Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Exploring the landscape of health technology assessment in Iran: perspectives from stakeholders on needs, demand and supply

BACKGROUND

The evaluation of health technologies plays a crucial role in the allocation of resources and the promotion of equitable healthcare access, known as health technology assessment (HTA). This study focuses on Iran's efforts to integrate HTA and aims to gain insights into stakeholder perspectives regarding capacity needs, demand and implementation.

METHODS

In this study, we employed the HTA introduction status analysis questionnaire developed by the International Decision Support Initiative (iDSI), which has been utilized in various countries. The questionnaire consisted of 12 questions divided into three sections: HTA need, demand and supply. To identify key informants, we conducted a literature review and consulted with the Ministry of Health and Medical Education (MOHME), as well we experts in policy-making, health service provision and HTA. We selected stakeholders who held decision-making positions in the healthcare domain. A modified Persian version of the questionnaire was administered online from September 2022 to January 2023 and was pretested for clarity. The analysis of the collected data involved quantitative methods for descriptive analysis and qualitative methods for thematic analysis.

RESULTS

In this study, a total of 103 questionnaires were distributed, resulting in a favourable response rate of 61% from 63 participants, of whom 68% identified as male. The participants, when assessing the needs of HTA, rated allocative efficiency as the highest priority, with a mean rating of 8.53, thereby highlighting its crucial role in optimizing resource allocation. Furthermore, healthcare quality, with a mean rating of 8.17, and transparent decision-making, with a mean rating of 7.92, were highly valued for their impact on treatment outcomes and accountability. The importance of budget control (mean rating 7.58) and equity (mean rating 7.25) were also acknowledged, as they contribute to maintaining sustainability and promoting social justice. In terms of HTA demand, safety concerns were identified as the top priority, closely followed by effectiveness and cost-effectiveness, with an expanded perspective on the economy. However, limited access to local data was reported, which arose from various factors including data collection practices, system fragmentation and privacy concerns. The priorities of HTA users encompassed coverage, payment reform, benefits design, guidelines, service delivery and technology registration. Evidence generation involved the participation of medical universities, research centres and government bodies, albeit with ongoing challenges in research quality, data access and funding. The study highlights government support and medical education as notable strengths in this context.

CONCLUSIONS

This study provides a comprehensive evaluation of Iran's HTA landscape, considering its capacity, demand and implementation aspects. It underlines the vital role of HTA in optimizing resources, improving healthcare quality and promoting equity. The study also sheds light on the strengths of evidence generation in the country, while simultaneously identifying challenges related to data access and system fragmentation. In terms of policy priorities, evidence-based decision-making emerges as crucial for enhancing healthcare access and integrating technology. The study stresses the need for evidence-based practices, a robust HTA infrastructure and collaboration among stakeholders to achieve better healthcare outcomes in Iran.

Overuse of computed tomography for mild head injury: A systematic review and meta-analysis

BACKGROUND

Computed tomography (CT) scan is a common imaging technique used to evaluate the severity of a head injury. The overuse of diagnostic interventions in the health system is a growing concern worldwide. Objectives: The aim of this systematic review is to investigate the rate of CT scan overuse in cases of mild head injury.

METHODS

Eligibility criteria: We encompassed observational studies-either designed as cohort, case-control, or cross-sectional investigations-that reported on CT scan overuse rates for mild head injuries. Studies had to be published in peer-reviewed, English-language sources and provide full content access Information sources: Web of Sciences, Scopus, Medline via PubMed, the Cochrane Library and Embase were searched from inception until April 1, 2023. Studies were included if reporting the overuse of CT scans for mild head injuries using validated criteria. Risk of bias: We used the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool to evaluate the risk bias assessment of included studies. Two independent reviewers evaluated the eligibility of studies, extracted data, and assessed study quality by using the Newcastle-Ottawa Scale. Synthesis of results: Overuse estimates were calculated using a random-effects model. Subgroup analyses were performed to investigate any sources of heterogeneity. Point rate of overuse of CT scans for mild head injuries was the main outcome measured as percentage point estimates with corresponding 95% CIs.

