Economic burden of type 2 diabetes in Iran: A cost-of-illness study.

Background and Aims: Type 2 diabetes mellitus (T2DM) is a prevalent public health problem worldwide, and the economic burden of the disease poses one of the main challenges for health systems in low- and middle-income countries. This study aimed to estimate the economic burden of T2DM in Iran, in 2018. Methods: This was a cost-of-illness study. Three hundred and seventy-five patients with T2DM who were referred to Imam Reza and Sina's educational and therapeutic centers and Asad Abadi clinic in Tabriz, Iran, in 2018 were included. A researcher-constructed checklist was used for data collection. Data were analyzed using EXCEL and SPSS software version 22. Results: Total economic burden of diabetes was estimated at 152,443,862,480.3 (purchasing power parity [PPP], Current International $) (approximately 7.69% of GDP, PPP, Current International $). The mean total direct and indirect costs were 11,278.68 (PPP) (62.35% of mean total cost) and 6808.88 (PPP, Current International $) (37.64% of the total cost), respectively. The mean total direct medical cost and the direct nonmedical cost were 10,819.43 (PPP, Current International $) (59.81% of mean total cost) and 459.24 (PPP, Current International $) (2.53% of mean total cost) per patient, respectively. Besides, the mean direct medical cost was 6.18 times the total per capita expenditure on health, and the total direct medical cost was 8.9% times the total expenditure on health. Conclusion: Diabetes imposes a substantial economic burden on patients, health systems, and the whole economy. Besides, since the cost of the disease in patients treated with insulin and those with diabetes complications is significantly higher, the reinforcement of self-care measures and focusing on modifying lifestyle (dietary modification and physical activity) in patients with T2DM can significantly reduce the costs of the disease.

Key Indicators Affecting Hospital Efficiency: A Systematic Review.

Background: Measuring hospital efficiency is a systematic process to optimizing performance and resource allocation. The current review study has investigated the key input, process, and output indicators that are commonly used in measuring the technical efficiency of the hospital to promote the accuracy of the results. Methods: To conduct this systematic review, the electronic resources and databases MEDLINE (via PubMed), Scopus, Ovid, Proquest, Google Scholar, and reference lists of the selected articles were used for searching articles between 2010 and 2019. After in-depth reviews based on the inclusion and exclusion criteria, among 1,537 studies, 144 articles were selected for the final assessment. Critical Appraisal Skills Programme (CASP) Checklist was used for evaluating the quality of the articles. The main findings of studies have been extracted using content analysis. Results: After the final analysis, the Context/Input indicators that were commonly considered by studies in analyzing hospital technical efficiency include different variables related to Hospital Capacity, Structure, Characteristics, Market concentration, and Costs. The Process/Throughput indicators include different variables related to Hospital Activity or services-oriented process Indicators, Hospital Quality-oriented process indicators, and Hospital Educational processes. Finally, the Output/Outcome indicators include different variables related to Hospital Activity-related output variables and Quality-related output/outcomes variables. Conclusion: This study has identified that it is necessary to mix and assess a set of input, process, and output indicators of the hospital with both quantitative and qualitative indicators for measuring the technical efficiency of hospitals comprehensively.

Assessment of medical equipment maintenance management: proposed checklist using Iranian experience.

BACKGROUND: Effective maintenance management of medical equipment is one of the major issues for quality of care, for providing cost-effective health services and for saving scarce resources. This study aimed to develop a comprehensive checklist for assessing the medical equipment maintenance management (MEMM) in the Iranian hospitals. METHODS: This is a multi-methods study. First, data related to factors which affect the assessment of MEMM were collected through a systematic review in PubMed, ProQuest, Scopus, Embase, and web of science without any time limitation until October 2015, updated in June 2017. Then, we investigated these factors affecting using document review and interviews with experts in the Iranian hospitals. In the end, the results of the first and second stages were combined using content analysis and the final checklist was developed in a two-round Delphi. RESULTS: Using a combination of factors extracted from the systematic and qualitative studies, the primary checklist was developed in the form of assessment checklists in seven dimensions. The final checklist includes 7 dimensions and 19 sub-categories: "resources = 3," "quality control = 3," "information bank = 4," "education = 1," "service = 3," "inspection and preventive maintenance = 2" and "design and implementation = 3." CONCLUSIONS: Developing an assessment checklist for MEMM provide a comprehensive framework for the proper implementation of accurate assessment of medical equipment maintenance. This checklist can be used to improve the profitability of health facilities and the reliability of medical equipment. In addition, it is implicated in the decision-making in support of selection, purchase, repair and maintenance of medical equipment, especially for capital equipment managers and medical engineers in hospitals and also for the assessment of this process.

