Is lifestyle modification with individual face-to-face education and counseling more effective than usual care for controlling hypertension? A systematic review and meta-analysis of randomized controlled trials.

Hypertension (HTN) management continues to be a concern due to challenges with behavioral risk factors. Patient education to modify unhealthy behaviors appears to be effective in managing HTN. Therefore, this meta-analysis aimed to determine whether individualized face-to-face education and counseling have a beneficial effect on systolic and diastolic blood pressure (SBP and DBP) in hypertensive patients. Studies were extracted from PubMed, Scopus, Cochrane Library, and Web of Science databases. Nine studies, comprising 2627 participants, were included. Random effects models were used to pool estimates of mean differences (MDs) with 95% confidence intervals (CIs) in SBP and DBP between the intervention and usual care groups. SBP and DBP were significantly reduced at the 6-month (MD = -4.38 mmHg, 95% CI: -6.95 to -1.81; MD = -2.09 mmHg, 95% CI: -3.69 to -0.50, respectively) and 12-month time points (MD = -2.48 mmHg, 95% CI: -3.96 to -1.01; MD = -1.71 mmHg, 95% CI: -2.88 to -0.55, respectively) with intervention. At the 24-month time point, there was a significant change in SBP (MD = -2.13 mmHg, 95% CI: -3.94 to -0.32) with intervention compared with the usual care group. This study showed that individualized face-to-face education and counseling add significant benefits to usual care for lowering blood pressure in hypertensive patients. Graphical Abstract.

Payment systems for dialysis and their effects: a scoping review.

BACKGROUND: End stage renal disease (ESRD) is a major health concern and a large drain on healthcare resources. A wide range of payment methods are used for management of ESRD. The main aim of this study is to identify current payment methods for dialysis and their effects. METHOD: In this scoping review Pubmed, Scopus, and Google Scholar were searched from 2000 until 2021 using appropriate search strategies. Retrieved articles were screened according to predefined inclusion criteria. Data about the study characteristics and study results were extracted by a pre-structured data extraction form; and were analyzed by a thematic analysis approach. RESULTS: Fifty-nine articles were included, the majority of them were published after 2011 (66%); all of them were from high and upper middle-income countries, especially USA (64% of papers). Fee for services, global budget, capitation (bundled) payments, and pay for performance (P4P) were the main reimbursement methods for dialysis centers; and FFS, salary, and capitation were the main methods to reimburse the nephrologists. Countries have usually used a combination of methods depending on their situations; and their methods have been further developed over time specially from the retrospective payment systems (RPS) towards the prospective payment systems (PPS) and pay for performance methods. The main effects of the RPS were undertreatment of unpaid and inexpensive services, and over treatment of payable services. The main effects of the PPS were cost saving, shifting the service cost outside the bundle, change in quality of care, risk of provider, and modality choice. CONCLUSION: This study provides useful insights about the current payment systems for dialysis and the effects of each payment system; that might be helpful for improving the quality and efficiency of healthcare.

Iranian medical students' tendency to migrate and its associated factors.

BACKGROUND: Medical staff migration is one of the challenges for both developed and developing countries affecting society's health and welfare, which limits access to equity. Therefore, this study was designed and conducted to investigate the tendency to migrate and the factors affecting it among medical students of the Tehran University of medical sciences, Tehran, Iran, in 2019. METHODS: This cross-sectional study was performed among 472 medical students using a valid questionnaire which was designed after reviewing the literature and using the opinions of experts. The tendency to migrate and its associated factors were analyzed and reported using the Pearson correlation test, independent t-test, one-way ANOVA test, Tukey post-hock test, and Kruskal-Wallis non-parametric test. RESULTS: According to this study, the tendency to migrate was 6.13 ± 2.82 out of 10. While there was no significant relationship between age, marital status, medical educational phase and the tendency to migrate (p > 0.05); There was a significant relationship between willingness to migrate with variables of gender (p = 0.027), pre-university study region (p < 0.001), father's academic degree (p = 0.007), mother's academic degree (p < 0.001), having the relative abroad (p < 0.001), foreign trip experience (p < 0.001), foreign language skills (p < 0.001), number of published articles (p = 0.005) and Iran's National Elite Foundation membership (p = 0.039). CONCLUSIONS: Females, elites, and those with higher socioeconomic state, previous exposure to foreign countries, the ability to speak foreign languages, and research activity are more likely to migrate. Considering the high tendency to migrate among Iranian medical students, urgent and severe strategies must be undertaken to solve this social and health problem.

