint=true, identifier: IR.AJUMS.REC.1399.747.

Explanation of Socio-economic Inequality in Medicine Use: A Cross-sectional Analysis from Iran.

Background: Despite the favorable progress in the production of medicines, there is no significant access to these important health inputs among different socio-economic groups. Objectives: This study aimed to measure and explain socio-economic inequality in prescribed and non-prescribed medicine use in Iran. Methods: Data were obtained from a recent household survey on health services in Iran conducted in 2016. The Erreygers concentration index (ECI) was used to measure socio-economic inequality in the use of prescribed and non-prescribed medicines. In addition, Decomposition analysis was conducted to explain socio-economic inequality. Results: The ECI revealed pro-rich socio-economic inequality in prescribed medicine use (ECI = 0.067, SE = 0.010), indicating that prescribed medicine use was concentrated on the better-offs. On the other hand, this index showed pro-poor inequality in non-prescribed medicine use (ECI = -0.064, SE = 0.009). Decomposition analysis showed that economic status and place of residence were the main determinants of socio-economic inequality in prescribing medicines. These factors and the number of health care needs explained the majority of socio-economic inequality in non-prescribed medicine use. Conclusions: Despite previous positive beliefs, we found remarkable socio-economic inequality in the use of medicines in Iran. Facilitating access to pharmaceutical services for disadvantaged households and rural residents and promoting of national essential medicines list could be recommended against socio-economic inequality in the pharmaceutical market of Iran.

Hospital Efficiency Measurement Before and After Health Sector Evolution Plan in Southwest of Iran: a DEA-Panel Data Study.

INTRODUCTION: Efficiency is one of the most important indicators of hospital performance evaluation. AIM: The study was conducted to measure the efficiency of public hospitals. MATERIAL AND METHODS: This was a cross-sectional and panel data study. Data were retrospectively collected using hospital records and hospital information system. In this study, panel data of 17 public hospitals affiliated with Ahvaz University of Medical Sciences, in southwest of Iran were studied during 2012-2016. The output-based data envelopment analysis technique and variable return to scale assumption (VRS) were used. Regression model was used to assess factors affecting hospital efficiency. Data were analyzed using Deap2.1 and R software. RESULTS: The mean of technical efficiency, managerial efficiency, and scale efficiency of the hospitals during 2012-2016 were 0.230, 0.272 and 0.732, respectively. Assessment of return to scale results over 5 years showed that 65% (11 cases) of hospitals had a decreasing return to scale, 24% (4 cases) had a constant return to scale, and 12% (2 cases) had an increasing return to scale. Also, mean of technical managerial, and scale efficiency in specialized hospitals were higher than other hospitals (0.331, 0.353, and 0.873). Beta regression analysis showed the effect of both variable length of stay and number of beds on hospital efficiency was significant (p-value <0.05).. CONCLUSIONS: The results showed that efficiency of selected public hospitals was the poor. Technical efficiency and managerial efficiency were lower than scale efficiency rate. Also, Multi- specialized hospitals were in critical status considering resource management and economies of scale.

Assessing Medical Tourism Services Quality Using SERVQUAL Model: A Patient's Perspective.

BACKGROUND: Continuous quality improvement of the hospital services is a basic requirement of medical tourism industry. The different dimensions of hospital services quality are assessed constantly to improve the service of medical tourism. The aim of this study was to determine the services quality of medical tourism in private and public hospitals. METHODS: In this cross-sectional study, the quality of hospital services were assessed in view of 250 Iraqi tourists referred to Ahvaz private and public hospitals in 2015. Data were collected using a valid medical tourism SERVQUAL questionnaire (MTSQ). This questionnaire includes 8 main dimensions with 31 items. Finally, Mann-Whitney, Kruskal-Wallis and Wilcoxon tests were used to analyze the data. RESULTS: The mean of age of patients was 39±2.2 yr. The mean of hospital length of stay was 3.87±1.36 days. The most patients were admitted to Orthopedics, Otorhinolaryngology, Obstetrics, and Gynecology departments, respectively. There was a negative gap in all of the dimensions of service quality in the studied hospitals (P>0.001). The highest and lowest quality gap was seen in the "exchange and travel facilities" (-2.63) and the "tangibles" (-0.68) dimension, respectively. CONCLUSION: There was a negative gap in all of the dimensions of service quality in the studied hospitals. Therefore, the hospital services quality is improved to attract the foreign patients.

