Physician Induced Demand: The Empirical Evidence of Angiography for Suspected Coronary Artery Disease.

Background: We aimed to investigate the existence of unnecessary demand for angiography and the factors affecting it to provide evidence for decision makers. Methods: This longitudinal panel study was conducted in public hospitals in Tehran, Iran by using 2458 patients' records that were undergoing angiography for suspected coronary artery disease 2013-2015. To modeling the physicians' behavior based on physician-induced demand (PID), the patients were classified as appropriate, uncertain, and inappropriate and then Hierarchical Linear Modeling (HLM) model besides the physician ethic index was developed and finally the existence of PID showed based on three scenarios. Results: Angiographies were performed inappropriately in 23.8% of 2458 patients as well 46.7% were uncertain, and 29.5% were appropriate. According to the HLM model, the physician-to-population ratio (δ0= -0.161) and the interaction variable coefficient are higher than zero and significant (δ1 = 253). The results of the physician ethic index showed that most physicians were at a moderate rate, meaning that their utility was a combination of both pecuniary and non-pecuniary profits (0 < | ɛpδ |<1). Considering the HLM model and the medical ethics index together has almost shown the condition of PID (the necessary condition δ1> 0 and the sufficient condition (1 ≤ |ɛpδ|)) existed for about 26% of all studied physicians who had pure profit maximizer. Conclusion: To reduce induced demand and improve medical ethics adherence in cardiologist, policy makers should develop native guidelines, rules, and instructions besides policies related to education, and increasing patients' awareness.

Community health workers (Behvarz) in primary health care: a qualitative inductive content analysis of challenges.

BACKGROUND: Behvarzs are the backbone of primary healthcare services in the Iranian health system and play a key role in providing efficient, responsive, and equitable services at the first level of service provision. This study aimed to identify the challenges of Behvarzs to provide a perspective for policymakers and managers to help them formulate future programs to enhance the efficiency of the health system. METHODS: Following a qualitative design, an inductive content analysis approach was used to analyse the data. The healthcare network of the Alborz province (Iran) was considered as the study context. A total of 27 interviews were conducted with policymakers, development managers, managers of Behavrz training centres, and Behvarz workers in 2020. All interviews were audio-taped and transcribed, followed by data analysis using MAXQDA ver. 10. RESULTS: Five themes were identified: service provision (scope of services, ambiguity of roles, non-compliance with the referral system, the quality of data entry, quality of services), access to equipment (quantity, quality), administrative issues (macro planning, micro planning), training (appropriateness of information, quality of training, recruiting related staff), perceived equity and fairness (balance between workload, income, and benefits, job satisfaction, job promotion). CONCLUSION: Occupational challenges affect the performance of Behvarzs in responding to society's needs because they not only play a major role in the health system, but also contribute to addressing the communication gap between local communities and high-level institutions, leading to the alignment of policy implementation. Therefore, strategies that emphasise the role of Behvarzs should be followed to promote community engagement.

Methods and criteria for the assessment of orphan drugs: a scoping review.

OBJECTIVES: This study aimed to identify different criteria for priority setting of rare diseases to help policy makers in making evidence-informed decisions. METHODS: A scoping review was conducted to comprehensively examine the existing various methods and criteria for prioritizing orphan drugs and rare diseases. We performed searching in Scopus, PubMed, Embase, and websites of health technology assessment (HTA) agencies, 2000-21, and data were extracted. RESULTS: From the 1,580 identified publications, eleven articles were included. Multicriteria decision analysis was the most frequent method (seven out of eleven studies) used for priority setting. The extracted criteria for priority setting of orphan products were analyzed based on six main categories as follows: health outcomes and clinical implications (six subsets which showed clinical implications), economic aspects (four subsets that indicated the economic effects of orphan drugs and rare diseases), disease and population characteristics (six subsets that included the characteristics of the rare diseases), therapeutic alternatives and uniqueness of orphan technologies (two subsets which discussed the alternatives and uniqueness of orphan technologies), evidence (three subsets which regarded the quality and availability of evidence), and other criteria (three subsets dealing with social and organizational criteria). Cost-effectiveness, budget impact, and disease severity were the most frequent criteria in the studies. CONCLUSIONS: Because of the high price of orphan drugs and limitations of using HTA for reimbursement of them, it is critical to explore them by precise technical methods like multiple criteria decision making in priority setting.

Appropriateness of angiography for suspected coronary artery disease.

The aim of this study was to assess the appropriate use of diagnostic catheterizations (DC) for the patients with suspected coronary artery disease performed in Iran. The Electronic Health Record System database and manual review of files were utilised to collect data between 2012 and 2014. Patients were categorized in three groups as appropriate, uncertain, and inappropriate usage of DC and the logistic regression was used to investigate the relationships between variables. One-quarter of the 2458 angiographies were rated as inappropriate, out of which 99% had no previous stress test. The rate of inappropriate DC between various hospitals were approximately the same. The regression showed that some risk factors (Sex, high cholesterol, smoking, chronic heart failure, renal failure, diabetes) were significantly associated with inappropriate rate.

