Development and validation of primary health care quality assessment tool.

BACKGROUND: Assessing the quality of health services gives insights to managers about the status of services delivered by them, especially from the client's perspective. Although various tools have been developed to measure the quality of primary health care (PHC), no specific tool was found in this field in Iran. Therefore, the present study was conducted to develop and validate the quality assessment tool of PHC in Iran. METHODS: This methodological study was conducted in 2021. In the first step, based on a literature review, an initial questionnaire was designed, and its face validity, content validity, construct validity, and reliability were evaluated. Descriptive tests, Kolmogorov-Smirnov, exploratory factor analysis, Kaiser-Myer-Olkin (KMO), and Cronbach's alpha were performed by using SPSS 22. RESULTS: The initial questionnaire included 33 items, of which three items were removed due to inconsistency with factorization. The final questionnaire consisted of 30 items and nine dimensions: interaction, efficiency, timeliness, accuracy, consultation, tangibility, safety, accessibility, and environment. The KMO and Cronbach's alpha index values were 0.734 and 0.82, respectively, indicating acceptable reliability and validity. The developed dimensions represented about 73% of the total variance. CONCLUSION: The designed questionnaire has relatively good validity and reliability and can be used to measure the quality of PHC and to identify weaknesses in service delivery. However, researchers should carefully examine it to enhance its applicability as a standard tool for measuring PHC quality.

Defensive medicine and its related risk factors: evidence from a sample of Iranian surgeons.

OBJECTIVES: Defensive medicine (DM) is the deviation of a physician from normal behavior or what is a good practice and is aimed at reducing or avoiding the risk of legal litigation from patients or their families. Therefore, this study aimed to determine DM-related behaviors and associated risk factors among Iranian surgeons. METHODS: In this cross-sectional study, 235 surgeons were selected using convenience sampling. The data gathering tool was a researcher-made questionnaire confirmed as a reliable and valid tool. Factors associated with DM-related behaviors were identified using logistic regression analysis. RESULTS: DM-related behaviors ranged from 14.9% to 88.9%. The most common positive DM-related behaviors, including unnecessary biopsy (78.7%), imaging and laboratory tests (72.4% and 70.6%), and refusing high-risk patients (61.7%), was the most common negative DM-related behavior. The likelihood of DM-related behaviors was more in younger and less experienced surgeons. Other variables, such as gender, specialty, and lawsuit history, positively affected some DM-related behaviors (p < 0.05). CONCLUSION: This study showed that the proportion of surgeons who frequently performed DM-related behaviors was higher than those who rarely performed it. Therefore, strategies including reforming the rules and regulations for medical errors and litigations, developing and implementing medical guidelines and evidence-based medicine, and improving the medical liability insurance system can reduce DM-related behaviors.

Interaction between physicians and the pharmaceutical industry: A scoping review for developing a policy brief.

Background: Payments to physicians by the pharmaceutical industry are common, but recent evidence shows that these payments influence physician prescribing behavior in the form of increased prescription of brand-name drugs, expensive and low-cost drugs, increased prescription of payer company drugs, etc. Considering that these payments increase drug costs for patients and health systems, there is a public interest in controlling them. Therefore, this study aimed to identify and propose policy options for managing physician-pharmaceutical industry interactions in the context of Iran's health system. Methods: In the first phase, a systematic search was conducted to identify relevant policies and interventions in Web of Science, PubMed, and ProQuest databases from 2000 to 2022. Then, the opinions of the research team and an expert group (physicians, health policy and transparency experts, and industry representatives) were used to categorize the interventions and propose policy options along with their advantages, disadvantages, and implementation considerations. Results: In the search, 579 articles were retrieved, and 44 articles were found suitable for the final analysis. Twenty-nine interventions and strategies were identified, and based on these; Five policy options were identified: prohibition, restriction, physician self-regulation, voluntary industry disclosure, and mandatory industry disclosure. Conclusion: The proposed policies in our study include advantages, challenges, and implementation considerations based on up-to-date evidence that can help policymakers use them to manage COI in physician-pharmaceutical industry interactions in Iran's health system. A combination of measures seems to help manage COI: firstly, using self-regulating physicians and industry to institutionalize transparency, and in the next step, implementing mandatory industry disclosure policies and establishing restrictions on some financial interactions.