Comparison of Responsiveness Level in Iranian Public and Private Physiotherapy Clinics: a Cross-Sectional Multi-center Study.

INTRODUCTION: Responsiveness is a main goal of health systems. Responsiveness focus on the non-medical aspects of health services delivery. This study was aimed to assess responsiveness level in public and private physiography clinics. METHODS: In this multicenter cross sectional study, 403 patients refers to 16 public and 64 private physical therapy clinics were studied randomly in Ahvaz, Iran, from 2013 to 2014. Data were collected based on a valid health system responsiveness questionnaire that was developed by WHO. Health system responsiveness questionnaire for outpatients care includes seven components and 25 questions. Statistical relationship between responsiveness level of centers and patients characteristics was analyzed using Pearson coefficient, Independent t-test and one-way ANOVA. RESULTS: Out of 403 patients, 299 (74.19%) patients were women. The mean (±SD) age of the patients was 42(±14.18) years and 92.1% of patients were 65> years. Responsiveness status in private and public physiotherapy clinics was assessed excellent (26.93±5.2) and very well (21.08±5.8) respectively. In private clinics, the mean score of communication dimension (3.96±1) and autonomy dimension (3.95±0.9) was higher than other dimensions. In public clinics the mean score of dignity (3.30±0.8), autonomy (3.16±0.9), and prompt attention (3.12±1) was higher than other areas respectively. In public and private clinics, quality of basic amenities area had the lowest score. CONCLUSIONS: The results showed that the some patients and center characteristics such as gender and work shift were factors affecting assessment of responsiveness. Responsiveness level in private centers was better than publics.

Validation of Medical Tourism Service Quality Questionnaire (MTSQQ) for Iranian Hospitals.

INTRODUCTION: Assessing service quality is one of the basic requirements to develop the medical tourism industry. There is no valid and reliable tool to measure service quality of medical tourism. This study aimed to determine the reliability and validity of a Persian version of medical tourism service quality questionnaire for Iranian hospitals. METHODS: To validate the medical tourism service quality questionnaire (MTSQQ), a cross-sectional study was conducted on 250 Iraqi patients referred to hospitals in Ahvaz (Iran) from 2015. To design a questionnaire and determine its content validity, the Delphi Technique (3 rounds) with the participation of 20 medical tourism experts was used. Construct validity of the questionnaire was assessed through exploratory and confirmatory factor analysis. Reliability was assessed using Cronbach's alpha coefficient. Data were analyzed by Excel 2007, SPSS version18, and Lisrel l8.0 software. RESULTS: The content validity of the questionnaire with CVI=0.775 was confirmed. According to exploratory factor analysis, the MTSQQ included 31 items and 8 dimensions (tangibility, reliability, responsiveness, assurance, empathy, exchange and travel facilities, technical and infrastructure facilities and safety and security). Construct validity of the questionnaire was confirmed, based on the goodness of fit quantities of model (RMSEA=0.032, CFI= 0.98, GFI=0.88). Cronbach's alpha coefficient was 0.837 and 0.919 for expectation and perception questionnaire. CONCLUSION: The results of the study showed that the medical tourism SERVQUAL questionnaire with 31 items and 8 dimensions was a valid and reliable tool to measure service quality of medical tourism in Iranian hospitals.

Comparison of Statistical Models of Predict the Factors Affecting the Length of Stay (LOS) in the Intensive Care Unit (ICU) of a Teaching Hospital.

INTRODUCTION: Modeling can be a useful tool to find out how the distributions of hospital length of stay (LOS) and the factors affecting the length of stay. The present study aims to determine factors affecting the length of stay and selecting suitable statistical models. MATERIAL AND METHOD: this is a cross - sectional study of 565 patients who were treated in the intensive care unit of Imam Khomeini hospital in Ahwaz. Preliminary data were collected retrospectively through the medical records of all patients admitted on intensive care units of Ahwaz Imam Khomeini Hospital in 2015. Statistical analysis and multivariate regression models were done using of SPSS 21 and STATA 7 software. RESULTS: Average length of stay in ICU was 8.16±0.75 days. The Mean and Median age of patients were 58.61±20 and 61 respectively, The Mean LOS for females (16.44±9.37 days) was more than the men (11.5±5.35 days) (p<0.01). The maximum and minimum lengths of stay belonged to patients with endocrine disorders (14.7±3.1 days) and patients with gastrointestinal disorders (5.53±1.1 days) respectively (p<0.01). The goodness of fit for Gamma model showed that this model was more suitable and powerful than Log-normal model to predict the factors affecting the patient's length of stay in intensive care units of hospital. CONCLUSION: Gamma regression model was more robust to predict factors regarding the hospital length of stay. According to Gamma model the key factor in predicting the length of stay in ICU was the type of disease diagnosis. The result of statistical modeling can help managers and policy makers to estimate hospital resources and allocate them for different hospital services.

