Compensation based on work relative value unit for cardiovascular surgeons in Iran: A mixed method study.

BACKGROUND: Work relative value unit (wRVU) is a tool for assessing surgeons' performance, compensation, and productivity. It appears that wRVU for cardiovascular procedures does not consider complexity and its value for lengthy operations is low. The aim of the study is to determine wRVU for cardiovascular procedures in Iran according to the proposed approach. MATTERIALS AND METHODS: This study was conducted as a mixed method in teaching hospitals in Tabriz in the period of September 2020 to December 2021. According to Hospital Information System and expert opinions, six procedures in cardiovascular surgery were included in the study. They were compared with 18 procedures in neurosurgery, orthopedics, and otorhinolaryngology in terms of the operation time and wRVU/min. Then, we calculated new wRVUs for the selected procedures based on surgeons' opinions, time measurements, and anesthetists' points of view by content analysis in qualitative and statistical analysis in quantitative parts. RESULTS: Among the six cardiac procedures, the wRVU for five was under-estimated. The wRVU/min value ranged from 0/28 to 1/15 in the studied procedures. Findings demonstrate no significant relationship between the length of operations and the wRVU announced by the Ministry of Health and Medical Education (P value >0/05). Compared to studied procedures in four specialties, thoracoabdominal aortic aneurysm repair has the longest surgery time at 417 minutes. According to anesthesiologists, cardiovascular; orthopedics; ear, nose, and tongue; and neurosurgery specialties obtained 4/2, 2/9, 2/8, and 4, respectively, in terms of surgery duration, complexity, risk, and physical effort. CONCLUSION: Despite policymakers' attempts to bring justice to payments, it seems that there has been little progress in paying cardiovascular surgeons. Improper payment to cardiovascular surgeons will affect the future of the workforce in this specialty. Today, the need to reconsider the wRVUs in heart specialty is felt more than before.

Factors Affecting Inequality in the Quality Diets: A Scoping Review.

OBJECTIVES: the current dietary pattern is found increasingly unsafe, unstable, and unequal for a huge part of the populations. Disadvantaged populations were usually known by less healthy diets and were at a higher risk of disease in comparison with high socioeconomic groups. The current scoping review study aims at indicating the effective factors on inequality in the quality of diets. METHODS: the academic databases, including Scopus, Web of science, PubMed, Scientific Information Database, Islamic World Science Citation Center, Google scholar search engine, World Health Organization, and the website of the European Union, until April 2021, were systematically reviewed. We used vote counting technique to identify the effective factors causing inequality in the quality of diets. RESULTS: The factors that have caused inequality in the quality of diets were divided into 3 categories of demographic, lifestyle, and socioeconomic. It was found that any increase in age, income, education, different ethnic groups, smoking, and occupational statues increased inequality in diet quality. Also, as a factor physical activity, could reduce inequality in diet quality. Moreover, type of residence in terms of access to food, dominant available food, and culture of the area could cause inequality in diet quality. CONCLUSIONS: According to the results of this study, the effective factors on inequality in the quality of diet are demographic and socioeconomic factors that cannot be manipulated by policy makers. Nevertheless, increasing the knowledge of individuals, improving their lifestyle, and providing subsidies to poorer individuals reduce inequality in the quality of the diets.

How Much Should We Pay to Deliver Comprehensive Mental and Social Health Services? Experiences from Iran.

Objective: Comprehensive mental and social health services is the new benefit package which had been aimed to provide mental health services to people who suffer from mental disorders. The aim of this study was to estimate the cost of plan and its drivers to provide evidence for decision-making by national policymakers. Method : We used the bottom-up costing approach to estimate the cost of plan. We identified the cost centers, services delivery process, and facilities. Data were collected via different sources and tools such as the new financial system, registration forms, and performance reporting forms. We categorized the cost into 4 groups and selected appropriate measures to estimate the cost. We estimate the total and unit cost for 3 levels in 2 scenarios by considering the 2017 prices. Results: Screening resulted in 8.9% new detection with a different incidence in urban and rural areas (urban: 16.5%; rural: 2.7%). Also, 61 842 million IRR was spent for the screening, diagnose, treatment, and rehabilitation of detected people in 2017. Personal cost is responsible for 90.6% and primary screening for 66.4% of the total cost. Conclusion: For the development of the program (from screening to rehabilitation) 530 513 IRR should be spent per capita. The cost of detection per client can vary due to differences in disease prevalence, especially treatment and rehabilitation costs. It is suggested to consider the variation of the prevalence in expanding the plan to the whole country. Integrating the services in primary health care lead to huge cost saving.