RESULTS

Included studies: Of the 913 potentially relevant studies identified, eight studies were selected for the final analysis. Synthesis of results: The pooled rate of CT scan overuse in patients with mild head injury was found to be 27% [95% CI: 16-43; I2 = 99%]. The rate of CT scan overuse in mild head injury cases varied depending on the criteria used. The rate of CT scan overuse was 37% [95% CI: 32-42; I2 = 0%] with the Glasgow Coma Scale (GCS), 30% [95% CI: 16-49; I2 = 99%] with the Canadian computed tomography head rule, and 10% [95% CI: 8-14; I2 = 0%] with the Pediatric Emergency Care Applied Research Network criterion (PERCAN). Based on subgroup analyses, the rate of CT scan overuse in mild head injury cases was observed to be 30% with the Canadian computed tomography head rule criterion, 43% with the National Institute for Health and Clinical Excellence criterion, and 18% with the New Orleans criterion.

CONCLUSION

Limitations of evidence: The restricted number of included studies may impact generalizability. High heterogeneity was observed, leading to subgroup analyses based on age, assessment criteria, and study region. Absent data on overuse causes hinders drawing conclusions on contributing factors. Furthermore, this study solely addressed overuse rates, not associated harm or benefits. Interpretation: The overuse of CT scans in mild head injury patients is concerning, as it can result in unnecessary radiation exposure and higher healthcare costs. Clinicians and policymakers should prioritize the implementation of guidelines to reduce unnecessary radiation exposure, healthcare costs, and potential harm to patients.

TRIAL REGISTRATION

The study protocol of this review was registered in PROSPERO under the identification code CRD42023416080. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023416080.

Prevalence of HIV in slums area: a systematic review and meta-analysis

BACKGROUND

Human Immunodeficiency Virus (HIV) remains a significant global health burden, particularly affecting vulnerable populations residing in slum areas which is characterized by overcrowding, poverty, and limited access to healthcare services, create an environment conducive to the transmission and spread of HIV. Despite the recognition of this issue, there is a lack of comprehensive understanding regarding the prevalence of HIV in slums. The aim of this study was to systematically synthesize the existing global evidence on HIV prevalence in slum populations.

METHODS

A rigorous systematic literature review was conducted by searching multiple electronic databases, including Medline via PubMed, Scopus, Embase, Web of Sciences, and Directory of Open Access Journals (DOAJ), covering the period from January 1, 1990, to March 31, 2023. The quality and risk of bias for each included study were assessed using the Newcastle-Ottawa Scale. The pooled prevalence with its corresponding 95% confidence interval (CI) was calculated using a random-effects model with the Freeman-Tukey double arcsine transformation. The degree of heterogeneity among the studies was evaluated using the I2 test. Publication bias was also assessed using Egger's test. Additionally, subgroup analysis was performed to explore potential factors contributing to the observed heterogeneity.

RESULTS

A systematic examination of the relevant literature resulted in the inclusion of a total of 22 studies for the purpose of this meta-analysis. These studies collectively assessed a sizable cohort consisting of 52,802 participants. Utilizing a random-effects model, an estimation of the overall prevalence of HIV in the slum area was determined to be 10% (95% CI: 7-13%). Further delineation through subgroup analysis based on the gender revealed a higher prevalence of HIV among women, standing at 13% (95% CI: 8-19%, 18 studies: I2 = 98%), as opposed to men, where the prevalence was found to be 8% (95% CI: 6-12%, 16 studies: I2 = 95%). A geographical breakdown of the included studies revealed that Africa exhibited the highest prevalence, with a figure of 11% (95% CI: 9-13%, 18 studies: I2 = 98%). Subsequently, studies conducted in the American continent reported a prevalence of 9% (95% CI: 7-11%, 2 studies: I2 = 57%). The Asian continent, on the other hand, displayed the lowest prevalence of 1% (95% CI: 0-3%, 2 studies: I2 = 94%). Notably, studies employing rapid tests indicated a prevalence of 13% (95% CI: 9-17%, 6 studies: I2 = 94%), while those relying on self-reported data reported a lower prevalence of 8% (95% CI: 5-11%, 6 studies: I2 = 99%). Moreover, studies utilizing ELISA reported a prevalence of 9% (95% CI: 6-12%, 10 studies: I2 = 96%). Finally, it was determined that studies conducted in upper-middle-income countries reported a higher prevalence of 20% (95% CI: 16-24%, 5 studies: I2 = 45%), whereas studies conducted in lower- and middle-income countries reported a prevalence of 8% (95% CI: 6-10%, 12 studies: I2 = 98%).