Health related quality of life in adults with asthma: a systematic review to identify the values of EQ-5D-5L instrument.

INTRODUCTION: The EQ-5D is the most popular generic preference-based instrument used for asthma patients. This study aims to explore the psychometric properties of the EQ-5D-5L instrument in patients with asthma and identify the EQ-5D-5L scores in these patients. METHOD: PubMed, Scopus, Web of Science, Google Scholar and CEA Registry were searched with English language from 2009 until April 2020. Retrieved studies were checked against the inclusion criteria. Reference lists of the included articles were also reviewed. The quality of included articles was evaluated using Mitton checklist and the data were extracted by a reviewer and were checked by a second reviewer. Meta-analysis was done to calculate the overall scores based on type of asthma control. RESULTS: A total of 17 articles were included. The EQ-5D-5L scores ranged from 0.45 to 0.93 and the VAS scores ranged from 35.67 to 83.80. The EQ-5D-5L is higher in well-controlled (0.88, 95% CI: 0.81-0.96, P = 0.0001) than partly controlled (0.80, 95% CI: 0.74-0.85, P = 0.001) and poorly controlled asthma (0.72, 95% CI: 0.67-0.77, P = 0.01). Validity in two studies was weak and, in other studies, it was moderate to strong. Responsiveness of the EQ-5D-5L, that was shown in a study, was less than other generic instruments, and reliability was adequate in only study that had been reported. Ceiling effects were between 8.30% to 35%. CONCLUSION: Higher score of the EQ-5D-5L was consistent with well-controlled asthma patients and those with lower severity of asthma. The assessment of psychometric properties of the EQ-5D-5L needs further observations.

Methods and criteria for the assessment of orphan drugs: a scoping review.

OBJECTIVES: This study aimed to identify different criteria for priority setting of rare diseases to help policy makers in making evidence-informed decisions. METHODS: A scoping review was conducted to comprehensively examine the existing various methods and criteria for prioritizing orphan drugs and rare diseases. We performed searching in Scopus, PubMed, Embase, and websites of health technology assessment (HTA) agencies, 2000-21, and data were extracted. RESULTS: From the 1,580 identified publications, eleven articles were included. Multicriteria decision analysis was the most frequent method (seven out of eleven studies) used for priority setting. The extracted criteria for priority setting of orphan products were analyzed based on six main categories as follows: health outcomes and clinical implications (six subsets which showed clinical implications), economic aspects (four subsets that indicated the economic effects of orphan drugs and rare diseases), disease and population characteristics (six subsets that included the characteristics of the rare diseases), therapeutic alternatives and uniqueness of orphan technologies (two subsets which discussed the alternatives and uniqueness of orphan technologies), evidence (three subsets which regarded the quality and availability of evidence), and other criteria (three subsets dealing with social and organizational criteria). Cost-effectiveness, budget impact, and disease severity were the most frequent criteria in the studies. CONCLUSIONS: Because of the high price of orphan drugs and limitations of using HTA for reimbursement of them, it is critical to explore them by precise technical methods like multiple criteria decision making in priority setting.

Responsiveness of hospitals to inpatient and outpatient services in the low- and middle-income countries: A systematic review.

Responsiveness is the ability of health system to satisfy non-clinical people's expectations. This review aimed at assessing responsiveness of hospitals' services in the low- and middle-income countries, and identifying the influencing factors. This systematic review followed the PRISMA guidelines. PubMed, Scopus, Web of Science and ProQuest were searched. Studies of all designs aiming to assess responsiveness of hospitals' services in the period from 2005 up to the end of 2018 were included. Quality was appraised based on McMaster University tool. Results were presented as a narrative review. Fifteen studies originated from five low-middle- income countries have been included. Results have been proposed under five subtopics; level and distribution of responsiveness and its domains at hospitals, rank of domains according to the participants, and factors affecting responsiveness and its related domains. Most studies have focused on responsiveness level, but not the distribution. Socioeconomic status, organisational, systemic, and contextual factors have led to varied responsiveness, consequently, policymakers would benefit from these valuable results while planning for improving health system in order to accomplish its intrinsic goals. Further research is required in the low- and middle-income countries other than the five included in this review. Using the World Health Organization questionnaires for measuring responsiveness is recommended, and the contextual variations should be considered.

