K-means clustering of outpatient prescription claims for health insureds in Iran.

OBJECTIVE: The segmentation of consumers based on their behavior and needs is the most crucial action of the health insurance organization. This study's objective is to cluster Iranian health insureds according to their demographics and data on outpatient prescriptions. SETTING: The population in this study corresponded to the research sample. The Health Insurance Organization's outpatient claims were registered consecutively in 2016, 2017, 2018, and 2019 were clustered. DESIGN: The k-means clustering algorithm was used to cross-sectionally and retrospectively analyze secondary data from outpatient prescription claims for secondary care using Python 3.10. PARTICIPANTS: The current analysis transformed 21 776 350 outpatient prescription claims from health insured into 193 552 insureds. RESULTS: Insureds using IQR were split into three classes: low, middle, and high risk. Based on the silhouette coefficient, the insureds of all classes were divided into three clusters. In all data for a period of four years, the first through third clusters, there were 21 799, 7170, and 19 419 insureds in the low-risk class. Middle-risk class had 48 348,23 321, 25 107 insureds, and 14 037, 28 504, 5847 insured in the high-risk class were included. For the first cluster of low-risk insureds: the total average cost of prescriptions paid by the insurance for the insureds was $211, the average age was 26 years, the average franchise was 88.5US$, the average number of medications and prescriptions were 409 and 62, the total average costs of prescriptions Outpatient was 302.5 US$, the total average number of medications for acute and chronic disease was 178 and 215, respectively. The majority of insureds were men, and those who were part of the householder's family. CONCLUSIONS: By segmenting insurance customers, insurers can set insurance premium rates, controlling the risk of loss, which improves their capacity to compete in the insurance market.

Examining active aging among Iranian provinces: a TOPSIS analysis.

BACKGROUND: Planning and decision-making for the elderly requires a special attention due to the beginning of aging process in Iran. By emphasizing the concept of active aging, determining the status of the elderly like their ability to continue work over time, to attain income and to participate in social and political life is significant. Active aging uses the indicators measuring the non-used potential of the elderly for having an active and healthy aging. This study aimed to determine the level of active aging among the provinces of Iran in 2018 by considering 11 indicators related to elderly's health, well-being and socioeconomic participation. METHODS: The raw data were obtained from Statistical Center of Iran. After establishing the indicators based on the Global Age Watch approach, the provinces were ranked by the TOPSIS method in terms of aging status. RESULTS: The results indicated that only Tehran and Alborz had the highest development level of active aging while 16% of the provinces had a semi-developed status and 77% failed at experiencing a satisfactory welfare, economic and social status. CONCLUSIONS: Four indicators had the highest importance included the percentage of the elderly with a diploma and academic degree, the percentage of the elderly with lower incomes than the median income, the median income of the elderly to the median income of the other people in society, and life expectancy among the 65-year old men. Studying the indicators deeply can result in the appropriate planning for each area in line with the improvement of the elderly status.

Preferences of Iranian average risk population for colorectal cancer screening tests.

PURPOSE: The purpose of this paper is to explore the preferences of the average risk Iranian population for colorectal cancer (CRC) screening tests. DESIGN/METHODOLOGY/APPROACH: A standard stated-preferences method with discrete choice models was used to identify the preferences. Data about socio-demographic status, health status and preferences for CRC screening tests were collected by a structured questionnaire that was completed by 500 people aged 50-75 years. Mixed logit model was used to analyze the preferences. FINDINGS: The regression model showed that the test process, pain, place, frequency, preparation, sensitivity, complication risk, mortality rate and cost were the final attributes; that had a statistically significant correlation with the preferences of the people in choosing CRC screening tests. The socio-demographic and health status of participants had no significant correlation with the individuals' preferences. PRACTICAL IMPLICATIONS: This study provides insight into how different characteristics of a CRC screening test might influence the preferences of individuals about that test. ORIGINALITY/VALUE: This was the first study of this type in Iran to elicit the preferences of the average risk population for CRC screening tests using a discrete choice model.

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.

Ageing and inpatient hospital expenditures: A study of steepening.