CONCLUSION

The current study elucidates the troublingly high prevalence of HIV infection within slums area. Also, this finding underscores the urgent necessity for targeted and tailored interventions specifically aimed at curtailing the spread of HIV within slums. Policymakers must take cognizance of these results and devote their efforts towards the implementation of effective strategies to mitigate gender disparities, address poverty alleviation, and empower the inhabitants of these marginalized areas.

Epidemiological, clinical, and economic burden of myocardial infarction patients in Iran during the COVID-19 pandemic

Background

To define changes in AMI case rates, patient demographics, cardiovascular comorbidities, treatment approaches, in-hospital outcomes, and the economic burden of COVID-19 during the pandemic.

Methods

We conducted a multicenter, observational survey with selected hospitals from three medical universities in Tehran city. A data collection tool consisting of three parts. The first part included socio-demographic information, and the second part included clinical information, major complications, and in-hospital mortality. Finally, the third part was related to the direct medical costs generated by AMI in COVID-19 and non-COVID-19 patients. The study cohort comprised 4,560 hospitalizations for AMI (2,935 for STEMI [64%] and 1,625 for NSTEMI [36%]).

Results

Of those hospitalized for AMI, 1,864 (76.6 %) and 1,659 (78 %) were male before the COVID-19 outbreak and during the COVID-19 era, respectively. The length of stay (LOS), was significantly lower during the COVID-19 pandemic era (4.27 ± 3.63 vs 5.24 ± 5.17, p = 0.00). Results showed that there were no significant differences in terms of patient risk factors across periods. A total of 2,126 AMIs were registered during the COVID-19 era, with a 12.65 % reduction (95 % CI 1.5-25.1) compared with the equivalent time in 2019 (P = 0.179). The risk of in-hospital mortality rate for AMI patients increased from 4.9 % in 2019 to 7.0 % in the COVID-19 era (OR = 1.42; 95 % CI 1.11-1.82; P = 0.004). Major complications were registered in 9.7 % of cases in 2020, which is higher than the rate of 6.6 % reported in 2019 (OR = 1.46, 95 % CI 1.11-1.82; P = 0.000). Total costs in hospitalized AMI-COVID patients averaged $188 more than in AMI patients (P = 0.020).

Conclusion

This cross-sectional study found important changes in AMI hospitalization rates, worse outcomes, and higher costs during the COVID-19 periods. Future studies are recommended to examine the long-term outcomes of hospitalized AMI patients during the COVID-19 era.

Applying systems thinking in the prosthetics and orthotics sector: investigating the common challenges in Iran

PURPOSE

We sought to explore the common challenges across stakeholder groups and also to recognize interactions among them to improve the Iranian prosthetics and orthotics (P&O) sector.

MATERIALS AND METHODS

Interviews were performed from January to June 2019. Participants, including 13 prosthetists/orthotists and six P&O faculty members, were selected using purposive and snowball sampling. The collected data were analyzed using the framework analysis method. Additionally, a systems thinking approach was applied to theorize potential leverage points to improve P&O services in Iran.

RESULTS

Challenges in leadership and governance included lack of united stewardship, inappropriate inter-sectoral cooperation, and poor awareness among decision-makers. Financing challenges included high out-of-pocket payments, inadequate insurance coverage, and insufficient governmental funding. Service delivery challenges included lack of prosthetists and orthotists in hospitals and medical centers, corrupt activities and a weak referral system. Human resource challenges included insufficient practical skills of graduates, misalignment of theoretical and clinical training, and inadequacy of continuing education courses.

CONCLUSIONS

This study provides the groundwork to develop and implement national strategies to address modifiable barriers and improve prosthetic and orthotic services.Implications for rehabilitationLack of united stewardship, inappropriate inter-sectoral cooperation, and poor awareness among decision-makers are the governance challenges of prosthetics and orthotics (P&O) and must be managed by the government.Government resources allocated to P&O services should increase, and P&O insurance coverage should improve.P&O services should be incorporated in health benefits packages to lessen the reliance on out-of-pocket payments.Planning should be done toward inclusion of P&O services in universal health coverage.Up-to-date scientific training and high-quality evidence are needed to enhance the practical skills of P&O graduates and consequently improve the quality of P&O services.Effective continuing training courses for P&O graduates are recommended.It is advantageous to provide P&O services in hospitals.