Economic Inequality in Visual Impairment: A Study in Deprived Rural Population of Iran.

PURPOSE: To determine economic inequality in visual impairment (VI) and its determinants in the rural population of Iran. METHODS: In this population-based, cross-sectional study, 3850 individuals, aged 3-93 years were selected from the north and southwest regions of Iran using multi-staged stratified cluster random sampling. The outcome was VI, measured in 20 feet. Economic status was constructed using principal component analysis on home assets. The concentration index (C) was used to determine inequality, and the gap between low and high economic groups was decomposed to explained and unexplained portions using the Oaxaca-Blinder decomposition method. RESULTS: Of the 3850 individuals that were invited, 3314 participated in the study. The data of 3095 participants were finally analyzed. The C was -0.248 (95% confidence interval [CI]: -0.347 - -0.148), indicating a pro-poor inequality (concentration of VI in low economic group). The prevalence (95% CI) of VI was 1.72% (0.92-2.52) in the high economic group and 10.66% (8.84-12.48) in the low economic group with a gap of 8.94% (6.95-10.93) between the two groups. The explained and unexplained portions comprised 67.22% and 32.77% of the gap, respectively. Among the study variables, age (13.98%) and economic status (80.70%) were significant determinants of inequality in the explained portion. The variables of education (coefficient: -4.41; P < 0.001), age (coefficient: 14.09; P < 0.001), living place (coefficient: 6.96; P: 0.006), and economic status (coefficient: -7.37; P < 0.001) had significant effects on inequality in the unexplained portion. CONCLUSIONS: The result showed that VI had a higher concentration in the low economic group, and the major contributor of this inequality was economic status. Therefore, policymakers should formulate appropriate interventions to improve the economic status and alleviate economic inequality.

Patients' attitude toward informal payments in Iran: an application of the cluster analysis method.

INTRODUCTION: Attitude is a factor affecting the behaviour of consumers. In the literature, the effect of health care consumer's attitude on making informal payments has been highlighted. The purpose of this study was to investigate the attitude of Iranian patients regarding informal payments and socio-demographic factors associated with it. METHODS: In this cross-sectional study, conducted in 2017 in Tehran, 450 patients who were admitted to the clinics of four public hospitals for post-surgical care and follow-up, were invited to participate in the study. The data collection tool was a questionnaire, which validity and reliability were confirmed. Cluster analysis was used to identify the main attitudinal groups. To investigate the effect of socio-demographic factors on patients' attitudes, generalized linear model regression analysis was carried out in SPSS 22. RESULTS: Our findings showed that 57.3% of patients had agreeing attitude, 24.2% indifferent attitude, and 18.4% opposing attitude toward informal payments. Patients from rural areas and those from the high-income group had higher odds of having an agreeing attitude. There was a significant association between informal payment history and attitude. The odds of having agreeing attitude among patients with a history of informal payment were two times higher than among patients who did not have an informal payment history (p ≤ 0.05). CONCLUSION: A positive attitude towards informal payments is an obstacle to the fight against this phenomenon. Therefore, changes in public attitudes regarding informal payments will be an essential strategy, among other strategies, for eradicating these payments. This could be achieved through public campaigns for raising people's awareness and knowledge.

Cost analysis of education for students in the School of Health of Alborz University of Medical Sciences: An application of activity-based costing technique.

INTRODUCTION: The educational service is expensive and having the right financial information is one of the most important tools for managing financial resources. Therefore, due to the importance of this issue, this study aimed to determine the cost of educational services for medical sciences students at Alborz University of Medical Sciences. METHODOLOGY: A cross-sectional study was conducted between March 20, 2018, and March 20, 2019, at Alborz University of Medical Sciences. The current and capital cost data were extracted from the university's financial database, and the cost price of services provided was calculated using the activity-based cost model. RESULTS: The mean annual cost of services per student was $4778, and the mean cost of education per hour was $113. The total cost price of services provided per student at the school was 65% for wages and salary, 26% for depreciation of building and equipment, and 9% for consumable goods and services. Furthermore, the share of different cost centers to the total cost price of services provided per student was 82% for educational services, 11.9% for student welfare services, and 6.1% for research services. CONCLUSION: Costs of personnel, especially pays to faculty members and the costs of capital expenditures, are the most important costs in higher education institutions. It seems reducing of pay to faculty members through novelty approach of education and evaluation, reducing capital expenditures through use effective of buildings and equipment that can be placed higher education institutions in the path to productivity.