Background: Considering the health economics aspect, the effect of population aging on the growth of medical expenditures is of great importance. Thus, the aim of this study was to investigate the growth rate of inpatient hospital expenditures (IHE) of older age groups compared to younger age groups or testing of steepening hypothesis. Methods: In this descriptive-analytic study, monthly IHE data of insured patients from April 2011 to March 2014 was collected from Iran Health Insurance Organization database. The sample consisted of 297,145 patients who were selected using stratified random sampling among the patients insured by different health insurance funds. Using the Age-cut method, patients were classified into two main age groups: older than 60 and under 60 years old. The average IHE of the two groups and the growth rate of their expenditures were estimated. At the 95% significance level, the difference in average growth rate of IHE was tested between the two age groups using tstatistic in Stata (version 13.0) software. Results: The findings of this study revealed that per capita IHE for the older and younger groups was $469 and $399, respectively. The monthly average growth rate of IHE for the older (60-90 yrs.) and younger groups (30-59 yrs.) was 2.43% and 2.38%, respectively. The difference between the monthly average growth rate of the older and younger groups was not statistically significant (t = - 0.0332; P value = 0.9736). Conclusion: Our study results rejected the steepening hypothesis. The monthly average growth rates of IHE in both older and younger age groups have risen to a similar extent over the period of 36 months. Further research should focus on the inpatient hospital expenditures of younger age groups to explain the causes of their increased expenditures.

Socio-economic, health and environmental factors influencing suicide rates: A cross-country study in the Eastern Mediterranean region.

BACKGROUND: Suicide is a crucial concern for public health in the world. To date, there is no synthesized evidence about the cross-country impact of suicide risk factors in the Eastern Mediterranean (EMRO). This paper aims to cover the gap and assess socio-economic, health, and environmental (SHE) factors influencing suicide rates among the EMRO countries from 1990 to 2019. METHODS: This analysis is a cross-sectional time-series design which uses random-effect panel data from 17 EMRO countries. SHE variables are inflation rate, economic growth, unemployment rate, urbanization, and female labor force participation rate, mental disorders prevalence and individuals using the internet. RESULTS: The models indicate that male suicide rates was positively associated with inflation rate (coefficient = 0.002, p < 0.05) unemployment rate (0.06, p < 0.01), mental disorders prevalence (0.0008, p < 0.01), and urbanization (0.08, p < 0.05). Conversely, individuals using the internet (-0.019, p < 0.01) was related to a reduction in male suicide rates. Variables correlated with an increase in female suicide rates included inflation rate (0.001, p < 0.05), mental disorders prevalence (coefficient = 0.0004, p < 0.01) and urbanization (0.03, p < 0.01). Individuals using the internet (-0.006, p < 0.01) and education index (-4.8, p < 0.01) had negative effect on female suicide rates. CONCLUSIONS: This research confirms that SHE factors appear to affect suicide. So policymakers should endeavor to control them if the nations are aimed at preventing suicides. Future researches are essential to scrutinize paradoxes in the field.

Designing and Evaluating a Nutrition Recommender System for Improving Food Security in a Developing Country.

BACKGROUND: Due to the increased price of foods in recent years and the diminished food security in Iran, nutrition recommender systems can suggest the most suitable and affordable foods and diets to users based on their health status and food preferences. Objective: The present study aimed to design and evaluate a recommender system to suggest healthy and affordable meals and provide a tele-nutrition consulting service. METHODS: This applied three-phase study was conducted in 2020. In the first stage, the food items' daily prices were extracted from credible sources, and accordingly, meals were placed in three price categories. After conducting a systematic review of similar systems, the requirements and data elements were specified and confirmed by 10 nutritionists and 10 health information management and medical informatics experts. In the second phase, the software was designed and developed based on the findings. In the third phase, system usability was evaluated by four experts based on Nielsen's heuristic evaluation. RESULTS: Initially, 72 meals complying with nutritional principles were placed in three price categories. Following a literature review and expert survey, 31 data elements were specified for the system, and the experts confirmed system requirements. Based on the information collected in the previous stage, the Web-based software TanSa in the Persian language was designed, developed, and presented on a unique domain. During the evaluation, the mean severity of the problems associated with Nielsen's 10 principles was 1.2, which is regarded as minor. CONCLUSION: To promote food security, the designed system recommends healthy, nutritional, and affordable meals to individuals and households based on user characteristics.

