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.

Valuing the SF-6Dv2 in the capital of Iran using a discrete choice experiment with duration.

BACKGROUND: The second version of the Short-Form 6-Dimension (SF-6Dv2) classification system has recently been developed. The objective of this study was to develop a value set for SF-6Dv2 based on the societal preferences of a general population in the capital of Iran. METHODS: A representative sample of the capital of Iran (n = 3061) was recruited using a stratified multistage quota sampling technique. Face-to-face interviews were conducted using binary choice sets from the international valuation protocol of the discrete choice experiment with duration. The conditional logit was used to estimate the final value set, and a latent class model was employed to assess heterogeneity of preferences. RESULTS: Coefficients generated from the models were logically consistent and significant. The best model was the one that included an additional interaction term for cases where one or more dimensions reached their most severe levels. It provides a value set with logical consistent coefficients and the lowest percentage of worse than death health states. Predicted values for the SF-6Dv2 were within the range of - 0.796-1. Pain dimension had the largest impact on utility decrement, whereas vitality had the least impact. The presence of preference heterogeneity was evident, and the Bayesian Information Criterion indicated the optimal fit for a latent class model with two classes. CONCLUSION: This study provided the SF-6Dv2 value set for application in the context of Iran. This value set will facilitate the use of the SF-6Dv2 instrument in health economic evaluations and clinical settings.

Health-related quality of life measured using the EQ-5D-3L: iranian population norms.

BACKGROUND: Normative values are valuable for comparing a specific population with the general population, making them particularly useful in disease burden studies and cost-effectiveness analysis. The objective of this study was to estimate HRQoL normative values for the EQ-5D measure in Iran. METHODS: The analysis was performed using a sample (n = 27,704) of the Iranian adult population, which was extracted from a nationwide survey conducted in 2021. Participants assessed their health-related quality of life using the EQ-5D-3 L instrument and a visual analogue scale (EQ VAS). Multivariable regression analyses were performed to examine the relationships between utility scores, EQ VAS scores, and various socio-demographic factors. RESULTS: The mean utility and EQ VAS scores of the total sample were 0.87 (95% CI: 0.86, 0.88) and 72.9 (95% CI: 72.7, 73.1), respectively. Almost half of the respondents (46.8%) reported a health state without any problems. The most prevalent problems were pain/discomfort (38.3%) and anxiety/depression (35.2%). Furthermore, EQ-5D values and EQ VAS scores were associated with gender, age, employment status, education level, marital status, and chronic illness. CONCLUSIONS: This study provided normative values for the general population in Iran. Policymakers and researchers can use these values as a reference for population norms in economic assessments and studies focusing on the population's health.

Direct Costs of Hypertension Treatment in Iran.

Background: Hypertension is a common public health problem with potentially serious consequences. We aimed to explore the direct costs of hypertension treatment in Iran. Methods: Literature review and STEPS survey were used to estimate the incidence and prevalence of hypertension for Iranian males and females and the proportion of its treatment coverage in 2020. A standard national protocol for hypertension treatment was used to estimate the required medical services including visits, medications, and lab tests. The cost of each service and the total cost of the disease were identified using the national reference costs. Results: About 23.39 million people suffer from moderate systolic blood pressure (BP of 120 to 139 mm/Hg) and a further 14.6 million people had severe BP (≥140 mm/Hg). Nearby 39.8% of these patients, receive BP treatment. The direct costs of hypertension treatment were 19,006.08 billion IR Rials (USD 87.54 million), of which 16.60% and 83.40% of the costs were related to new and prior cases, respectively. The costs of patient visits, medications, and lab tests were 56%, 35.51%, and 8.49% of the total costs, respectively. Conclusion: The prevalence and economic burden of hypertension are relatively high in Iran. Early detection and treatment of hypertension might have a significant effect on reducing its complications and costs.

Health-Related Quality of Life in Osteoporosis Patients with and without Fractures in Tehran, Iran.