Adaptation Frameworks for Clinical Guidelines and Proposing a Framework for Iran: A Review and Comparative Study.

Background: Clinical Practice Guidelines (CPGs) can be adapted to local conditions to prevent any resources from being wasted. Adaptation of CPGs implies a systematic view of developed guidelines through maintaining evidence-based principles in order to find the ones most relevant with patients' conditions and its integration with the cultural and regional requirements of the target population and health system facilities. The main purpose of the study was to describe, interpret and compare different frameworks for adaptation of clinical guidelines and proposing a comprehensive framework for Iran. Methods: This study was based on a review and comparative analysis of adaptation frameworks of CPGs. Initially, all adaptation frameworks were collected by systematic search in the literature. We searched the following electronic databases: PubMed, Scopus, Trip Database, Science Direct, and Google Scholar. Then, based on the stages of the comparative study, frameworks were described, interpreted, juxtaposed, and compared. Finally, a comprehensive framework for the adaptation of clinical guidelines was proposed by consulting a panel of experts. Results: Our literature search resulted in 26 frameworks, of which 18 were potentially relevant. Based on inclusion/exclusion criteria, nine frameworks were included in the study and have been described, interpreted, and compared. The proposed comprehensive framework for the adaptation of clinical guidelines consists of ten main steps. Conclusion: The proposed comprehensive framework is an appropriate tool for the adaptation of clinical guidelines in Iran that can be used in other countries. However, further validation of the framework requires case studies and expert consultation to determine its application to the adaptation of clinical guidelines.

Cost per DALY averted in low, middle- and high-income countries: evidence from the global burden of disease study to estimate the cost-effectiveness thresholds.

BACKGROUND: Determining the cost-effectiveness thresholds for healthcare interventions has been a severe challenge for policymakers, especially in low- and middle-income countries. This study aimed to estimate the cost per disability-adjusted life-year (DALY) averted for countries with different levels of Human Development Index (HDI) and Gross Domestic Product (GDP). METHODS: The data about DALYs, per capita health expenditure (HE), HDI, and GDP per capita were extracted for 176 countries during the years 2000 to 2016. Then we examined the trends on these variables. Panel regression analysis was performed to explore the correlation between DALY and HE per capita. The results of the regression models were used to calculate the cost per DALY averted for each country. RESULTS: Age-standardized rate (ASR) DALY (DALY per 100,000 population) had a nonlinear inverse correlation with HE per capita and a linear inverse correlation with HDI. One percent increase in HE per capita was associated with an average of 0.28, 0.24, 0.18, and 0.27% decrease on the ASR DALY in low HDI, medium HDI, high HDI, and very high HDI countries, respectively. The estimated cost per DALY averted was $998, $6522, $23,782, and $69,499 in low HDI, medium HDI, high HDI, and very high HDI countries. On average, the cost per DALY averted was 0.34 times the GDP per capita in low HDI countries. While in medium HDI, high HDI, and very high HDI countries, it was 0.67, 1.22, and 1.46 times the GDP per capita, respectively. CONCLUSIONS: This study suggests that the cost-effectiveness thresholds might be less than a GDP per capita in low and medium HDI countries and between one and two GDP per capita in high and very high HDI countries.

The impact of common chronic conditions on health-related quality of life: a general population survey in Iran using EQ-5D-5L.

BACKGROUND: Diseases have undeniable effects on Health-Related Quality of Life (HRQoL). Chronic diseases, in particular, limit the productive potentials and HRQoL of individuals. EQ-5D is a very popular generic instrument, which can be used to estimate HRQoL scores in any diseases. The current study investigates mean HRQoL scores in certain chronic diseases and examines the relationship between utility scores and chronic diseases in Iran. METHOD: This cross-sectional study was carried out among the general adult population of Tehran. 3060 individuals were chosen by a stratified probability sampling method. The EQ-5D-5L questionnaire was applied. The utility scores were estimated using the Iranian crosswalk-based value set. The effect of chronic diseases on the HRQoL scores was derived by the Ordinary Least Squares (OLS) method. Data was analyzed using Stata version 13 software. RESULTS: The mean ± standard deviation utility and EQ-VAS scores were 0.85 ± 0.14 and 76.73 ± 16.55 in the participants without any chronic conditions. The scores were 0.69 ± 0.17 and 61.14 ± 20.61 in the participants with chronic conditions. The highest and lowest mean utility scores were related to thyroid disease (0.70) and Stroke (0.54), respectively. Common chronic conditions had significant negative effects on the HRQoL scores. Stroke (0.204) and cancer (0.177) caused the most reduction in the EQ-5D-5L utility scores. Lumbar disc hernia, digestive diseases, osteoarthritis, breathing problems, and anxiety/nerves cause 0.133, 0.109, 0.108, 0.087, and 0.078 reductions, respectively, in the EQ-5D-5L utility scores. CONCLUSION: This study provides insight into some common chronic conditions and their effects on the HRQoL. Policymakers and planners should pay attention to the effects of chronic conditions especially high prevalence one. They should adopt effective interventions to control this issue and increase health. The results of this study can also be beneficial in economic evaluation studies.