Hospital Expenditure at the End-of-Life: A Time-to-Death Approach.

BACKGROUND: In recent years the use of time to death (TTD) variables in the modeling of individual health expenditures has been of interest to health economics researchers. The aim of this study was to investigate the effect of age and TTD on hospital inpatient expenditure (HIE). METHODS: We used a claims database from Iran Health Insurance Organization of Tehran city that includes considerable proportion of Tehran residents and contains information on insured individuals' HIE. We included HIE of all insured decedents (30 to 90 years old) who died during March 2013 and March 2014 (n=1018). No sampling was required. According to the decedents' date of death, we extracted their last 24 months HIE. The period of time March 30, 2011 until March 30, 2014 (3 years) was used to guarantee a full 24 months of observations for decedents. A two-part econometric model was employed to investigate the effect of age, TTD, and some demographic variables on probability and conditional amount of individuals' hospital expenditure. Stata software (version 16.0) was used for data processing and analysis. RESULTS: Our results demonstrated that the month-based TTDs especially near months before death of decedents (TTD1 to TTD10) significantly affected both probability and conditional amount of HIE. One month before death incurred more HIE than the rest of the months. A further interesting finding is that after including TTD, age variable as a conditional driver of HIE loses its direct effect on decedents' HIE, but age TTD interaction effect on HIE is still positive and statistically significant. CONCLUSION: The results confirm that TTD as a proxy of mortality indicator has a considerable effect on decedents' HIE. The age variable has not directly affected decedents' HIE but indirectly and through its interaction with TTD has a statistically significant effect on HIE. In addition to age, policy-makers should consider TTD to make better predictions of future HIE.

Estimation and predictors of direct hospitalisation expenses and in-hospital mortality for patients who had a stroke in a low-middle income country: evidence from a nationwide cross-sectional study in Iranian hospitals.

OBJECTIVE: Stroke is the second most prevalent cardiovascular disease in Iran. This study investigates the estimation and predictors of hospitalisation expenses and in-hospital mortality for patients who had a stroke in Iranian hospitals. SETTING: Patients who had a stroke in Iran between 2019 and 2020 were identified through the data collected from the Iran Health Insurance Organization and the Ministry of Health and Medical Education. This study is the first to conduct a pervasive, nationwide investigation. DESIGN: This is a cross-sectional, prevalence-based study. Generalised linear models and a multiple logistic regression model were used to determine the predictors of hospitalisation expenses and in-hospital mortality for patients who had a stroke. PARTICIPANTS: A total of 19 150 patients suffering from stroke were studied. RESULTS: Mean hospitalisation expenses per patient who had a stroke in Iran amounted to US$590.91±974.44 (mean±SD). Mean daily hospitalisation expenses per patient who had a stroke were US$55.18±37.89. The in-hospital mortality for patients who had a stroke was 18.80%. Younger people (aged ≤49 years) had significantly higher expenses than older patients. The OR of in-hospital mortality in haemorrhagic stroke was significantly higher by 1.539 times (95% CI, 1.401 to 1.691) compared with ischaemic and unspecified strokes. Compared with patients covered by the rural fund, patients covered by Iranian health insurance had significantly higher costs by 1.14 times (95% CI, 1.186 to 1.097) and 1.319 times (95% CI, 1.099 to 1.582) higher mortality. There were also significant geographical variations in patients who had a stroke's expenses and mortality rates. CONCLUSION: Applying cost-effective stroke prevention strategies among the younger population (≤49 years old) is strongly recommended. Migration to universal health insurance can effectively reduce the inequality gap among all insured patients.

Health Expenditure and Its Human Capital Determinants in Iran.