BACKGROUND: This study aimed to measure the health-related quality of life (HRQOL) of patients with osteoporosis with and without fractures in Tehran, the capital city of Iran. METHODS: We surveyed a sample of 478 patients with osteoporosis aged over 50 years. Participants with fractures included patients referred to hospitals due to osteoporotic fractures which were alive 6 months after the fracture. Participants without fractures were randomly selected from patients with a definite diagnosis of osteoporosis admitted to 3 outpatient clinics in Tehran. Data were collected using the EuroQol 5-dimensional 5-level questionnaire. Statistical differences between patients with and without fracture were tested with Pearson's χ2 test, Student's t-test, and the Mann-Whitney U-test. The association between HRQOL and other variables was evaluated using a multiple linear regression model. RESULTS: The patients' mean age±standard deviation was 67.3±11.9 years, and 74.1% were women. One hundred and seventeen (23%) patients had hip fractures, 56 (11%) had vertebral fractures, 127 (25%) had forearm fractures, and 178 (40%) had no fractures. The median (interquartile range) values of HRQOL scores of those with hip, vertebral, and forearm fractures and those with no history of fracture were 0.53 (0.22), 0.60 (0.28), 0.64 (0.26), and 0.64 (0.27), respectively. The multiple regression model revealed a significant relationship between the HRQOL scores and sex, marital status, employment status, presence of any chronic illness in addition to osteoporosis, and type of fracture. CONCLUSIONS: Osteoporosis and its related fractures can reduce the HRQOL.

A national survey of Iranian general population to estimate a value set for the EQ-5D-5L.

OBJECTIVES: The main aim of this study is to estimate a national value set of the EQ-5D-5L questionnaire for Iran. METHODS: The composite time trade-off (cTTO) and discrete choice experiment (DCE) methods; and the protocol for EuroQol Portable Valuation Technology (EQ-PVT) were used to estimate the Iran national value set. 1179 face-to-face computer-assisted interviews were conducted with adults that were recruited from five Iran major cities in 2021. Generalized least squares, Tobit, heteroskedastic, logit, and hybrid models were used to analyze the data and to identify the best fitting model. RESULTS: According to the logical consistency of the parameters, significance levels and prediction accuracy indices of the MAE; a heteroscedastic censored Tobit hybrid model combining cTTO and DCE responses was considered as the best fitting model to estimate the final value set. The predicted values ranged from - 1.19 for the worst health state (55555) to 1 for full health (11111), with 53.6% of the predicted values being negative. Mobility was the most influential dimension on health state preference values. CONCLUSIONS: The present study estimated a national EQ-5D-5L value set for Iranian policy makers and researchers. The value set enables the EQ-5D-5L questionnaire to use to calculate QALYs to assist the priority setting and efficient allocation of limited healthcare resources.

Policy analysis of nutrition stewardship for prevention and control of Non-communicable diseases in Iran.

BACKGROUND: Non- communicable diseases (NCDs) are the main cause of death, which lead to over 73% of death and 62% of DALYs globally. As an unhealthy diet is the leading behavioral risk factor of NCDs, in line with the national action plan for the prevention and control of NCD, this study explored the nutrition-related stewardship problems to reduce the burden of NCDs in Iran. METHODS: This is a qualitative study. We interviewed 30 purposefully identified key informants, i.e., stakeholders, policymakers, and academics, from December 2018 to August 2019. All interviews were recorded and transcribed verbatim. We analyzed data using qualitative content analysis facilitated by MAXQDA 11 software. RESULTS: Ample policies and laws were identified, most of which were not or partially implemented. Despite some plausible efforts, NCDs do not seem to be a top priority for high-level managers and decision-makers. Besides, the role of non-state actors, i.e., the private sector, is marginal in NCD's planning and management. Whereas the government, e.g., the Food and Drug Organization (FDO), is the biggest player. Worse still, many harmful products are advertised and easily distributed across the country. CONCLUSION: Iran's government has created a noticeable roadmap to battle NCDs despite imposing many sanctions and related socioeconomic problems. Nevertheless, more interventions are needed to strengthen the stewardship of NCDs by various stakeholders. We recommend the government to monitor the implementation of policies and advertisement of harmful products to prioritize prevention and control of NCDs. In addition, we advocate employing the capacity of non-state actors to reduce the consumption of unhealthy food and the burden of NCDs across the country, ultimately.