The impact of the Iranian health transformation plan policy on equitable access to medical imaging services in West Iran

OBJECTIVE

Equity in the delivery of health services, including diagnostic imaging, is crucial to achieving universal health coverage. The Health Transformation Plan (HTP), launched in 2014, represents a major healthcare policy to improve the quality and accessibility of healthcare services. This study aimed to explore the impact of the HTP on equity in the access to medical imaging in Lorestan province, located in west Iran, from 2014 to 2023. Annual growth rates (AGR) of imaging devices were calculated, whilst equity assessment of medical imaging distribution was carried out by means of the Gini coefficient and the Lorenz curve per 100,000 population. The latter was generated using the cumulative distribution of imaging devices, as well as the cumulative population ratio.

RESULTS

Between 2014 and 2023, the number of imaging devices has increased threefold. The AGR of installing CT and MRI scanners in Lorestan province increased between 2014 and 2023. The Gini coefficients increased from 0.12 for CT and 0.16 for MRI in 2014 to 0.33 in 2023 for both devices. This indicates a decrease in equity in access to these fundamental health technologies despite the increase in their figures. Policymakers should better allocate medical equipment based on the specific health needs of different regions throughout Iran.

Cost-effectiveness of cardiovascular magnetic resonance imaging compared to common strategies in the diagnosis of coronary artery disease: a systematic review

Cardiovascular magnetic resonance imaging (CMR) has established exceptional diagnostic utility and prognostic value in coronary artery disease (CAD). An assessment of the current evidence on the cost-effectiveness of CMR in patients referred for the investigation of CAD is essential for developing an economic model to evaluate the cost-effectiveness of CMR in CAD. We conducted a comprehensive search of multiple electronic databases, including PubMed, Scopus, Web of Science core collection, Embase, National Health Service Economic Evaluation Database (NHS EED), and health technology assessment, to identify relevant literature. After removing duplicates and screening the title/abstract, a total of 13 articles were deemed eligible for full-text assessment. We included studies that reported one or more of the following outcomes: incremental cost-effectiveness ratio (ICER), cost per quality-adjusted life year (QALYs), cost per life year gained, sensitivity and specificity rate as the primary outcome, and health utility measures or health-related quality of life as the secondary outcome. The quality of the included studies was assessed using the CHEERS 2022 guidelines. The findings of this study demonstrate that in patients undergoing urgent percutaneous coronary intervention, CMR over a one-year and lifetime horizon leads to higher quality-adjusted life years (QALYs) compared to current strategies in cases of multivessel disease. The systematic review indicates that the CMR-based strategy is more cost-effective when compared to standard methods such as single-photon emission computed tomography (SPECT), coronary computed tomography angiography (CCTA), and coronary angiography (CA) (CMR = $19,273, SPECT = $19,578, CCTA = $19,886, and immediate CA = $20,929). The results also suggest that the CMR strategy can serve as a cost-effective gatekeeping tool for patients at risk of obstructive CAD. A CMR-based strategy for managing patients with suspected CAD is more cost-effective compared to both invasive and non-invasive strategies, particularly in real-world patient populations with a low to intermediate prevalence of the disease.

Barriers and facilitators of integrating physiotherapy into primary health care settings: A systematic scoping review of qualitative research

Purpose

This scoping review investigated the barriers and facilitators to integrating physiotherapy into primary health care (PHC).

Materials and methods

PubMed, Scopus, Web of Science, Embase, ProQuest, and REHABDATA were searched. Two independent reviewers were involved in screening, selecting, and extracting data. Data were synthesized using thematic analysis.

Results

Of the 483 screened documents, 44 qualitative studies, primarily from high-income countries, were included. All of the studies had good methodological quality. Barriers and facilitators of integrating physiotherapy into PHC were extracted within the WHO six building blocks framework. In total, 41 items were identified as barriers to the integration process. The studies included 49 recommendations to facilitate integrating physiotherapy services into PHC.

Conclusion

Integrating physiotherapy services into PHC faces many barriers. The most commonly suggested potential barriers are poor knowledge of physicians about physiotherapy, ineffective teamwork, physiotherapists' time constraints/workload, a lack of clarity over the role and knowledge of physiotherapists, unawareness of physiotherapy users about these services, and lack of intra- and inter-professional collaborations. The most commonly suggested recommendations to facilitate the integration process include: Clarifying the role of involved professionals, strengthening teamwork, improving intra- and inter-professional collaborations, and providing comprehensive training programs for physiotherapists.