Cost Analysis of Hospitalized Patients with Chronic Obstructive Pulmonary Disease: A State-Level Cross-Sectional Study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common disease with important healthcare, social, and economic consequences. The aim of this study was to analyze the costs of hospitalizing patients with COPD. MATERIALS AND METHODS: In this state-level cross-sectional study, data from 165 COPD patients who had presented to our hospital between April 1, 2011 and March 31, 2013 were reviewed retrospectively. Patients were eligible for inclusion if they had a diagnosis of COPD [international classification of diseases-10 (ICD-10) code J44]. Costs of COPD patients were calculated by multiplying the amount of services used by the unit cost. Finally, we used multivariate regression analysis to determine predictors of hospital costs. RESULTS: Mean (SD) age of the patients was 68.6 ± 12 years and 65.5% of them were ≥ 65. The mean (SD) and median length of stay (LOS) for patients were 8.5 ± 11.5 and five days [IQR 3; 9], respectively. All hospital cost drivers had significant relationships with LOS, and the mean cost per patient was higher in patients with hospital LOS longer than nine days. Prolonged LOS (LOS > 9 days) involved 830 bed/days. Therefore, the mean cost per each extra day of hospital stay was estimated to be US $115.80. The mean costs per patient with and without hypertension were US $1,422.5 and US $627.4, respectively (P=0.017). CONCLUSION: Hospitalization and medication costs were the two major cost drivers for patients hospitalized with COPD exacerbation. Duration of hospital stay, history of hypertension, and the number of clinical consultations other were significant predictors associated with hospital cost in patients with COPD.

Bed Capacity Planning Using Stochastic Simulation Approach in Cardiac-surgery Department of Teaching Hospitals, Tehran, Iran.

BACKGROUND: To determine the hospital required beds using stochastic simulation approach in cardiac surgery departments. METHODS: This study was performed from Mar 2011 to Jul 2012 in three phases: First, collection data from 649 patients in cardiac surgery departments of two large teaching hospitals (in Tehran, Iran). Second, statistical analysis and formulate a multivariate linier regression model to determine factors that affect patient's length of stay. Third, develop a stochastic simulation system (from admission to discharge) based on key parameters to estimate required bed capacity. RESULTS: Current cardiac surgery department with 33 beds can only admit patients in 90.7% of days. (4535 d) and will be required to over the 33 beds only in 9.3% of days (efficient cut off point). According to simulation method, studied cardiac surgery department will requires 41-52 beds for admission of all patients in the 12 next years. Finally, one-day reduction of length of stay lead to decrease need for two hospital beds annually. CONCLUSION: Variation of length of stay and its affecting factors can affect required beds. Statistic and stochastic simulation model are applied and useful methods to estimate and manage hospital beds based on key hospital parameters.

Multivariate Analysis of Factors Influencing Length of Hospital Stay after Coronary Artery Bypass Surgery in Tehran, Iran.

Length of hospital stay (LOS) is a key indicator for hospital management. Reducing hospital stay is a priority for all health systems. We aimed to determine the length of hospital stay following Coronary Artery Bypass Surgery (CABG) based on its clinical and non-clinical factors. A cross-sectional study of 649 consecutive patients who underwent coronary artery bypass graft surgery was conducted in Imam Khomeini and Shariati university hospitals, Tehran, Iran. Data was analyzed by using non-parametric univariate tests and multiple linier regression models. Thirty seven independent variables including pre-operative, intra-operative and post-operative variables were analyzed. Finally, an appropriate model was constructed based on the associated factors. The results showed that 70.3% of the patients were male, and the mean age of the patients was 59.3 ± 10.4 years. The Mean (±SD) and median of the LOS were 11.7 ± 7.1 and 9 days, respectively. Of 37 investigated variables, 24 qualitative and quantitative variables were significantly associated with length of stay (p<0.05). Multiple linear regression analysis showed that independent variables including age, medical insurance type, body mass index, and prior myocardial infarction; admission day, admission season, Cross-clamp time, pump usage, admission type, the number of laboratory tests and the number of specialty consultation had more effect on the hospital stay. We concluded that some significant factors influencing hospital stay after CABG were predictable and modifiable by hospital managers and decision makers to manage hospital beds.