Drug prescription patterns and their association with mortality and hospitalization duration in COVID-19 patients: insights from big data.

Background: Different medication prescription patterns have been associated with varying course of disease and outcomes in COVID-19. Health claims data is a rich source of information on disease treatment and outcomes. We aimed to investigate drug prescription patterns and their association with mortality and hospitalization via insurance data for a relatively long period of the pandemic in Iran. Methods: We retrieved hospitalized patients' data from Iran Health Insurance Organization (IHIO) spanning 26 months (2020-2022) nationwide. Included were patients with ICD-10 codes U07.1/U07.2 for confirmed/suspected COVID-19. A case was defined as a single hospitalization event for an individual patient. Multiple hospitalizations of a patient within a 30-day interval were aggregated into a single case, while hospitalizations with intervals exceeding 30 days were treated as independent cases. The Anatomical Therapeutic Chemical (ATC) was used for medications classification. The two main study outcomes were general and intensive care unit (ICU) hospitalization periods and mortality. Besides, various demographic and clinical associate factors were analyzed to derive the associations with medication prescription patterns and study outcomes using accelerated failure time (AFT) and logistic regression models. Results: During the 26 months of the study period, 1,113,678 admissions with COVID-19 diagnosis at hospitals working in company with IHIO were recorded. 917,198 cases were detected from the database, among which 51.91% were females and 48.09% were males. Among the main groups of medications, antithrombotics (55.84% [95% CI: 55.74-55.94]), corticosteroids (54.14% [54.04-54.24]), and antibiotics (42.22% [42.12-42.32]) were the top used medications among cases with COVID-19. Investigation of the duration of hospitalization based on main medication groups showed antithrombotics (adjusted median ratio = 0.94 [0.94-0.95]) were significantly associated with shorter periods of overall hospitalization. Also, antithrombotics (adjusted odds ratio = 0.74 [95%CI, 0.73-0.76]), corticosteroids (0.97 [0.95-0.99]), antivirals (0.82 [0.80-0.83]), and ACE inhibitor/ARB (0.79 [0.77-0.80]) were significantly associated with lower mortality. Conclusion: Over 2 years of investigation, antithrombotics, corticosteroids, and antibiotics were the top medications for hospitalized patients with COVID-19. Trends in medication prescription varied based on various factors across the country. Medication prescriptions could potentially significantly impact the trends of mortality and hospitalization during epidemics, thereby affecting both health and economic burdens.

Public preferences regarding the priority setting criteria of health interventions for budget allocation: results of a survey of Iranian adults.

OBJECTIVES: Priority setting in health directly impacts the general public as payers and final consumers, so the public preferences must be considered. The present study aimed to provide public preferences about health intervention allocation criteria for the optimal allocation of public health budget in Iran. METHODS: A choice-based survey method was used to assess the general public's preferences regarding 8 critical criteria with a societal aspect. One thousand sixty-four adult citizens of Tehran, Iran, participated in the study. Participants were asked to allocate a hypothetical budget between the two groups with differences in allocation criteria. Public preferences were inferred from absolute majority responses i.e., more than 50% of participants' allocation for a criterion. The Logistic Regression Model was used to investigate the factors affecting the preferences regarding the importance of allocation criteria. RESULTS: Based on expressed participants' preferences, criteria of disease severity, age, daily care needs, Number of alternative interventions, individual's economic status, and diseases with absence from work were important. Thus, 77, 69, 61, 57, 54, and 51% of participants preferred to allocate the hypothetical budget to the treatment of patients with poor economic status, treatment of patients with diseases leading to absence from work, treating patients with severe diseases, treatment of diseases in need of daily care and treatment of children's diseases, respectively. Findings from the factors affecting participants' preferences regarding allocation criteria also showed that people with different characteristics had different preferences. CONCLUSIONS: Iranian general public pays special attention to the criteria of equitable allocation, including patients' economic status, criteria with societal aspects such as absenteeism from work and the need for daily care, as well as criteria with medical aspects such as disease severity and access to alternative interventions which may sometimes be less considered in decision making.