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.

Cost Effectiveness of Mobile versus Fixed Computed Tomography and Magnetic Resonance Imaging: A Systematic Review.

BACKGROUND: Mobile technologies are widely used in healthcare. The purpose of this study was to compare the effectiveness and cost-effectiveness of fixed computed tomography (CT) and magnetic resonance imaging (MRI) with the mobile ones. METHODS: In this systematic review, PubMed, Cochrane Library, Scopus and CRD database were searched from 1995 to 2015. The data on safety and effectiveness of technologies were extracted from included studies. Because the review showed no significant differences in the performance of mobile CT and MRI compared to the fixed ones, then a cost minimization approach was used to explore the cost-effectiveness of three scenarios. RESULTS: Twenty two articles were included in the review that showed no statistically significant differences in the performance of mobile MRI and CT scan compared to the fixed ones. The cost minimization approach showed that the third scenario based on purchasing a common mobile MRI and CT scan; and using it by two or more hospitals that are in rational distance from each other is associated with the lowest costs, so it is the most cost-effectiveness strategy. CONCLUSION: The performance of Mobile CT and mobile MRI is comparable to the fixed ones; and using a combined mobile CT and MRI by two or three hospitals is the most cost-effective approach.

Caesarean Section vs. Normal Vaginal Delivery: A Game Theory Discussion in Reimbursement Interventions.

BACKGROUND: The rate of caesarean section (C-section) in Iran is too high, so having a plan to control it is crucial. Since one of the most important reasons for inclination of providers to do C-section is financial issues, the purpose of this study was offering financial solutions for increasing normal vaginal delivery (NVD) and decreasing non-indicated C-section. METHODS: This analytical-descriptive research, used game theory for offering financial mechanisms. The game was a dynamic one in which the backward induction was used to obtain a Nash equilibrium. Financial structure and the mean number of NVD and C-section in a certain period of time in comparison with standards were as the main influential factors on financial dimensions and were included in the model. RESULTS: The effect of financial structure was shown through a specified insurance for childbirth, existence of a monitoring department and tariffs. CONCLUSION: The main solution for controlling C-section in designed game was taxes and fines for physician or hospital in non- indicated cases and giving reward otherwise.

Erratum to: Rhinoplasty as a Medicalized Phenomenon: A 25-Center Survey on Quality of Life Before and After Cosmetic Rhinoplasty.

Erratum to: Aesth Plast Surg (2014) 38:615­619. DOI 10.1007/s00266-014-0323-5. The correct affiliation for A. Pourreza, M. Mahmoodi, and F. Akbari is Tehran University of Medical Sciences. The authors regret their error.

Rhinoplasty as a medicalized phenomenon: a 25-center survey on quality of life before and after cosmetic rhinoplasty.

BACKGROUND: Cosmetic surgery, including rhinoplasty, has been dramatically increasing in Iran through the last two decades. It is performed mainly on the youth for the purpose of beauty, an area not directly related to medicine but strongly medicalized. This study aimed to explore the effects of rhinoplasty on the quality of life experienced by individuals who have undergone the surgery. METHODS: From all the plastic surgery clinics in Teheran, 25 were selected randomly as sites for the study. In the next step, 110 patients who had undergone rhinoplasty were selected randomly from these clinics. Only patients whose surgery had been performed 3 to 18 months before the interview were included in the statistical population. Data were collected through a Likert-type questionnaire that queries three major quality-of-life dimensions: general benefit, social support, and physical health. The collected data were analyzed by SPSS. RESULTS: The mean scores for quality of life before and after surgery were 66.54 and 61.11, respectively. The difference was statistically significant (P = 0.008), showing a decline in quality of life after rhinoplasty. Whereas the mean score for social support and physical health decreased, the score for general benefit increased after the surgery. The main motivating factors for surgery were external factors (e.g., friends, family). In addition, the date of the surgery and the time of the interview were positively correlated. In other words, the longer the time since surgery, the greater was the increase in the patients' satisfaction and quality of life. CONCLUSIONS: The overall quality of life among the statistical population decreased. This could be attributed to unnecessary surgeries, medical errors, and performance of rhinoplasty because of its recognized popularity. The reduction in social support may have resulted from unacceptable consequences of rhinoplasty, particularly in terms of appearance, and reactions of family and peer group. The physical health of the respondents was negatively affected by rhinoplasty. Malfunction of the upper respiratory system after rhinoplasty is a known main reason for the negative effect of rhinoplasty on the quality of life. Correlations between the times of the surgery and the interview suggest a long-term rather than an immediate assessment of effects that such surgeries have on the quality of life. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.