Developing Framework and Strategies for Capacity Building to Apply Evidence-Informed Health Policy-Making in Iran: Mixed Methods Study of SAHSHA Project.

BACKGROUND: SASHA, which stands for "evidence-informed health policy-making (EIHP)" in Persian, is a national project to draw a roadmap for strengthening EIHP in Iran. As a part of SASHA, this research aimed to develop evidence-based and context-aware policy options for increasing the capacity of decision-makers to apply EIHP in Iran. METHODS: This was a qualitative study, which was informed by a literature review of pull efforts' capacity building programs. Based on the review, we developed policy options and validated them through an expert panel that involved twelve experts. Data were analyzed using a content analysis method. RESULTS: We extracted data from 11 articles. The objectives of capacity building programs were: single-skill development, personal/professional development, and organizational development. According to these objectives, the contents and training methods of the programs vary. Capacity building programs have shown positive impacts on individual knowledge/attitudes to use EIHP. However, the impacts of programs at the organizational or the health system level remain under-researched. We followed several threads from the literature review through to the expert panel that included training the management team, instead of training managers, training for problem-solving skills, and designing tailored programs. Barriers of capacity building for EIHP regard the context of the health system (weak accountability and the widespread conflict of interest) and healthcare organizational structures (decision support systems, knowledge management infrastructures, and lack of management team). Experts suggested interventions on the barriers, particularly on resolving the conflict of interests before launching new programs. A proposed framework to increase the capacity of health policy-makers incorporates strategies at three levels: capacity building program, organizational structure, and health system context. CONCLUSION: To prepare the context of Iranian healthcare organizations for capacity building programs, the conflict of interests needs to be resolved, decision-makers should be made more accountable, and healthcare organizations need to provide more knowledge management infrastructures and decision support systems.

Describing Iranian hospital activity using Australian Refined DRGs: a case study of the Iranian Social Security Organisation.

OBJECTIVE: To describe Iran's hospital activity with Australian Refined Diagnosis Related Groups (AR-DRGs). METHOD: A total of 445,324 separations was grouped into discreet DRG classes using AR-DRGs. L(3)H(3); IQR and 10th-95th percentile were used to exclude outlier cases. Reduction in variance (R(2)) and coefficient of variation (CV) were applied to measure model fit and within group homogeneity. RESULTS: Total hospital acute inpatients were grouped into 579 DRG groups in which 'surgical' cases represented 63% of the total separations and 40% of total DRGs. Approximately 12.5% of the total separations fell into DRGs O60C (vaginal delivery) and 28% of the total separations classified into major diagnostic category (MDC) 14 (pregnancy and childbirth). Although reduction in variance (R(2)) for untrimmed data was low (R(2)=0.17) for LOS, trimming by L(3)H(3), IQR, and 10th-95th percentile methods improved the value of R(2) to 0.53, 0.48, and 0.51, respectively. Low value of R(2) for AR-DRGs within several MDCs were identified, and found to reflect high variability in one or two DRGs. High within-DRG variation was identified for 23% of DRGs using untrimmed data. CONCLUSION: Low quality and incomplete data undermines the accuracy of casemix information. This may require improvement in coding quality or further classification refinement in Iran. Further study is also required to compare AR-DRG performance with other versions of DRGs and to determine whether the low value of R(2) for several MDCs is due to the weakness of the AR-DRG algorithm or to Iranian specific factors.

Recent Iranian Health System Reform: An Operational Perspective to Improve Health Services Quality.

The operational management of healthcare services is expected to directly touch patient experiences. Iranian Ministry of Health and Medical Education (MoHME) for the first time, as such, has sought to improve the operational management of healthcare delivery within a reform agenda by setting benchmarks for 'number of visit per hour' and waiting time in outpatient clinics of about 700 affiliated hospitals. As a new initiative, it has faced with mixed reactions and various doubts have been cast on its successful implementation. This manuscript aims to shed some light on the operational challenges of the initiative and the requirements of its successful implementation.

Comparison of SF-6D and EQ-5D Scores in Patients With Breast Cancer.

BACKGROUND: Utility values are a key component of a cost-utility analysis. The EQ-5D and SF-6D are two commonly used measures for deriving utilities. Of particular importance is assessing the performance of these instruments in terms of validity. OBJECTIVES: This study aimed to compare the performance of the EQ-5D and the SF-6D in different states of breast cancer. PATIENTS AND METHODS: This was a cross-sectional study of 163 patients with breast cancer who attended the breast cancer subspecialty clinic affiliated with the breast cancer research center (BCRC) at ACECR, in Tehran, Iran, and were consecutively recruited. Patients completed several questionnaires, including the EQ-5D, SF-36, and general questions regarding their demographic characteristics. Utility values for different states of breast cancer were obtained using predetermined algorithms for the EQ-5D and SF-6D. The distribution of the utility values and the differences between the different states for both instruments were statistically assessed. Furthermore, the agreement between the two instruments was evaluated using intra-class correlation coefficients and Bland-Altman plots. RESULTS: The mean and median EQ-5D utility scores for the total sample were 0.685 and 0.761, respectively. The mean SF-6D utility score for the total sample was 0.653, and the median utility score was 0.640. The mean utility values of the EQ-5D for "state P," "state R," "state S," and "state M" were estimated as 0.674, 0.718, 0.730, and 0.552, respectively. The SF-6D provided mean utility values of 0.638, 0.677, 0.681, and 0.587 for those states. Both instruments assigned statistically significant (P < 0.01) scores for different states. The intra-class correlation for the two measures was 0.677 (95% confidence interval (CI): 0.558 - 0.764). The Bland-Altman plot indicated a better agreement on the higher values and that at higher values, the EQ-5D yields a higher score than the SF-6D; this relationship was reversed at lower values. CONCLUSIONS: Although the two instruments were able to discriminate between various states, the values derived from these instruments were quite different. This distinction could have influenced the conclusions of an economic evaluation. Further research is required to determine which instrument should be used in economic evaluations.