BACKGROUND: Human capital is an effective variable on the health condition of a society and its changing changes health expenditure as the proxy of health. This study aimed to investigate the relationship between human capital determinants and health expenditure. METHODS: An empirical model was used with 7 variables included gender parity (GPI) index, literacy rate, life expectancy at birth, GDP per capita, physician per capita, and hospital's bed as the independent variable and health expenditure as depended variable. After unit root test of data by using Zivot-Andrews method, the model was estimated by ordinary least square (OLS) method. RESULT: GPI had the negative and significant impact on health expenditure. Literacy had the positive and significant impact on depended variable. In addition, GDP per capita and life expectancy had positive and significant on health expenditure. Hospital bed and physician per capita did not have the significant relationship with health expenditure. The value of R-squared and Durbin-Watson statistic were 0.99 and 1.95 respectively, which showed good model fit. CONCLUSION: literacy rate and GPI index as the proxy of human capital had the different impact on health expenditure. The first had positive and the latter had negative. GDP per capita had the positive impact that showed health was a normal good.

A Scoping Review of Components of Physician-induced Demand for Designing a Conceptual Framework.

OBJECTIVES: The current study presents a new conceptual framework for physician-induced demand that comprises several influential components and their interactions. METHODS: This framework was developed on the basis of the conceptual model proposed by Labelle. To identify the components that influenced induced demand and their interactions, a scoping review was conducted (from January 1980 to January 2017). Additionally, an expert panel was formed to formulate and expand the framework. RESULTS: The developed framework comprises 2 main sets of components. First, the supply side includes 9 components: physicians' incentive for pecuniary profit or meeting their target income, physicians' current income, the physician/population ratio, service price (tariff), payment method, consultation time, type of employment of physicians, observable characteristics of the physician, and type and size of the hospital. Second, the demand side includes 3 components: patients' observable characteristics, patients' non-clinical characteristics, and insurance coverage. CONCLUSIONS: A conceptual framework that can clearly describe interactions between the components that influence induced demand is a critical step in providing a scientific basis for understanding physicians' behavior, particularly in the field of health economics.

'Seeking affluent neighbourhoods?' a time-trend analysis of geographical distribution of hospitals in the Megacity of Tehran.

OBJECTIVE: Access to hospitals in megacities in low and middle income countries might be hampered by travel barriers and distance. We assessed the 'inverse care law' hypothesis: whether hospitals tended to be built in the relatively better-off areas through the time. METHODS: A longitudinal time-series study (1966 to 2011) in Tehran to measure inequality in the distribution of hospital beds. We assessed correlations between the district socioeconomic status and availability of hospital beds via regression analyses, estimated correlation, Gini and concentration indices, and used GIS models to map hospital distributions through time. FINDING: We found a clear relationship between socioeconomic status and number of hospital beds per capita ( P -values <0.05). Gini coefficients were about 0.6 and 0.8 for public and private beds, respectively. A third of the variations in hospital bed distribution was explained by the welfare status of the district. For every extra residential room per capita, 130 to 280 extra beds were observed per ten thousand population at the district level. In 2011, out of 162 hospitals, 110 were located in six districts around the centre and northern part of the city. During the time period only two private hospitals were built in relatively disadvantaged districts. CONCLUSION: Over a period of about fifty years new hospitals had been established in the relatively affluent areas of the city and the relationship between socioeconomic status of district with total, private and public beds were direct and intensive. Results indicate the problem of inequality may remain over time and be resistant to policy initiatives and major political changes.

Female Labor Supply and Fertility in Iran: A Comparison Between Developed, Semi Developed and Less Developed Regions.

BACKGROUND: Female labor supply has been changed dramatically in the recent yr. In this study, we examined the effects of development on the relationship between fertility and female labor supply. METHODS: We used data of population and housing census of Iran and estimated three separate models. To do this we employed Logistic Regressions (BLR). RESULTS: The estimation results of our study showed that there was a negative relationship between fertility rate and female labor supply and there are some differences for this relationship in three models. CONCLUSION: When fertility rate increases, FLS would decreases. In addition, for higher fertility rates, the woman might be forced to work more because of the economic conditions of her family; and negative coefficients of the fertility rate effects on FLS would increase with a diminishing rate.