Application of discrete choice experiments to estimate value of life: a national study protocol in Iran.

BACKGROUND: Global concerns regarding the significant burden of non-communicable diseases and injuries (NCDIs) exist from both public health and economic perspectives. Our research focuses on the reduction of fatal risks due to NCDIs and the citizens' preferences about health programs and intervention to reduce premature death due to NCDIs. Governments and health authorities need reliable evidence and information to prioritize the interests of their citizens. One crucial piece of evidence to justify the resources spent on NCDIs is the value derived from the interventions on prevention and NCDIs control. This concept is usually called "Value of Statistical Life" (VSL), meaning the monetary value that individuals place on changes in the risk levels of life- threatening events. To the best of our knowledge, for the first time, our study will estimate the statistical value of life for selected interventions for the prevention and control of NCDIs at both national and sub-national levels in the context of Iran. This paper reports the development of a national protocol through Discrete Choice Experiments (DCEs) method. METHODS AND DESIGNS: Our study comprises several stages: (a) a literature review to identify the attributes and levels of the prevention programs and Willingness to Pay (WTP) for reducing the NCDI's fatal risks; (b) experimental design to assessing, prioritizing, and finalizing the identified attributes and levels; (c) instrumental design to conduct face-to-face structured survey interviews of 3180 respondents aged 18-69 across the entire country; (d) statistical analysis to estimate the results through the Mixed Multinomial logit (MMNL) model. DISCUSSION: We anticipate that our findings will help build a stronger empirical basis for monetizing the value of small changes in selected fatality risks. It paves the way for other national or vast VSL estimates for NCDIs, as well as other major causes of morbidity and mortality in the context of Iran, and perhaps other low and middle-income countries (LMICs).

Economic burden of medication-overuse headache in Iran: direct and indirect costs.

BACKGROUND AND OBJECTIVE: Medication-overuse headache (MOH) as a secondary chronic headache imposes a considerable burden on both individuals and societies. Nevertheless, little is known about the burden of MOH in Iran. Therefore, in the current study, we aimed to quantify the annual cost of MOH among Iranian patients. METHODS: In this cross-sectional study, 84 patients were recruited. Demographic data, headache attack characteristics, related disability, and information about the economic burden of MOH were collected through face-to-face interview. Direct medical and nonmedical costs as well as indirect costs were included in our cost analysis. The prevalence-based approach was applied to estimate the economic burden of MOH. RESULTS: We found that MOH patients in Iran spend averagely $1046 for medical services, $132 for nonmedical services, and $1432 due to lost productivity per year. The per-person annual cost of MOH was US$2610, and the total annual cost for Iran was $10,179,000,000, with direct and indirect cost accounting for 45% and 55%, respectively. CONCLUSION: MOH leads to substantial healthcare costs and significant loss of productivity in Iran. Therefore, raising awareness in this area especially for policymakers can use in future health planning and lead to resource allocation in the field of disabling type of headache disorders such as MOH. Our findings also provide a different insight into the burden of MOH, which are likely closer to the actual costs in middle- and low-income countries, and also it could be a sample of such a study in western Asia.

Assessing progress in the national health financing system towards universal health coverage in Iran: a mixed-method study protocol.