Hospitals Productivity Measurement Using Data Envelopment Analysis Technique.

BACKGROUND: This study aimed to measure the hospital productivity using data envelopment analysis (DEA) technique and Malmquist indices. METHODS: This is a cross sectional study in which the panel data were used in a 4 year period from 2007 to 2010. The research was implemented in 12 teaching and non-teaching hospitals of Ahvaz County. Data envelopment analysis technique and the Malmquist indices with an input-orientation approach, was used to analyze the data and estimation of productivity. Data were analyzed using the SPSS.18 and DEAP.2 software. RESULTS: Six hospitals (50%) had a value lower than 1, which represents an increase in total productivity and other hospitals were non-productive. the average of total productivity factor (TPF) was 1.024 for all hospitals, which represents a decrease in efficiency by 2.4% from 2007 to 2010. The average technical, technologic, scale and managerial efficiency change was 0.989, 1.008, 1.028, and 0.996 respectively. There was not a significant difference in mean productivity changes among teaching and non-teaching hospitals (P>0.05) (except in 2009 years). CONCLUSION: Productivity rate of hospitals had an increasing trend generally. However, the total average of productivity was decreased in hospitals. Besides, between the several components of total productivity, variation of technological efficiency had the highest impact on reduce of total average of productivity.

Factors affecting family physicians' drug prescribing: a cross-sectional study in Khuzestan, Iran.

BACKGROUND: Rational prescription is a considerable issue which must be paid more attention to assess the behavior of prescribers. The aim of this study was to examine factors affecting family physicians' drug prescribing. METHODS: We carried out a retrospective cross-sectional study in Khuzestan province, Iran in 2011. Nine hundred eighty-six prescriptions of 421 family physicians (including 324 urban and 97 rural family physicians) were selected randomly. A multivariate Poisson regression was used to investigate potential determinants of the number of prescribed drug per patient. RESULTS: The mean of medication per patient was 2.6 ± 1.2 items. In the majority (91.9%) of visits a drugs was prescribed. The most frequent dosage forms were tablets, syrups and injection in 30.1%, 26.9%, and 18.7% of cases respectively. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and antibiotics were 29.7% and 17.1% of prescribed drugs respectively. The tablets were the most frequent dosage forms (38.6% of cases) in adult's patients and syrups were the most frequent dosage forms (49% of cases) in less than 18 years old. Paracetamols were popular form of NSAIDs in two patients groups. The most common prescribed medications were oral form. CONCLUSION: In Khuzestan, the mean of medication per patient was fewer than national average. Approximately, pattern of prescribed drug by family physicians (including dosage form and type of drugs) was similar to other provinces of Iran.

A study on the direct and indirect costs of multiple sclerosis based on expanded disability status scale score in khuzestan, iran.

BACKGROUND: Multiple sclerosis is a common and chronic neurologic disorder. This disorder imposes physical, economic, and psychosocial burden on individuals, their families and society. This study aims to analyze the costs of multiple sclerosis disease based on the severity of disability. METHODS: We performed a cross-sectional cost of illness study. This study was conducted in 332 patients of Khuzestan province of Iran. Data were included: Patient's characteristics, disability status, medical, and nonmedical costs and were gathered by using the questionnaire during 3 months period. Costs analysis was performed in the basis of expanded disability status scale (EDSS). Data were analyzed by using SPSS 18 software. RESULTS: Mean age of the patients was 33.5 (standard deviation [SD]: 9.1) and 70.5% of patients were female. Mean EDSS score of the patients was 2.2 (SD: 1.6). Most patients (92.1%) had relapsing remitting multiple sclerosis (MS) form of the disease. Costs mean per patients was 8.6 ± 7.9 million Rial. The direct and indirect costs were 93.1% and 6.9% of total costs, respectively. The major cost of the disease belongs to the pharmaceutical treatment (22% of costs). The majority costs (approximately 62%) attributed to EDSS of 6-7 and >7. Furthermore, there was strong significant relationship between cost of illness and disability severity of patients (P < 0.05). CONCLUSIONS: Cost mean per MS patients was relatively high. Furthermore, the results showed that cost of disease had positive and significant relationships with EDSS score that is, progression of disability increase costs of patients.