Challenges of and corrective recommendations for healthcare-associated infection's case findings and reporting from local to national level in Iran: a qualitative study.

BACKGROUND: The accuracy of health care-associated infections (HAIs) statistics in many countries is questionable and the main reasons of this inaccuracy are not well-known. The study aim was to explore inhibitors of and corrective recommendations for HAIs case findings and reporting in some of Iran hospitals. METHODS: Sixteen face-to-face interviews and an expert panel were performed with expertise of infection prevention and control (IPC) programs in hospitals, and Deputies of Health and Treatment in medical university and Ministry of Health from Feb 2018 to May 2019. Using conventional content analysis, code, subcategories and categories were developed. RESULT: Three categories emerged including improper structure preparation, conflict of interest, and inadequate motivation. Allocating distinct budget and adequate staff to IPC programs, developing a user-friendly surveillance system and engaging physicians and nurses for HAIs reporting are the main corrective recommendations accepted by the expert panel. CONCLUSION: Despite the improvement in growing case-findings and reporting of HAIs in Iran, there are many challenges which inhibit accurate case finding and reporting of HAIs. So it is necessary to update the structure, system and rules to reach accurate HAIs data in Iran.

The impact of social determinants of health on early childhood development: a qualitative context analysis in Iran.

BACKGROUND: Social determinants have a significant impact on children's development and their abilities and capacities, especially in early childhood. They can bring about inequity in living conditions of children and, as a result, lead to differences in various dimensions of development including the social, psychological, cognitive and emotional aspects. We aimed to identify and analyze the social determinants of Early Childhood Development (ECD) in Iran and provide policy implications to improve this social context. METHODS: In a qualitative study, data were collected through semi-structured interviews with 40 experts from October 2017 to June 2018. Based on Leichter's (1979) framework and using the deductive approach, two independent researchers conducted the data analysis. We used MAXQDA.11 software for data management. RESULTS: We identified challenges related to ECD context in the form of 8 themes and 22 subthemes in 4 analytical categories relevant to the social determinants of ECD including: Structural factors (economic factors: 6 subthemes, political factors: 2 subthemes), Socio-cultural factors (the socio-cultural setting of society: 6 subthemes, the socio-cultural setting of family: 4 subthemes), Environmental or International factors (the role of international organizations: 1 subtheme, political sanctions: 1 subtheme), and Situational factors (genetic factors: 1 subtheme, the phenomenon of air pollution: 1 subtheme). We could identify 24 policy recommendations to improve the existing ECD context from the interviews and literature. CONCLUSION: With regard to the challenges related to the social determinants of ECD, such as increasing social harms, decreasing social capital, lack of public awareness, increasing socio-economic inequities, economic instability, which can lead to the abuse and neglect of children or unfair differences in their growth and development, the following policy-making options are proposed: focusing on equity from early years in policies and programs, creating integration between policies and programs from different sectors, prioritizing children in the welfare umbrella, empowering families, raising community awareness, and expanding services and support for families, specially the deprived families subject to special subsidies.

A cost-effectiveness modeling study of treatment interventions for stage I to III esophageal squamous cell carcinoma.