Cost-Effectiveness of Three Rounds of Mammography Breast Cancer Screening in Iranian Women.

BACKGROUND: Breast cancer is the most common cancer in Iranian women as is worldwide. Mammography screening has been introduced as a beneficial method for reducing mortality and morbidity of this disease. OBJECTIVES: We developed an analytical model to assess the cost effectiveness of an organized mammography screening program in Iran for early detection of the breast cancer. PATIENTS AND METHODS: This study is an economic evaluation of mammography screening program among Iranian woman aged 40 - 70 years. A decision tree and Markov model were applied to estimate total quality adjusted life years (QALY) and lifetime costs. RESULTS: The results revealed that the incremental cost effectiveness ratio (ICER) of mammography screening in Iranian women in the first round was Int. $ 37,350 per QALY gained. The model showed that the ICER in the second and third rounds of screening program were Int. $ 141,641 and Int. $ 389,148 respectively. CONCLUSIONS: Study results identified that mammography screening program was cost-effective in 53% of the cases, but incremental cost per QALY in the second and third rounds of screening are much higher than the accepted payment threshold of Iranian health system. Thus, evaluation of other screening strategies would be useful to identify more cost-effective program. Future studies with new national data can improve the accuracy of our finding and provide better information for health policy makers for decision making.

Application of the Activity-Based Costing Method for Unit-Cost Calculation in a Hospital.

BACKGROUND: Choosing an appropriate accounting system for hospital has always been a challenge for hospital managers. Traditional cost system (TCS) causes cost distortions in hospital. Activity-based costing (ABC) method is a new and more effective cost system. OBJECTIVE: This study aimed to compare ABC with TCS method in calculating the unit cost of medical services and to assess its applicability in Kashani Hospital, Shahrekord City, Iran. METHODS: This cross-sectional study was performed on accounting data of Kashani Hospital in 2013. Data on accounting reports of 2012 and other relevant sources at the end of 2012 were included. To apply ABC method, the hospital was divided into several cost centers and five cost categories were defined: wage, equipment, space, material, and overhead costs. Then activity centers were defined. ABC method was performed into two phases. First, the total costs of cost centers were assigned to activities by using related cost factors. Then the costs of activities were divided to cost objects by using cost drivers. After determining the cost of objects, the cost price of medical services was calculated and compared with those obtained from TCS. RESULTS: The Kashani Hospital had 81 physicians, 306 nurses, and 328 beds with the mean occupancy rate of 67.4% during 2012. Unit cost of medical services, cost price of occupancy bed per day, and cost per outpatient service were calculated. The total unit costs by ABC and TCS were respectively 187.95 and 137.70 USD, showing 50.34 USD more unit cost by ABC method. ABC method represented more accurate information on the major cost components. CONCLUSION: By utilizing ABC, hospital managers have a valuable accounting system that provides a true insight into the organizational costs of their department.

Investigating DRG cost weights for hospitals in middle income countries.

Identifying the cost of hospital outputs, particularly acute inpatients measured by Diagnosis Related Groups (DRGs), is an important component of casemix implementation. Measuring the relative costliness of specific DRGs is useful for a wide range of policy and planning applications. Estimating the relative use of resources per DRG can be done through different costing approaches depending on availability of information and time and budget. This study aims to guide costing efforts in Iran and other countries in the region that are pursuing casemix funding, through identifying the main issues facing cost finding approaches and introducing the costing models compatible with their hospitals accounting and management structures. The results show that inadequate financial and utilisation information at the patient's level, poorly computerized 'feeder systems'; and low quality data make it impossible to estimate reliable DRGs costs through clinical costing. A cost modelling approach estimates the average cost of 2.723 million Rials (Iranian Currency) per DRG. Using standard linear regression, a coefficient of 0.14 (CI = 0.12-0.16) suggests that the average cost weight increases by 14% for every one-day increase in average length of stay (LOS).We concluded that calculation of DRG cost weights (CWs) using Australian service weights provides a sensible starting place for DRG-based hospital management; but restructuring hospital accounting systems, designing computerized feeder systems, using appropriate software, and development of national service weights that reflect local practice patterns will enhance the accuracy of DRG CWs.