INTRODUCTION: Health financing systems have a key role in achieving universal health coverage (UHC) across the globe. However, little is known about how best to monitor health financing system progress towards UHC, especially in low- and middle-income countries. This is a protocol of a study that will aim to assess health financing system progress towards achieving UHC in Iran. METHODS: An explanatory mixed-method approach will be used in two phases. In the quantitative phase, the performance of the Iranian health financing system will be assessed using a well-established set of indicators to draw on progress over 5-year intervals starting in the year 2000 up to the present. Data will be extracted from the global health expenditure database using a specific form and will be classified in accordance with each indicator. A qualitative phase will then take place considering the Kutzin et al. framework and by using health financing progress matrices. The qualitative phase will consist of two successive stages; first, a descriptive overview on the major health coverage schemes along with key attributes of each scheme. This initial mapping will be the underlying background for the second stage. In the second stage, the matrices comprised of a series of questions and relevant to the core functions of health financing and cross-cutting options will be invested in enhancing the evaluation of the ongoing reforms or policies. In this phase, data will be collected by reviewing national policy documents and in-depth interviews with key informants who will be recruited using purposive sampling. Finally, a policy discussion with key stakeholders will be held in order to review and verify the consistency between the current health financing policy and UHC goals. DISCUSSION: This study will provide a comprehensive image about the current status of the national health financing system progress towards achieving UHC in Iran. Such assessment will give detailed insight about the performance of the current financing system through identifying encountered challenges. Furthermore, some other defects in the design of the financing system are expected to appear. In all likelihood, the results will be fruitful enough to make informed decisions about interventions and policies in relation to UHC. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics Committee for Research at Tehran University of Medical Sciences. Informed consent will be obtained from all key informants and the data will be collected and transcribed anonymously in order to maintain utmost confidentiality. The results will be disseminated in peer-reviewed journals and presented in national and international conferences and meetings.

Assessment of public hospitals performance in Gaza governorates using the Pabón Lasso Model.

BACKGROUND: Measuring hospital performance can be undertaken in different areas including efficiency, productivity, and quality. Many studies have been conducted using several indicators in this regard. AIM: This study aimed at measuring efficiency of obstetrics and gynaecology, and paediatrics departments at the public hospitals affiliated with the Palestinian Ministry of Health in 2016, 2017 and 2018. METHOD: This descriptive study includes 12 hospitals; four (A-D) and eight (E-L) providing obstetrics and gynaecology, and paediatrics services, respectively. Data were collected from health annual reports for the 3-year study period. Pabón Lasso charts were drawn using Microsoft Excel 2013. RESULTS AND CONCLUSION: During the 3 years, hospitals B, D and C lied in zones 3, 1 and 2, respectively. Hospital A was in Zone 4 in 2016 and 2018, but in Zone 1 in 2017. In 2016, hospitals E, F and H were in Zone 3, while, hospitals I, J, K, and L were in Zone 1. In 2017, hospital G shifted from Zone 2 to Zone 3, and backed to Zone 2 in 2018. Hospital L has moved from Zone 1 to Zone 2 in 2018, whereas other hospitals have remained in the same zones. Inefficiency in hospitals provides an important opportunity for addressing the gaps in a quality and less costly manner. Emphasis antenatal care in primary healthcare is important. Further researches are required to cover other types of hospitals through employing frontier techniques of efficiency measurement.

Health-related quality of life measured using the EQ-5D-5 L: population norms for the capital of Iran.

OBJECTIVES: EQ-5D is the most commonly used generic preference-based health-related quality of life (HRQoL) measure. The current study aimed at estimating the HRQoL index scores using EQ-5D-5 L measure in the capital of Iran; moreover, identifying some determinants of the HRQoL. METHODS: A sample of 3060 subjects was selected by a stratified random sampling method from the general adult population of Tehran. Face-to-face interview was conducted to fill out the questionnaire, in this cross-sectional survey. EQ-5D-5 L utility score were estimated using an interim value set, based on a crosswalk methodology. Additionally, the relationships between HRQoL and sociodemographic characteristics were tested by generalized linear model, using STATA version 13. RESULTS: The mean ± standard deviation utility and EQ-VAS scores were 0.79 ± 0.17 and 71.72 ± 19.37. The utility scores ranged 0.61 ± 0.19 in > 69 year-old females to 0.88 ± 0.12 in < 30 year-old males. In mobility, self-care, and usual activity dimensions, most of the respondents reported "no problems" (70.47, 90.62, and 76.34%, respectively). However, in anxiety/depression and pain/discomfort dimensions, most of the respondents had problems (53.23 and 54.03%, respectively). Females had lower utility score than males; the utility score reduced with age increase; the educational level lead to higher utility scores; and the utility scores of individuals without spouse (divorced or widowed) were lower than those of the married individuals and never married ones. CONCLUSIONS: The current study reported HRQoL norm data for the general adult population in the capital of Iran; these data could be very useful for policy making and economic evaluations. A significant percentage of people in Tehran reported anxiety/ depression, which highlights the risk of psychological problems. Effective interventions are needed to increase their HRQoL, especially for the vulnerable groups of the community.