The catastrophic out-of-pocket health expenditure of multiple sclerosis patients in Iran.

BACKGROUND: The present study was designed and conducted to evaluate multiple sclerosis (MS) treatment costs and the resulting economic impact imposed on MS patients in Iran. METHODS: This was a cross-sectional study, among randomly selected 300 MS patients, registered in the MS Association of East Azerbaijan Province, Iran (1 year after their treatment began). The regression analysis, ANOVA, T-test, and chi-square were used. RESULTS: The average amount of out-of-pocket payments (OOPs) by MS patients during the previous year was 1669.20 USD, most of which was spent on medication, rehabilitation care, and physician visits. Their mean annual income was 5182.84 USD. Fifty four percent of families with an MS patient suffer from catastrophic health expenditure (CHE) and 44% experience poverty caused by the OOPs. Occupational status, having supplemental health insurance, and being residents of Tabriz significantly affect OOPs, CHE, and the resulting poverty (P < 0.05). CONCLUSION: The catastrophic financial burden of health care costs on MS patients and their families justifies health policymakers to promote pre-payment systems and provide subsidies to less well-off patients to protect them from the unfairness of OOPs and its resulting CHE and poverty.

Economic costs incurred by the patients with multiple sclerosis at different levels of the disease: a cross-sectional study in Northwest Iran.

BACKGROUND: Multiple sclerosis (MS) causes significant economic burden to the patients, families, health systems and society. This study aimed to estimate the annual economic costs incurred by patients with multiple sclerosis (pwms) at different levels of the disease. METHOD: This was a cross-sectional study, using the Expanded Disability Status Scale (EDSS) tool for assessing the disease level of 300 (=N) pwms in East Azerbaijan province, Iran. To estimate the cost of MS, a questionnaire with its validity and reliability (CVR 92% and CVI 87%) and pilot test (Cronbach's alpha score 0.89) was used. The data were collected by interviewing pwms and reviewing their clinical records. Multivariate linear regression was used to assess the relationship between disease levels and incurred costs. RESULTS: The results revealed that the mean annual cost for pwms in Iran is 97,521,740 IRR (equivalent to 2321.94 USD; 1978.93 EURO) and the mean score of EDSS in pwms was 3.14. The annual cost incurred by pwms with mild, moderate and severe levels of disease were 83,918,150 IRR (1998.05 USD; 1702.88EURO), 137,772,660 IRR (3280.30 USD; 2795.71 EURO) and 119,962,670 IRR (2856.25 USD;2434.30 EURO), respectively. Also, on average, each increase in EDSS score in pwms in Iran led to increase 8,139,260 IRR (equivalent to 193.79 USD; and 165.16 EURO) in total annual cost which must paid from pwms and their households exclusively. Also, there was a significant relationship between total annual cost and disease severity in such a way that any increase in EDSS degree is led to 8,139,260 IRR (193.79 USD; 165.16 EURO) added cost for pwms. CONCLUSION: The study results could be helpful for Iranian health managers to solve problems which are facing by the patients with multiple sclerosis and their families.

Stewardship as a Fundamental Challenge in Strategic Purchasing of Health Services: A Case Study of Iran.

OBJECTIVE: To understand the stewardship challenges in strategic purchasing of health care in Iran's health system from the viewpoints of experts, policy makers, and decision makers. STUDY DESIGN: This was a qualitative study. METHODS: Researchers used interviews and FGDs for collecting and framework analysis for analyzing data. RESULTS: Stewardship challenges were classified into three themes and nine subthemes. A lack of management information systems, a lack of enforcement for rules and laws, a lack of stewardship units, and the conflict of interest between the Ministry of Health and insurers as care purchasers in the health system are among the main challenges identified in the implementation of the strategic purchasing of health care in Iran. CONCLUSION: A strong stewardship is needed for implementing strategic purchasing of health care, which requires participation of all stakeholders.