BACKGROUND: Esophageal cancer causes considerable costs for health systems. Appropriate treatment options for patients with esophageal squamous cell carcinoma (ESCC) can reduce medical costs and provide more improved outcomes for health systems and patients. This study evaluates the cost-effectiveness of treatment interventions for patients with ESCC according to the Iranian health system. MATERIAL AND METHODS: A five-state Markov model with a 15-year time horizon was performed to evaluate the cost-effectiveness of treatment interventions based on stage for ESCC patients. Costs ($US 2021) and outcomes were calculated from the Iranian health system, with a discount rate of 3%. One-way sensitivity analyses were performed to assess the potential effects of uncertain variables on the model results. RESULTS: In stage I, the Endoscopic Mucosal Resection (EMR) treatment yielded the lowest total costs and highest total QALY for a total of $1473 per QALY, making it the dominant strategy compared with esophagectomy and EMR followed by ablation. In stages II and III, chemoradiotherapy (CRT) followed by surgery dominated esophagectomy. CRT followed by surgery was also cost-effective with an incremental cost-effectiveness ratio (ICER) of $2172.8 per QALY compared to CRT. CONCLUSION: From the Iranian health system's perspective, EMR was the dominant strategy versus esophagectomy and EMR followed by ablation for ESCC patients in stage I. The CRT followed by surgery was a cost-effective intervention compared to CRT and esophagectomy in stages II and III.

Policy analysis of socio-cultural determinants of salt, sugar and fat consumption in Iran.

BACKGROUND: Noncommunicable diseases (NCDs) are the first reason for death worldwide, in which poor diet is the leading risk factor. It is estimated that 20% of all death is related to food. The Unhealthy diet includes many foods with excessive salt, sugar and fat. This paper reports a national study on the socio-cultural determinants affecting salt, sugar and fat consumption in Iran. METHODS: This is a qualitative study. We conducted semi-structured interviews with 30 various purposefully identified key stakeholders to collect data from December 2018 until August 2019 in Iran. RESULTS: We identified socio-cultural determents of salt, fat and sugar consumption as follows: Inadequate structure of traditional medicine and people's desire for traditional foods, low health literacy, the global trend of nutritional transition and its impact on Iranian society, The progressive decline of people's trust in NGOs, and Inappropriate media management. Worse still, the global trend of nutritional transition and people's tendency towards fast foods, unhealthy diet and junk foods, partially due to establishing children's taste mainly with salty, high-fat and sweet foods, has jeopardized their desire to eat healthily during adulthood. CONCLUSION: Reducing salt, fat and sugar consumption is problematic in Iran, mainly due to multi-dimensional socio-cultural determinants. In line with sustainable development goal (SDG) 3.4 to reduce 30% of premature death due to NCDs and related risk factors by 2030 in Iran, various stakeholders from multiple sectors need to initiate coherent series of interventions to alter people's approach to select food so that they may reduce the consumption of foods with excessive salt, fat and sugar.

The economic burden of esophageal cancer in Iran.

Background: Studies on economic burden demonstrate the impacts of some diseases and provide invaluable information for specifying priorities and resource needs when designing cancer control strategies. The current study aimed to estimate the cost of esophageal carcinoma (EC) in Iran in 2018. Methods: This study was conducted on the prevalence approach to estimate the economic burden of EC in Iran from a social perspective. The direct cost was estimated by summing the diagnosis, treatment, follow-up, terminal care, and transport costs. Additionally, a human capital approach was adopted to estimate productivity losses. Various resources were used for data collection, including the GLOBOCAN 2018 report, and the medical record in the Cancer Institute of Iran. Also, data such as exchange rates, employment, and housekeeping rates were extracted from the Central Bank of Iran Statistics. Results: The economic burden of EC in Iran was $69.2 million in 2018, of which $38.7 million is caused by indirect costs and $30.5 million by direct costs. The mortality cost accounted for 49% of the economic burden, followed by 34% direct medical cost, 10% direct non-medical cost, and 7% morbidity cost. Conclusions: Mortality and medical cost appeared to be the main contributor to the economic burden. Therefore, policy-makers are recommended to adopt early detection and effective treatment as a highly cost-effective strategy for controlling costs.

COVID-19 in Homelessness: A Worldwide Scoping Review on Vulnerabilities, Risks, and Risk Management.

Homeless individuals are at greater risk of death due to social inequalities during Covid-19 pandemic. Strategies taken for general population to prevent the spread of Covid-19, such as social distance, staying at home, and observing personal hygiene are not possible for this group of people. This is a scoping review on articles published and other credible resources published analyze studies done on homeless people during the COVID-19 pandemic. In this scoping review, for the first time, we studied published articles on the situation of the homeless during the Covid-19 epidemic and by extracting and categorizing vulnerabilities, risks, as well as risk management plans, Finally we presented, useful guidance for organizations providing health and social services during the spread of diseases.