Cost-consciousness among Iranian internal medicine residents.

Background: Study aimed at assessing residents' cost awareness and their attitude about health care costs.Methods: Internal medicine residents at teaching hospitals of Tehran University of Medical Sciences were surveyed during August-December 2016 using a researcher-made questionnaire comprising attitude statements and cost estimation of diagnostic and treatment items.Results: Eighty-nine residents completed the survey (response rate = 56.6%). The results indicate that less than one quarter (23.69%) of cost estimates were in the range of correct answers. The mean (SD) for correct estimation of medications (out of 8 scores), lab tests (out of 20 scores), and total (out of 35 scores) were 1.25 (0.96), 4.92 (0.27), and 7.97 (0.34), respectively. An analysis of variance showed that the level of residency was positively correlated with residents' correct cost estimation (F (3, 77)=9.98, p = 0.029). There was a significant positive correlation between age of residents with the correct estimate of medication prices (p = 0.018, r = 0.261).Conclusions: The internal medicine residents of Tehran University of Medical Sciences have poor knowledge of health care costs, including medications, diagnostic tests, and hospitalization costs. The results of this study explain the necessity of developing a training program for the transfer of cost information to physicians.

Capacity of Palestinian primary health care system to prevent and control of non-communicable diseases in Gaza Strip, Palestine: A capacity assessment analysis based on adapted WHO-PEN tool.

The prevalence of non-communicable diseases (NCDs) are increasing in low-income countries including Palestine. This study was conducted to assess the capacity of Palestinian primary health care system to prevent and control of NCDs. This cross-sectional study in which, the World Health Organization package of essential NCDs interventions (WHO-PEN) tool, was used to assess the capacity of primary health care centers (PHCs) to prevent and control of NCDs. All governmental PHCs (n = 52) in Gaza Strip, Palestine were included in the final analysis. The centers readiness score was calculated as the average of domains indices. Then, the indices were compared to an agreed cutoff at 70%. Statistical analysis was performed using SPSS version 22. Out of 52 PHCs, only 21 (40.4%) were considered ready to prevent and control of NCDs; the highest readiness score was 79.4% and the lowest score was 29.2%. Furthermore, all governorates were not ready to prevent and control of NCDs (The readiness scores were < 70%), distributed as follow: 68.6%, 68.1%, 67.7%, 62.5% and 56.4%, for Rafah, Gaza, Khan-Yunis, Deir Al Balah and North Gaza, respectively. The governorates were differed significantly in terms of availability of aneroid blood pressure measuring devices, electrocardiography devices, Glibenclamide and Salbutamol tablets, patients counseling for diabetes self-management, patients education for self-administration of insulin (P values <.05 for all). The current study demonstrated critical gaps in the governmental PHCs capacity to prevent and control of NCDs, as most of PHCs failed to reach the minimum threshold of the WHO-PEN standards.

Extent and nature of dual practice engagement among Iran medical specialists.

BACKGROUND: Dual practice (DP) by medical specialists is a widespread issue across health systems. This study aims to determine the level of DP engagement among Iran's specialists. METHODS: A pre-structured form was developed to collect the data about medical specialists worked in all 925 Iran hospitals in 2016. The forms were sent to the hospitals via medical universities in each province. The data were merged at the national level and matched using medical council ID codes, national ID codes, and eventually a combination of the first name, surname, and father's name. RESULTS: A total of 48 345 records were collected for 30 273 specialists from 858 (93%) hospitals out of total 925 hospitals. Sixteen thousand eight hundred forty-nine (69% of) specialists were non-faculty members and 6317 (26% of) specialists were employed on a contract basis. Eleven thousand six hundred and thirty-eight (47.7% of) specialists were engaged in DP on total. Female specialists had 0.78 times less DP chance; faculties compared to non-faculties had 0.65 times more DP chance and full-time geographic specialists compared to non-full-time specialists had 0.15 times more DP chance. DP was more frequent in specialists with higher age and more job experience and in provinces with more population, deprivation, and higher number of specialists per facility (P < 0.05). CONCLUSIONS: The level of DP is relatively high among Iran medical specialists, especially in geographic full-time specialists. However, they are totally banned and they receive extra payment for being full-time; restrictive regulations and financial incentives without considering other factors might not eliminate DP in specialists and it should be addressed based on conditions of each country and regions inside the country.