Effective coverage as a new approach to health system performance assessment: a scoping review.

BACKGROUND: Delivering interventions is the main task of health systems whose accurate measurement is an essential input into tracking performance. Recently, the concept of effective coverage was introduced by World Health Organization to incorporate into health system performance assessment. The aim of present scoping review was mapping the key elements and steps of effective coverage assessment in practical efforts including kinds of interventions, criteria for selecting them and the need, use and quality estimation approaches and strategies of each intervention. METHODS: We conducted a scoping review of health system/program assessments which assessed effective coverage till May 2017. Seven databases were systematically searched with no time and language restriction through applying combined keyword of "effective coverage". RESULTS: Eighteen studies contributed findings on monitoring effective coverage of health interventions and they all were included in the review. Only 4 contributed findings on health system and the others were related to specific intervention(s) assessment. The interventions monitored by effective coverage were mainly in child health, prenatal and antenatal care and delivery, and chronic conditions areas. Potential impact on the burden of disease, leading causes of mortality and morbidity, and high occurrence and prevalence rate were among the main intervention selection criteria. Availability of data was the critical prerequisite, especially, in all of the studies applied ex post approach in estimating effective coverage. Estimation based on a norm, self- reporting from surveys and biomarkers were the main strategies and methods of need, utilization and quality measurement, respectively. CONCLUSIONS: More studies are needed to contribute to the ongoing improvement in the development of effective coverage concept and increasing practical efforts, especially through defining prospective approaches and strategies into estimation of composite measures based on the effective coverage framework. Also, further attention needs to be paid to quality measures of effective coverage in a manner that better conceptualizes and measures the connection between coverage rates and interventions' effectiveness. At the administrative system level, more innovation is needed to develop data systems in order to enhance capacity of routine health service information.

Cost-Effectiveness Analysis of Biogeneric Recombinant Activated Factor VII (AryoSeven™) and Activated Prothrombin Complex Concentrates (FEIBA™) to Treat Hemophilia A Patients with Inhibitors in Iran.

Nowadays, bypassing agents such as recombinant activated factor VII (rFVIIa) and activated prothrombin complex concentrates (aPCC) are used to treat bleeding episodes in the Hemophilia patients with inhibitors. AryoSeven® is an Iranian biogeneric rFVIIa with homogeneity of efficacy and the nature to NovoSeven in a comparative trial. The current clinical trial aimed to evaluate the cost-effectiveness of FEIBA and AryoSeven® by Decision Analytic Model according to the Iranian healthcare system. An open label, multi-center, cross-over clinical trial was designed. Patients were categorized into 3 groups based on their prior tendency to one or none of the products. To determine the premium therapeutic strategy, the Incremental cost-effectiveness ratio (ICER) was calculated. Protocol F led to more treatment success in group F than the other groups (P= 0.03). Also, there was a significant statistical difference between the mean of effectiveness scores in the groups using protocol F (P = 0.01). The effectiveness of protocol F and A were 89% and 72%, respectively. ICER cost US$ to manage an episode of bleeding to get one more unit of effectiveness using FEIBA VS. AryoSeven. Although the results showed that AryoSeven was more cost-effective compared to FEIBA, the two strategies were undominated. In other words, both medicines can be applied in the first line of the treatment if the cost of FEIBA was reduced. The present clinical trial was registered at IRCT website, under ID No.2013020612380N1.

Development and Psychometric Evaluation of a Socioeconomic Status Questionnaire for Urban Households (SESIran): The Preliminary Version.

BACKGROUND: The aim of present study was to develop and validate an appropriate socioeconomic status (SES) assessment questionnaire to be used through health studies in Iranian urban households. METHODS: The study was conducted through a mixed method study design in Tabriz, northwest of Iran in 2014. It was conducted in several stages including: development of initial version, qualitative study, feasibility evaluation, and assessment of the validity as well as the reliability. The internal consistency, test-retest reliability, content validity, concurrent validity and construct validity were assessed. RESULTS: With respect to the assessment of construct validity, 5 domains (factors) were extracted includ-ing: main factor (α=0.84), self-evaluation of expenditure capacity (α=0.96), wealth (α=0.70), home and furniture (α=0.66) and costs related to health (α=0.55). Intraclass correlation coefficient was above 0.6 for all factors except for wealth domain. CONCLUSION: The questionnaire developed appeared to be a valid and reliable SES assessment tool. It may be of value to be used not only as a complementary questionnaire in most health surveys or clini-cal studies, but also as a main questionnaire in health equity and health economics research.