Incidence of pressure ulcers in intensive care units and direct costs of treatment: Evidence from Iran.

BACKGROUND AND OBJECTIVE: Pressure ulcer (PU) is one of the important and frequent complications of hospitalization, associated with high treatment costs. The present study was conducted to determine the incidence of PU and its direct treatment costs for patients in intensive care unit (ICU) in Iran. MATERIAL AND METHODS: In this retrospective study, medical records of 643 discharged patients from ICU of two selected hospitals were examined. The demographic and clinical data of all patients and data of resources and services usage for patients with PU were extracted through their records. Data analysis was done using logistic regression tests in SPSS 22 software. The cost of PU treatment was calculated for each grade of ulcer. RESULTS: The findings showed that 8.9% of patients developed PU during their stay in ICU. Muscular paralysis (OR = 5.1), length of stay in ICU (OR = 4.0), diabetes (OR = 3.5) age (OR = 2.9), smoking (OR = 2.1) and trauma (OR = 1.4) were the most important risk factors of PU. The average cost of PU treatment varied from USD 12 for grade I PU to USD 66 834 for grade IV PUs. The total treatment costs for all studied patients with PU was estimated at USD 519 991. CONCLUSION: The cost of PU treatment is significant. Since the preventive measures are more cost-effective than therapeutic measures, therefore, effective preventive interventions are recommended.

Cost of Tuberculosis Treatment: Evidence from Iran's Health System.

OBJECTIVES: This study aimed to estimate the cost of smear-positive drug-susceptible pulmonary tuberculosis (TB) treatment of the patients in the Azadshahr district, Golestan Province, Iran. METHODS: In this retrospective study, all new smear positive pulmonary TB patients who had been registered at the district's health network between April, 2013 and December, 2015 and had successfully completed their treatment were entered into the study (45 patients). Treatment costs were estimated from the provider's perspective using an activity-based costing (ABC) method. RESULTS: The cost of treating a new smear-positive pulmonary TB patient was US dollar (USD) 1,409.00 (Iranian Rial, 39,438,260), which can be divided into direct and indirect costs (USD 1,226.00 [87%] and USD 183.00 [13%], respectively). The highest cost (58.1%) was related to care and management of TB patients (including 46.1% human resources costs and 12% directly-observed treatment, short course implementation) and then respectively related to hospitalization (12.1%), supportive activity centers (11.4%), transportation (6.5%), medicines (5.3%), and laboratory tests and radiography (3.2%). CONCLUSION: Using disease-specific cost studies can help the healthcare system management to have correct insight into the financial burden created by the disease. This can subsequently be used in prioritization, planning, operational budgeting, economic evaluation of programs, interventions, and ultimately in disease management.

Hospital responsiveness and its effect on overall patient satisfaction.

Purpose Hospital responsiveness to the patient expectations of non-medical aspect of care can lead to patient satisfaction. The purpose of this paper is to investigate the relationship between the eight dimensions of responsiveness and overall patient satisfaction in public and private hospitals in Tehran, Iran. Design/methodology/approach This cross-sectional study was conducted in 2015. In all, 500 patients were selected by the convenient sampling method from two public and three private hospitals. All data were collected using a valid and reliable questionnaire consisted of 32 items to assess the responsiveness of hospitals across eight dimensions and four items to assess the level of overall patient satisfaction. Data analysis was performed using descriptive statistics and multivariate regression was performed by SPSS 18. Findings The mean score of hospital responsiveness and patient satisfaction was 3.48±0.69 and 3.54±0.97 out of 5, respectively. Based on the regression analysis, around 65 percent of the variance in overall satisfaction can be explained by dimensions of responsiveness. Seven independent variables had a positive impact on patient satisfaction; the quality of basic amenities and respect for human dignity were the most powerful factors influencing overall patient satisfaction. Originality/value Hospital responsiveness had a strong effect on overall patient satisfaction. Health care facilities should consider including efforts to responsiveness improvement in their strategic plans. It is recommended that patients should be involved in their treatment processes and have the right to choose their physician.