A review of appropriate indicators for need-based financial resource allocation in health systems.

BACKGROUND: Optimal, need-based, and equitable allocation of financial resources is one of the most important concerns of health systems worldwide. Fulfilling this goal requires considering various criteria when allocating resources. The present study was conducted to identify the need indicators used to allocate health resources in different countries worldwide. METHODS: A systematic review conducted on all published articles and reports on the need-based allocation of health financial resources in the English language from 1990 to 2020 in databases, including PubMed, Cochrane, and Scopus as well as those in Persian language databases, including magiran, SID, and Google and Google scholar search engines. After performing different stages of screening, appropriate studies were identified and their information were extracted independently by two people, which were then controlled by a third person. The extracted data were finally analyzed by content analysis method using MAXQDA 10 software. RESULT: This search yielded 823 studies, of which 29 were included for the final review. The findings indicated that many need-based resource allocation formulas attempt to deal with health care needs using some weighting methods for individuals. In this regard, the most commonly used indicators were found as follows: age, gender, socio-economic status or deprivation, ethnicity, standardized mortality ratio (SMR), the modified health indicators (disease consequences, self-assessed health, and disability), geographical area / place of residence (geographical) (rural versus urban), cross-boundary flows, cost of services, and donations. CONCLUSION: The indicators used in allocating the health systems' financial resources in each country should be designed in order to be simple and transparent and in accordance with the moral norms of that society. Moreover, these should be a good representative of the health needs of people in different geographical areas of that country. In addition, their related data should be available to an acceptable extent.

Development of a local model for measuring the work of surgeons.

Objectives: The Relative Value Unit (RVU) is the main method of calculating surgeons' reimbursements and a tool for measuring the work of surgeons. Existing evidence shows that the work Relative Value Unit (wRVU) does not accurately represent surgeon's work. Therefore, the current study attempted to develop a local model to measure surgeons' work. Material and Methods: This study was conducted in two main phases of determining the metrics and model development using quantitative and qualitative approaches from December 2019 to April 2021. Literature review, focused group discussions, and interviews were used to collect data. Con- tent analysis and Exploratory Data Analysis techniques were applied to analyze data. Results: The findings demonstrated that patient's conditions (age, severity of disease at referring time, and comorbidities), disease specifications (time, complexity, physical effort, and risk), and provider characteristic (surgeon's willingness, imposed stress, and surgeon's skill) were important by 17, 51, and 32%, respectively, in determining surgeons' work. Conclusion: Determining a fixed value for each procedure does not accurately estimate the amount of required surgeon's work for any procedure. Many factors, such as the patient's condition, surgeon's characteristics, and disease specification affect surgeons' work in the operation room. Proper measurement of the surgeon's work is an important step towards establishing equity in payment in the health system.

Is Newborn Hearing Screening Cost Effective? Economic Consideration for Policy Makers.

BACKGROUD: Hearing loss is the most common congenital disorder that appears as a unilateral or bilateral deafness. Early detection by screening and appropriate intervention lead to better oral communication and language development. The aim of this study was to evaluate the cost per new case identification of neonate hearing screening. METHODS: The cost effectiveness of two stage hospital based newborn hearing loss screening was evaluated in this study. We gathered data for 11168 newborns born in 10 hospitals. We included a direct cost and new case identification as cost and outcome measures from health system prospective in our model. RESULTS: We found 19 new cases with hearing loss from 11168 screened neonates (1.7 per 1000). The referral rates in the first and second stages were respectively 28% and 7%. The total cost of screening program was 132167 US$. The main cost item is screening test (OAE). CONCLUSIONS: We concluded cost per new case detection is 6956 US$ in Iranian neonate hearing screening program. Almost, it is equal to GDP per capita and it may be cost effective. Since there are many strategies to screening of newborn, it is suggested that all alternative screening strategies be analyzed by a cost effectiveness method to find the best strategy for hearing loss screening.