Cost-utility analysis of disease-modifying drugs in relapsing-remitting multiple sclerosis in Iran.

BACKGROUND: Disease-modifying drugs (DMDs) are a significant expenditure for treating multiple sclerosis (MS). However, there is limited report on assessment of the cost-utility of DMDs compared with symptom management in the presence of long-term data. This study aimed to assess the lifetime cost-utility from the Iranian healthcare perspectives of 4DMDs relative to symptom management alone in patients with relapsing-remitting multiple sclerosis using evidence from long-term published studies. METHODS: A Markov model was developed with patients transitioning through health states based on Kurtzke's expanded disability status scale.Patient costs included drug costs, other medical and lost worker productivity costs. Patient quality of life was considered in the form of utilities. Costs were valued in 2011 USD, and were discounted at 7.2% per annum. Various parameters and assumptions were tested in sensitivity analyses. RESULTS: Total costs per patient over the time horizon of a patient's lifetime were estimated at 20285, 144194, 299279, 251255 and 69796 USD for symptom management, Avonex, Betaferon, Rebif and CinnoVex, respectively. As a result, the incremental cost per quality adjusted life years (QALY) for patients receiving Avonex, Betaferon, Rebif and CinnoVex was 607397, 1374355, 1166515 and 1010429 USD, respectively, when compared with symptom management. The results were sensitive to changes in time horizon, disease progression and drug costs. CONCLUSION: DMDs in relapsing-remitting MS patients was associated with increased benefits compared with symptom management, albeit at higher costs. Because patients receiving Avonex incurred slightly higher QALYs than patients receiving other DMDs, treatment with Avonex dominates other DMDs in Iran.

Cost-utility analysis of immune tolerance induction therapy versus on-demand treatment with recombinant factor VII for hemophilia A with high titer inhibitors in Iran.

BACKGROUND: In developing countries, the treatment of hemophilia patients with inhibitors is presently the most challenging and serious issue in hemophilia management, direct costs of clotting factor concentrates accounting for >98% of the highest economic burden absorbed for the health care of patients in this setting. In the setting of chronic diseases, cost-utility analysis, which takes into account the beneficial effects of a given treatment/health care intervention in terms of health-related quality of life, is likely to be the most appropriate approach. OBJECTIVE: The aim of this study was to assess the incremental cost-effectiveness ratios of immune tolerance induction (ITI) therapy with plasma-derived factor VIII concentrates versus on-demand treatment with recombinant-activated FVIIa (rFVIIa) in hemophilia A with high titer inhibitors from an Iranian Ministry of Health perspective. METHODS: This study was based on the study of Knight et al, which evaluated the cost- effectiveness ratios of different treatments for hemophilia A with high-responding inhibitors. To adapt Knight et al's results to the Iranian context, a few clinical parameters were varied, and cost data were replaced with the corresponding Iranian estimates of resource use. The time horizon of the analysis was 10 years. One-way sensitivity analyses were performed, varying the cost of the clotting factor, the drug dose, and the administration frequency, to test the robustness of the analysis. RESULTS: Comparison of the incremental cost-effectiveness ratios between the three ITI protocols and the on-demand regimen with rFVIIa shows that all three ITI protocols dominate the on-demand regimen with rFVIIa. Between the ITI protocols the low-dose ITI protocol dominates both the Bonn ITI protocol and the Malmö ITI protocol and would be the preferred ITI protocol. All of the three ITI protocols dominate the on-demand strategy, as they have both a lower average lifetime cost and higher quality-adjusted life-years (QALYs) gained. The cost per QALY gained for the Bonn ITI protocol compared with the Malmö ITI protocol was $249,391.84. The cost per QALY gained for the Bonn ITI protocol compared with the low-dose ITI protocol was $842,307.69. CONCLUSION: The results of data derived from our study suggest that the low-dose ITI protocol may be a less expensive and/or more cost-effective option compared with on-demand first-line treatment with rFVIIa.