Nurses' Perspectives on Inpatient Care Responsiveness at the Gazan Public Hospitals.

BACKGROUND: Responsiveness is one of the intrinsic goals of health systems. This study aimed at assessing the responsiveness of inpatient care in accordance to nurses' perspectives, particularly in internal medicine 'medical' and surgical departments, at the Gazan public general hospitals in 2020. METHODS: This cross-sectional descriptive study was conducted at 5 public general hospitals in Gaza. Data were collected from 277 nurses using an interview-based questionnaire composed mainly of 36 items to measure responsiveness on a 4-point Likert scale. Descriptive statistics, independent t-test and analysis of variance (ANOVA) using SPSS 22.0. RESULTS: The overall responsiveness was about 77.5%. Access to social support was the highest-performing domain but it was the less important. Dignity was the second-highest in performance but the most important domain. Choice of provider and quality of basic amenities were almost the lowest in both performance and importance. Hospital, marital status, educational level, position at work, income, department, and the experience in the current ward have led to significant differences in the level of responsiveness. CONCLUSION: Supply-side should be considered to delineate the status quo of responsiveness accurately. There is a room for further improvement in the interpersonal domains of responsiveness without extravagant expenditures. Policymakers need to emphasize on better allocation of budget for client-orientation domains of responsiveness as well. Hospital characteristics had a pivotal role in creating significant differences among respondents. Likewise, socioeconomic status and cultural diversity of nurses led to significant variations in their responses, hence, this calls for robust and well-designed researches, including non-public hospitals, to determine the most influential factors.

Performance evaluation and ranking of regional primary health care and public health Systems in Iran.

BACKGROUND: The present study has been undertaken with the aim to evaluate performance and ranking of various universities of medical sciences that are responsible for providing public health services and primary health care in Iran. METHODS: Four models; Weighted Factor Analysis (WFA), Equal Weighting (EW), Stochastic Frontier Analysis (SFA), and Data Envelopment Analysis (DEA) have been applied for evaluating the performance of universities of medical sciences. This study was commenced based on the statistical reports of the Ministry of Health and Medical Education (MOHME), census data from the Statistical Center of Iran, indicators of Vital Statistics, results of Multiple Indicator of Demographic and Health Survey 2010, and results of the National Survey of Risk Factors of non-communicable diseases. RESULTS: The average performance scores in WFA, EW, SFA, and DEA methods for the universities were 0.611, 0.663, 0.736 and 0.838, respectively. In all 4 models, the performance scores of universities were different (range from 0.56-1, 0.53-1, 0.73-1 and 0.83-1 in WFA, EW, SFA and DEA models, respectively). Gilan and Rafsanjan universities with the average ranking score of 4.75 and 41 had the highest and lowest rank among universities, respectively. The universities of Gilan, Ardabil and Bojnourd in all four models had the highest performance among the top 15 universities, while the universities of Rafsanjan, Ahvaz, Kerman and Jiroft showed poor performance in all models. CONCLUSIONS: The average performance scores have varied based on different measurement methods, so judging the performance of universities based solely on the results of a model can be misleading. In all models, the performance of universities has been different, which indicates the need for planning to balance the performance improvement of universities based on learning from the experiences of well-performing universities.

Integrated early childhood development policy in Iran: a stakeholder analysis.