Factors influencing medical specialists' dual practice in the Islamic Republic of Iran.

BACKGROUND: Dual practice (DP) is performing several different jobs at the same time and has effects on healthcare services delivery. AIMS: To identify the causes of medical specialists' tendency towards DP in the Islamic Republic of Iran. METHODS: We used a qualitative approach to identify the factors affecting DP in medical specialists in 2016. We used a purposive and outlier sampling method to conduct semistructured deep interviews with 14 key informants. The data analysis was performed simultaneously with data collection using thematic content analysis by MAXQDA (version 10.0). Interviews continued up to data saturation. The quality of the study was ensured by addressing the criteria of Guba and Lincoln. RESULTS: The results of the interviews showed six themes and 16 subthemes for specialists' propensity to DP. Major themes included financial incentives, cultural attitudes about professional identity of physicians, experience and academic level of specialists, controlling approaches in the public sector, available infrastructure for responding to the population needs in the public sector, and regional characteristics of health service locations. CONCLUSIONS: Medical specialists' DP is a multidimensional issue, influenced by different factors such as financial incentives, cultural attitudes and available infrastructure. Considering the capacities and conditions of each country, control and management of this phenomenon require regulatory and incentive mechanisms, which in the long term can modify private and public sector differences and increase the willingness of doctors to work in the public sector.

Effect of dual practice on service delivery time by surgeons in the Islamic Republic of Iran: multi-level analysis of a national survey, 2016.

BACKGROUND: One of the work patterns which affects the supply of specialists is the phenomenon of dual practice (DP), i.e., working simultaneously in the public and private sectors. Uncontrolled DP in the surgery health workforce can have adverse effects on access to surgeons, efficiency, effectiveness and quality of surgery services. AIMS: The aim of this article is to examine the impact of DP on service delivery time by surgeons. METHODS: We used a prestructured form to collect data on surgery specialists in all 925 Iranian hospitals. National medical ID codes, council ID codes, first name, surname and father's name were used for data matching. Multilevel linear regression was used to assess the association between DP and study variables, which were recruitment type, faculty status, experience, sex and age. RESULTS: The 4642 surgery specialists in this study, representing 31.08% of the total number of surgeons identified, spent mean 1.09 (standard deviation 0.33) hours full-time equivalent (FTE) on health care service delivery. Specialists with DP had long service delivery time (ß = 0.427). Female specialists (ß = -0.049) and full-time specialists (ß = -0.082) spent less time on health care service delivery. Permanent specialists had higher FTE (P < 0.001) and as the population increases, FTE increases (P < 0.05). CONCLUSIONS: Although DP had a direct impact on surgeons' working hours, it seems that a greater share of the difference in working time was used in the private sector services, leading to poor access to surgery services in the public sector. Therefore, it is necessary to develop a systems approach to regulate DP.

Developing attributes and levels for a discrete choice experiment on basic health insurance in Iran.

Background: Nonmarket stated preferences valuation, especially discrete choice experiments (DCEs), is one of the commonly used techniques in the health sector. The primary purpose of this approach is to help select attributes and attributes-levels that are able to properly describe health care products or services. This study aimed at developing attributes and attributes-levels for basic health insurance system in Iran. Methods: This study was conducted in 3 phases. First, narrative review was performed to identify related attributes. Also, 9 experts were interviewed to identify relevant attributes of health insurance in context. Other 36 experts rated the attributes and levels. Then, the research team decided on the inclusion of attributes and levels in the final design. The design was constructed using generic and Defficient method with SAS 9.1. The design was divided into 3 blocks, each having 8 choice sets. Finally, the choice set was piloted with 45 participants. Results: Public hospitals, and private hospitals benefits, dental insurance coverage, inpatient benefits, rehabilitation therapy, and paraclinical benefits, long-term care, medical devices benefits (Ortez, Protez, etc.), and monthly premium were identified and included in the final attribute design (D-efficiency = 98.16). The pilot study revealed that participants could easily understand and answer all the choice sets. Conclusion: The results of our study indicated that health insurance service benefit packages and premium were among the most important attributes that need to be included in the final attribute design for Iranians. The policymakers and health insurance organizations should emphasize these attributes in the benefit packages to make improvements. The emphasis on these attributes can help elicit people's preferences and willingness to pay for attributes.