Service quality of hospital outpatient departments: patients' perspective.

PURPOSE: Assessment of patient perceptions of health service quality as an important element in quality assessments has attracted much attention in recent years. The purpose of this paper is to assess the service quality of hospital outpatient departments affiliated to Shahid Beheshti University of Medical Sciences from the patients' perspective. DESIGN/METHODOLOGY/APPROACH: This cross-sectional study was conducted in 2014 in Tehran, Iran. The study samples included 500 patients who were selected by multi-stage random sampling from four hospitals. The data collection instrument was a questionnaire consisting of 50 items, and the validity and reliability of the questionnaire were confirmed. For data analysis, exploratory and confirmatory factor analysis, Friedman test, and descriptive statistics were used through LISREL 8.54 and SPSS 18 applications. FINDINGS: Eight significant factors were extracted for outpatient service quality, which explained about 67 per cent of the total variance. Physician consultation, information provided to the patient, and the physical environment of the clinic were the three determining factors of the quality of outpatient services. The highest and lowest perceptions were related to physician consultation and perceived waiting time dimension, respectively. The mean score of patients' perception of outpatient service quality was 3.89 (±0.60). About 59.5 per cent of patients assessed the quality of outpatient services as good, 38.2 per cent as moderate, and 2.3 per cent as poor. Practical implications - The instrument developed for this study is valid and reliable, and it can help hospital managers to identify the areas needing improvement and correction. ORIGINALITY/VALUE: According to the findings of this study, the majority of patients had a positive experience with outpatient departments of teaching hospitals, and the services provided in these centres were of adequate quality, based on patient assessments.

Predictors of inappropriate hospital stay: experience from Iran.

OBJECTIVE: Hospital services are the most expensive component of modern health care systems and inappropriate hospital stay is one of the most important challenges facing hospitals in many countries. The purpose of this study was to determine the extent of inappropriate hospital stay and investigate the related factors in Semnan city (Iran). METHODS: In this study, the Iranian version of Appropriateness Evaluation Protocol (AEP) was used in a representative sample of 300 hospital admissions and 905 hospital days. Data collection was performed during six weeks in January and February 2014 in four wards (two internal medicine and two surgical wards) of two hospitals in Semnan city (Iran). RESULTS: The results showed that 7.4% of admissions and 22.1% of stays have been inappropriate. Inappropriate stays were mainly concerned to the factors, including length of stay, inappropriate admissions, as well as factors related to hospitals. The most frequent causes of unjustifiable days were due to waiting for diagnostic or therapeutic procedures (35.1%), and 20.6% delay in discharge of patients by physicians due to conservative medical policy. CONCLUSION: In conclusion, this study confirms the existence of inappropriate hospital stays which may be due to patient characteristics and hospital factors. The most unjustifiable reasons for inappropriate hospital stay were related to internal processes of hospital, which mostly could be prevented through appropriate management Therefore, some steps must be taken to decrease inappropriate hospital stay and preserve hospital resources for patients who need them.

Factors affecting job motivation among health workers: a study from Iran.

OBJECTIVE: Human resources are the most vital resource of any organizations which determine how other resources are used to accomplish organizational goals. This research aimed to identity factors affecting health workers' motivation in Shahid Beheshti University of Medical Sciences (SBUMS). METHOD: This is a cross-sectional survey conducted with participation of 212 health workers of Tehran health centers in November and December 2011. The data collection tool was a researcher-developed questionnaire that included 17 motivating factors and 6 demotivating factors and 8 questions to assess the current status of some factors. Validity and reliability of the tool were confirmed. Data were analyzed with descriptive and analytical statistical tests. RESULTS: The main motivating factors for health workers were good management, supervisors and managers' support and good working relationship with colleagues. On the other hand, unfair treatment, poor management and lack of appreciation were the main demotivating factors. Furthermore, 47.2% of health workers believed that existing schemes for supervision were unhelpful in improving their performance. CONCLUSIONS: Strengthening management capacities in health services can increase job motivation and improve health workers' performance. The findings suggests that special attention should be paid to some aspects such as management competencies, social support in the workplace, treating employees fairly and performance management practices, especially supervision and performance appraisal.