Cost-Effectiveness Analysis of Colorectal Cancer Screening: A Systematic Review.

INTRODUCTION: Colorectal cancer (CRC) is a significant health problem with an increasing incidence worldwide. Screening is one of the ways, in which cases and deaths of CRC can be prevented. The objective of this systematic review was to evaluate the cost-effectiveness of the different CRC screening techniques and to specify the efficient technique from a cost-effectiveness perspective. METHODS: The economic studies of CRC screening in general populations (average risk), aged 50 years and above were reviewed. Two reviewers independently reviewed the titles, abstracts, and full-texts of the studies in five databases: Cochrane, Embase, Scopus, Web of Science and PubMed. The disagreements between reviewers were resolved through the authors' consensus. The main outcome measures in this systematic review were the incremental cost-effectiveness ratio (ICER) of screening versus no-screening and then in comparison with other screening techniques. The ICER is defined by the difference in cost between two possible interventions, divided by the difference in their effect. RESULTS: Eight studies were identified and retained for the final analysis. In this study, when screening techniques were compared to no-screening, all CRC screening techniques showed to be cost-effective. The lowest ICER calculated was $PPP -16265/quality-adjusted life-year (QALY) (the negative ICERs were between purchasing power parity in US dollar ($PPP) -16265/QALY to $PPP -1988/QALY, whereas the positive ICERs were between $PPP 1257/QALY to $PPP 55987/QALY). For studies comparing various screening techniques, there was great heterogeneity in terms of the structures of the analyses, leading to diverse conclusions about their incremental cost-effectiveness. CONCLUSION: All CRC screening techniques were cost-effective, compared with the no-screening methods. The cost-effectiveness of the various screening techniques mainly was dependent on the context-specific parameters and highly affected by the framework of the cost-effectiveness analysis. In order to make the studies comparable, it is important to adopt a reference-based methodology for economic evaluation studies.

Future Development Through the Past: Pathology of the Financing Dimension of Iran's Health Transformation Plan.

BACKGROUND: In Iran, during the years, the budgeting model used for healthcare funding is affected by factors such as global oil prices and fluctuation in the exchange rates. So, developing or continuing to implement a plan in the health system depends on the current and future global and local economic trends. OBJECTIVE: To analyze the future of the recent significant reform called Health Transformation Plan (HTP), started on June 15, 2014, in the light of potential financial barriers and challenges. METHODS: Face-to-face interviews were conducted with health policymakers at different levels of the health system, health researchers, health insurance officers, and faculty members. Also, published and unpublished documents about HTP in the country and worldwide were reviewed. Data analysis was done using a qualitative inductive content analysis approach and assisted by qualitative data management software. RESULTS: Instability of financial resources and allocation of gross domestic product (GDP) to the HTP in the traditional way is a challenge in continuing this policy reform. Also, the bureaucratic procedures in allocation and distribution of funds, the discrepancy between health insurance funds and affiliated units of Ministry of Health and Medical Education (MoHME) especially Medical Sciences Universities (MSU), the lack of purchaser-provider split, inappropriate payments and compensation mechanisms, and dependence of MSU on especial revenues are the main challenges that threaten the future of HTP in Iran. CONCLUSION: Given the current situation, where the country's funding resources are often unpredictable, it seems that such funding challenges will lead to poor HTP results. Therefore, the continuance of such a high cost-based plan requires the strategies and policies to ensure raising additional funds through various types of innovative financing to overcome challenges.

Comparing selected countries using sin tax policy in sustainable health financing: Implications for developing countries.

BACKGROUND: Sustainable health financing is one of the main challenges of policy makers and planners. This study aimed at comparing the experiences of countries in using the sin tax policies for sustainable health financing resources. METHODS: This qualitative study was conducted in two phases. First, a comparative study was carried out by searching databases from 1990 to 2017, and six countries (Thailand, England, Australia, the Philippines, South Africa, and Vietnam) were selected. Second, the existing Iranian high policy documents from 2005 to 2017 were reviewed deeply by using the content analysis method. RESULTS: The sin tax, such as taxes on tobacco and alcohol, was one of the main policies to provide sustainable health financing in all selected countries. The Iranian health system had no significant-related legal and political gap, but there were limitations in enforcing and implementing them. Finally, it is necessary to evaluate the policy and follow its effects up. CONCLUSIONS: The main financial resources in the selected countries included health promotion funds with different names and goals which took taxes on harmful goods, tobacco, and alcohol. Weaknesses in implementing laws and monitoring them were the main reasons for the lack of sustainable financing.