Health System Response to Refugees' and Migrants' Health in Iran: A Strengths, Weaknesses, Opportunities, and Threats Analysis and Policy Recommendations

Objective: Iran is one of the main hosts of Afghan refugees. This study aims to provide comprehensive evidence to increase Afghan migrants' access to healthcare services in Iran. Methods: To assess the health system's response to Afghan migrants in Iran, we conducted three phases for SWOT analysis, including: 1-developing a review and comprehensive analysis of documents, laws, and, programs, 2-conducting semi-structured interviews with policymakers and experts, and 3-mapping the results through the Levesque's conceptual framework for healthcare access. Results: We evaluated the response of the health system to Afghan migrants' health needs in three domains: 1-Approachability and ability to perceive migrants; 2-Ability to reach, engage, and availability and accommodation and appropriateness; 3-The ability to pay and affordability. For each of the three domains, we identified strengths, weaknesses, opportunities, and threats, complemented with evidence-based suggestions to improve migrants' access to needed healthcare services. Conclusion: Given the rising trend of immigration and deteriorating financial crises, we recommend appropriate strategies for the adoption of specialized focus services, gateway services, and restricted services. Also simplifying financial procedures, and implementing innovative insurance mechanisms are essential.

Developing an organizational capacity assessment tool and capacity-building package for the National Center for Prevention and Control of Noncommunicable Diseases in Iran

Non-communicable diseases represent 71% of all deaths worldwide. In 2015, Sustainable Development Goals, including target 3.4 of SDGs, were seated on the world agenda; "By 2030, reduce premature mortality from NCDs by one-third. More than half of the world's countries are not on track to reach SDG 3.4, and the COVID-19 crisis has hampered the delivery of essential NCD services globally, which means the premature death of millions of people and indicates the need for capacity building for health systems. We designed a tool to measure the capacity of the National Center for Non-Communicable Disease and then presented the proposed policy package to enhance the national center's organizational capacity. The data for this explanatory sequential mixed method study was collected using quantitative and qualitative approaches between February 2020 and December 2021. The tool for assessing organizational capacity for NCDs was developed, and its validity and reliability were measured. The developed tool assessed the organizational capacity by evaluating NCNCD's managers and experts. Following the quantitative phase, a qualitative phase focused on the low-capacity points revealed by the tool. The causes of low capacity were investigated, as well as potential interventions to improve capacity. The developed tool comprises six main domains and eighteen subdomains, including (Governance, Organizational Management, Human Resources Management, Financial Management, Program Management, and Relations Management) which verified validity and reliability. In seven separate National Center for Non-Communicable Disease units, the organizational capacity was measured using the designed tool. (Cardiovascular disease and hypertension; diabetes; chronic respiratory disease; obesity and physical activity; tobacco and alcohol; nutrition; and cancers). The organizational management dimensions and the sub-dimensions of the organizational structure of the Ministry of Health and Medical Education and units affiliated with the national center, in all cases, were almost one of the main challenges that affected the country's capacity to fight against NCDs. However, all units had a relatively good situation in terms of governance (mission statement, vision, and written strategic plan). The content analysis of experts' opinions on the low-capacity subdomains highlighted challenges and recommended capacity-building interventions. Transparency in methods and processes is necessary to allocate funding among various health programs and evaluate their effects through cost-effectiveness indicators. This study identified weak points or areas where capacity building is required. The root causes of low capacity and interventions to build capacity are listed in each dimension of the tool. Some of the proposed interventions, such as strengthening organizational structures, have the potential to impact other domains. Improving organizational capacity for NCDs can assist countries to achieve national and global goals with greater efficiency.

The role of Iran's context for the development of health technology assessment: challenges and solutions

Health technology assessment (HTA) is a comprehensive and structured evaluation that aims to analyze the potential impacts of health technologies, including medical devices, diagnostic tools, pharmaceuticals, and public health interventions. Its purpose is to provide policymakers with evidence-based information to inform decisions related to the utilization and implementation of these technologies. HTA allows for the comparison of various scenarios related to a technology across a wide range of factors. This can aid in the creation of an essential drug list and health benefits package that is tailored to the actual needs of the community within a given healthcare system. In the present paper, we review the role of Iran's context for the development of HTA, in terms of challenges and solutions.