BACKGROUND: Many stakeholders are involved in the complicated process of policy making in integrated early childhood development (IECD). In other words, there are many challenges for IECD policy making in developing countries, including Iran. The aim of this study was to identify potential stakeholders and their interactions in IECD policy making in Iran. METHOD: A mixed-methods study was conducted in two phases in 2018. First, forty semi-structured interviews and a review of IECD-related documents were conducted to identify potential stakeholders and their roles. Second, using a designed checklist, these stakeholders were assessed for power, interest, and position in IECD policy making. Then, a map of stakeholders and a three-dimensional stakeholder analysis figure were designed. RESULTS: The results of this study showed that various stakeholders, including governmental, semi-governmental, social, non-governmental and international organizations, potentially influence IECD policy in Iran. They were found to have diverse levels of power, interest and position in this regard, leading to their different impacts on the process. This diversity is assumed to have affected their levels of participation and support. Also, we found that the stakeholders with a high-power level do not have a high level of interest in, or support for, IECD policy. In general, organizational competition, complicated inter-sectoral nature of this process, insufficient budget, insufficient awareness about the importance of IECD, lack of priority given to IECD in relevant organizations, economical views rather than developmental perspectives, and lack of commitment among top managers are the reasons why this policy enjoys a low degree of support. CONCLUSIONS: There are weaknesses in effective interactions and relationships among IECD policy stakeholders. This will lead to the lack of equal opportunities for optimal early childhood development. To improve this process, advocacy from high-level authorities of the organizations, negotiation with child-friendly groups, establishing a body to coordinate and oversee children's affairs, using the capacity of non-governmental organizations, strengthening inter-sectoral collaboration by clarifying the roles and responsibilities of stakeholders and the relationships between them, and increasing public awareness can be helpful.

Direct costs of common osteoporotic fractures (Hip, Vertebral and Forearm) in Iran.

BACKGROUND: Osteoporotic fractures impose significant costs on society. The objective of this study was to estimate the direct costs of the hip, vertebral, and forearm fractures in the first year after fracture incidence in Iran. METHODS: We surveyed a sample of 300 patients aged over 50 years with osteoporotic fractures (hip, vertebral, and forearm) admitted to four hospitals affiliated to Tehran University of Medical Sciences, Iran, during 2017 and were alive six months after the fracture. Inpatient cost data were obtained from the hospital patient records. Using a questionnaire, the data regarding outpatient costs were collected through a phone interview with patients at least six months after the fracture incidence. Direct medical and non-medical costs were estimated from a societal perspective. All costs were converted to the US dollar using the average exchange rate in 2017 (1USD = IRR 34,214) RESULTS: The mean ± standard deviation (SD) age of the patient was 69.83 ± 11.25 years, and 68% were female. One hundred and seventeen (39%) patients had hip fractures, 56 (18.67%) patients had vertebral fractures, and 127 (42.33%) ones had forearm fractures. The mean direct cost (medical and non-medical) during the year after hip, vertebral and forearm fractures were estimated at USD5,381, USD2,981, and USD1,209, respectively. CONCLUSION: The direct cost of osteoporotic fracture in Iran is high. Our findings might be useful for the economic evaluation of preventive and treatment interventions for osteoporotic fractures as well as estimating the economic burden of osteoporotic fractures in Iran.

Model for Value-based Policy-making in Health Systems.

BACKGROUND: Values are at the heart of discussions related to policy-making and any kind of reforms in health systems. Despite wide recognition of its importance, the concept of value is still vague and the policy-making processes remain astray with respect to values. This study aims to provide a model of value-based policy-making and to explain the concept value and how it affects policy-making. METHODS: The main question of the current study is to explain the concept of value-based policy-making and developing a model, based on the explained concept. In this line, critical review method and Carnwell and Daly approach and using particular keywords related to stewardship, and searching databases were used. In the initial search, 739 studies were obtained, of which using targeted sampling method, 11 studies were finally selected. Then, in order to design and explain different aspects of the value concept in the health system and to develop a model, selected studies were criticized, and finally, the conceptual model of value is designed and explained. RESULTS: The concept of value and its effects, dimensions and its relation to principles, evidence and criteria were determined at different stages of the policy-making process. It was also revealed that value-based policy-making in a health system is contingent upon the realization of terminal values. CONCLUSIONS: In the process of selecting the best policy option, it is necessary to identify the relationship between terminal, instrumental, criterion, and evidence to avoid deviating from the reference value framework in any country and to avoid blindly imitating other experiences in other countries.