Sustainable financing of health promotion services in selected countries: Best experience for developing countries.

Background: Sustainable health financing is one of the main challenges of policymakers in the health system. Thus, this study aimed to investigate the sustainable financing of health promotion services in 7 selected countries and to analyze the related documents in Iran in 2018. Methods: This was a comparative and qualitative study (document analysis). In the comparative phase, the studies related to the selected countries- Australia, England, Germany, Japan, Turkey, Sweden, and Denmark- were investigated. In the second phase of the study, through a qualitative method of content analysis, 60 related documents were examined from 2005 to 2018. The initial evaluation of the documents was done using the Scott method and data were analyzed using Nvivo 8 software. Results: Based on the main findings of the study, there were a variety of approaches to the sustainable financing of health promotion services: excise taxes on goods; health-related behaviors regarding tobacco and alcohol consumption and gambling; using the capacities of social insurance funds in Germany and Turkey; and relying on the government budget in all the studied countries. According to the results of documents analysis related to the sustainable financing of health promotion in Iran, 3 main issues and 11 sub issues were identified. Conclusion: Using any of these methods or a combination of them depends on the political, social, and cultural structure of each country. The provisions of the law seem to be almost comprehensive; however, implementation, operationalization and monitoring of these elements are of significant importance.

Forecasting health expenditures in Iran using the ARIMA model (2016-2020).

Background: Accurate economic forecast has important effects on governmental policy and economic planning, and it can help policymakers to make decisions for future and create new infrastructures for the development of new forecasting methods. This study calculated total health expenditure, public health expenditure and out of pocket (OOP) payment for 2016-2020. Methods: Autoregressive Integrated Moving Average Process (ARIMA) is one of the most important forecasting models. In this study, five-year values were forecasted using EViews8 software according to health expenditures in Iran from 1971 to 2015. Results: Applying annual data for total health expenditure, resulted in the ARIMA (1,1,1) model being the most appropriate to predict these costs. The results of this study indicate that total health expenditures will reach from about 1228338 billion IRR in 2016 to 2698346 billion IRR in 2020 and the amount of out of pocket (OOP) will become more than 41% of total health expenditure in 2020. Conclusion: Total health expenditures in 2020 will become more than two halves in 2016. These expenditures indicated there is a need for continued governmental support of this sector during the upcoming years.

The Study of Effective Factors on Iran's Pharmaceutical Export Supply and Demand.

The importance of drug as a valuable export product in the global economy becomes clearer every day. Understanding the problems of exports and factors affecting it, can be an important step to keep Iran's position in the world markets and further export development of this product. In this study, Iranian pharmaceutical exports' supply and demand functions were calculated using co-integration and error correction techniques through time series quarterly data of 2000-2014 in order to identify the factors affecting pharmaceutical exports (short run and long run relationships among the variables) and price and income elasticities. The long run price elasticity of demand of -2.28 indicates that an increase in Iran's export price relative to competitor's export price will have a negative impact on pharmaceutical export volume. Also, the long run income elasticity of foreign demand for pharmaceutical exports of Iran is 1.11. That is an increase in income of foreign countries will have a positive impact on Iran's pharmaceutical export. On the other hand, the long run price elasticity of export supply is 1.09, indicating that the supply of pharmaceutical export is sensitive to the relative price changes. In other words, an increase in export price relative to domestic price as well as an expansion of the pharmaceutical production capacity will increase its export supply. Being aware of the factors affecting the pharmaceutical exports can prepare the ground to develop the pharmaceutical industry and balance the supply and demand in the long run. Therefore, the results of this study can help Iran's policymakers and managers to choose a clearer path for the pharmaceutical trade policies.

Linagliptin versus sitagliptin in patients with type 2 diabetes mellitus: a network meta-analysis of randomized clinical trials.

BACKGROUND: Diabetes is one of the most common chronic and costly diseases worldwide and type 2 diabetes is the most common type which accounts for about 90% of cases with diabetes. New medication-therapy regimens such as those containing linagliptin alone or in combination with other medications (within the category of DDP-4 inhibitors) must be evaluated in terms of efficacy and compared with other currently used drugs and then enter the medication list of the country. Hence, this study aimed to compare the clinical efficacy of the two drugs, i.e. linagliptin and sitagliptin, in patients with type 2 diabetes. METHODS: A systematic review was conducted to identify all clinical trials published by 2015 which compared the two drugs in patients with type 2 diabetes. Using keywords such as "linagliptin", "type 2 diabetes mellitus", "sitagliptin" and related combinations, we searched databases including Scopus, PubMed, and Web of Science. The quality of the selected studies was evaluated using the Jadad score. Considering primary and secondary outcomes extracted from the reviewed studies, a network meta-analysis was used to conduct a systematic comparison between the two studied drugs. RESULTS: This network meta-analysis included 32 studies (Linagliptin vs PLB: n = 8, Sitagliptin vs PLB: n = 13, Linagliptin + MET vs PLB + MET: n = 4, and Sitagliptin + MET vs PLB + MET: n = 7) and a total of 13,747 patients. The results showed no significant difference between linagliptin and sitagliptin in terms of key efficacy and safety outcomes such as HbA1c changes from baseline, body weight change from baseline, percentage of patients achieving HbA1c <7, and percentage of patients experiencing hypoglycemic events (p > 0.05). The results showed that the efficacy of the two drug regimens was the same. CONCLUSIONS: Based on the results, there was no significant difference between the two drugs, i.e. linagliptin and sitagliptin, in terms of efficacy; in other words, the efficacy of the two drugs was the same. Therefore, the use of these two drugs depends on their availability and cost. Graphical abstract of the network meta-analysis performed to evaluate the alternatives under the study.

Social accounting matrix and the effects of economic reform on health price index and household expenditures: Evidence from Iran.

Background: Socioeconomic indicators are the main factors that affect health outcome. Health price index (HPI) and households living costs (HLC) are affected by economic reform. This study aimed at examining the effect of subsidy targeting plan (STP) on HPI and HLC. Methods: The social accounting matrix was used to study the direct and indirect effects of STP. We chose 11 health related goods and services including insurance, compulsory social security services, hospital services, medical and dental services, other human health services, veterinary services, social services, environmental health services, laundry& cleaning and dyeing services, cosmetic and physical health services, and pharmaceutical products in the social accounting matrix to examine the health price index. Data were analyzed by the I-O&SAM software. Results: Due to the subsidy release on energy, water, and bread prices, we found that (i) health related goods and services groups' price index rose between 33.43% and 77.3%, (ii) the living cost index of urban households increased between 48.75% and 58.21%, and (iii) the living cost index of rural households grew between 53.51% and 68.23%. The results demonstrated that the elimination of subsidy would have negative effects on health subdivision and households' costs such that subsidy elimination increased the health prices index and the household living costs, especially among low-income families. The STP had considerable effects on health subdivision price index. Conclusion: The elimination or reduction of energy carriers and basic commodities subsidies have changed health price and households living cost index. Therefore, the policymakers should consider controlling the price of health sectors, price fluctuations and shocks.

Cost effectiveness of type 2 diabetes screening: A systematic review.

BACKGROUND: Although studies reported diabetes mellitus screening cost effective, the mass screening for type2 diabetes remains controversial. In this study we reviewed the recently evidence about the cost effectiveness of mass screening systematically. METHODS: We reviewed the MEDLINE, Scopus, Web of Science (WOS), and Cochrane library databases by MeSH terms to identify relevant studies from 2000 to 2013. We had 4 inclusion and 6 exclusion criteria and used the Drummond's checklist for appraising the quality of studies. RESULTS: The initial search yielded 358 potentially related studies from selected databases. 6 studies met our inclusion and exclusion criteria and included in final review. 3 and 2 of them were conducted in Europe and America and only one of them in Asia. Quality-adjusted life year (QALY) was the main outcome to appraise the effectiveness in the studies. Incremental cost effectiveness ratio (ICER) was computed in range from $516.33 to $126,238 per QALY in the studies. CONCLUSION: A review of previous diabetes screening cost effectiveness analysis showed that the studies varied in some aspects but reached similar conclusions. They concluded that the screening may be cost effective, however further studies is required to support the diabetes mass screening.

Cost effectiveness analysis of Avonex and CinnoVex in Relapsing Remitting MS.

INTRODUCTION: Multiple sclerosis is a chronic and degenerative neurological disease characterized by loss of myelin sheath of some neurons in brain and spinal cord. It is associated with high economic burden due to premature deaths and high occurrence of disabilities. The aim of the current study was to determine cost effectiveness of two major products of interferon 1a in patients with relapsing-remitting multiple sclerosis. METHOD AND MATERIALS: Altogether, 140 patients who have consumed Avonex and CinnoVex in Relapsing Remitting MS for at least two years were randomly selected (70 patients in each group). Health-related quality of life (HRQoL) was assessed using the adopted MSQoL-54 instrument. Costs were measured and valued from Ministry of Health and Medical Education (MOHME) perspective. Two-way sensitivity analysis was used to check robustness of the results. RESULTS: Patients in CinnoVex group reported significantly higher scores in both physical (69.5 vs. 50.9, P<0.001) and mental (63.3 vs. 56.6, P=0.03) aspects of HRQoL than Avonex group. On the other hand, annual cost of CinnoVex and Avonex were 2410 US$ and 4515US$ per patient, respectively (P<0.001). CONCLUSIONS: The results showed that CinnoVex was dominant option over the study period. It is suggested that results of the current study should be considered in allocating resources to MS treatments in Iran. Of course, our findings should be interpreted with caution duo to short term horizon and lack of HRQoL scores at baseline (before the intervention).

Temperature measurement in WTE boilers using suction pyrometers.

The temperature of the flue-gas in the post combustion zone of a waste to energy (WTE) plant has to be maintained within a fairly narrow range of values, the minimum of which is prescribed by the European Waste Directive 2000/76/CE, whereas the maximum value must be such as to ensure the preservation of the materials and the energy efficiency of the plant. A high degree of accuracy in measuring and controlling the aforementioned temperature is therefore required. In almost the totality of WTE plants this measurement process is carried out by using practical industrial thermometers, such as bare thermocouples and infrared radiation (IR) pyrometers, even if affected by different physical contributions which can make the gas temperature measurements incorrect. The objective of this paper is to analyze errors and uncertainties that can arise when using a bare thermocouple or an IR pyrometer in a WTE plant and to provide a method for the in situ calibration of these industrial sensors through the use of suction pyrometers. The paper describes principle of operation, design, and uncertainty contributions of suction pyrometers, it also provides the best estimation of the flue-gas temperature in the post combustion zone of a WTE plant and the estimation of its expanded uncertainty.

Geographic distribution of need and access to health care in rural population: an ecological study in Iran.

INTRODUCTION: Equity in access to and utilization of health services is a common goal of policy-makers in most countries. The current study aimed to evaluate the distribution of need and access to health care services among Iran's rural population between 2006 and 2009. METHODS: Census data on population's characteristics in each province were obtained from the Statistical Centre of Iran and National Organization for civil registration. Data about the Rural Health Houses (RHHs) were obtained from the Ministry of Health. The Health Houses-to-rural population ratio (RHP), crude birth rate (CBR) and crude mortality rate (CMR) in rural population were calculated in order to compare their distribution among the provinces. Lorenz curves of RHHs, CMR and CBR were plotted and their decile ratio, Gini Index and Index of Dissimilarity were calculated. Moreover, Spearman rank-order correlation was used to examine the relation between RHHs and CMR and CBR. RESULTS: There were substantial differences in RHHs, CMR and CBR across the provinces. CMR and CBR experienced changes toward more equal distributions between 2006 and 2009, while inverse trend was seen for RHHs. Excluding three provinces with markedly changes in data between 2006 and 2009 as outliers, did not change observed trends. Moreover; there was a significant positive relationship between CMR and RHP in 2009 and a significant negative association between CBR and RHP in 2006 and 2009. When three provinces with outliers were excluded, these significant associations were disappeared. CONCLUSION: Results showed that there were significant variations in the distribution of RHHs, CMR and CBR across the country. Moreover, the distribution of RHHs did not reflect the needs for health care in terms of CMR and CBR in the study period.