Implementation Challenges of Family Physician Program: A Systematic Review on Global Evidence

Background

The family physician program, as one of the core arms of health care systems, has faced various implementation challenges around the world. Experiences in the implementation of family physician program can be helpful for nations that seek to apply for similar programs. The aim of this study is to systematically review the implementation challenges of family physician program across the world.

Methods

A systematic search was conducted from January 2000 to February 2022 across scientific databases of Embase, MEDLINE, Web of Science, Scopus, CINAHL, EBSCO, and Google Scholar. The Framework approach was used to analyze the selected studies. The quality of the included studies was evaluated using the McMaster Critical Review Form for qualitative studies.

Results

35 studies upon the study inclusion criteria were included. Based on the Six Building Blocks frame, seven themes and 21 subthemes were developed as the implementation challenges of family physician program. 1) Governance: policy guidance, intelligence, coalition, regulation, system design, and accountability; 2) Financing: financing and payment system; 3) Health workforce: education, research, recruitment and motivation opportunities; 4) Service delivery: management of health services, service package, referral system, continuity of care; 5) Health information systems: production and evaluating the health information system; 6) Availability: provision basic health services, maintenance of facilities; and 7) Cultural considerations: behavior and social determinants of health.

Conclusion

Scientific governance, financing, and payment mechanisms, workforce empowerment, designing a strong health information system, and providing access to services with cultural considerations can result in the successful implementation of the family physician program in communities.

A SWOT analysis of the development of health technology assessment in Iran

BACKGROUND

Health systems need to prioritize their services, ensuring efficiency and equitable health provision allocation and access. Alongside, health technology assessment (HTA) seeks to systematically evaluate various aspects of health technologies to be used by policy- and decision-makers. In the present study, we aim to identify strengths, weaknesses, opportunities, and threats in developing an HTA in Iran.

METHOD

This qualitative study was conducted using 45 semi-structured interviews from September 2020 to March 2021. Participants were selected from key individuals involved in health and other health-related sectors. Based on the objectives of the study, we used purposive sampling (snowball sampling) to select individuals. The range of length of the interviews was between 45 to 75 minutes. Four authors of the present study carefully reviewed the transcripts of interviews. Meanwhile, the data were coded on the four domains of strengths, weaknesses, opportunities, and threats (SWOT). Transcribed interviews were then entered into the software and analyzed. Data management was performed using MAXQDA software, and also analyzed using directed content analysis.

RESULTS

Participants identified eleven strengths for HTA in Iran, namely the establishment of an administrative unit for HTA within the Ministry of Health and Medical Education (MOHME); university-level courses and degrees for HTA; adapted approach of HTA models to the Iranian context; HTA is mentioned as a priority on the agenda in upstream documents and government strategic plans. On the other hand, sixteen weaknesses in developing HTA in Iran were identified: unavailability of a well-defined organizational position for using HTA graduates; HTA advantages and its basic concept are unfamiliar to many managers and decision-makers; weak inter-sectoral collaboration in HTA-related research and key stakeholders; and, failure to use HTA in primary health care. Also, participants identified opportunities for HTA development in Iran: support from the political side for reducing national health expenditures; commitment and planning to achieve universal health coverage (on behalf of the government and parliament); improved communication among all stakeholders engaged in the health system; decentralization and regionalization of decisions; and capacity building to use HTA in organizations outside the MOHME. High inflation and bad economic situation; poor transparency in decisions; lack of support from insurance companies; lack of sufficient data to conduct HTA research; rapid change of managers in the health system; and economic sanctions against Iran are threats to the developmental path of HTA in Iran.

CONCLUSION

HTA can be properly developed in Iran if we use its strengths and opportunities, and address its weaknesses and threats.

Prevalence of Toxoplasma gondii in HIV-Infected Individuals in Iran: A Systematic Review and Meta-Analysis

INTRODUCTION

Toxoplasma gondii is an obligate intracellular protozoan that can infect almost all warm-blooded animals, including humans. Patients with co-infection with toxoplasmosis and HIV have a 30-40% risk of developing toxoplasmosis encephalitis. This study aimed to describe the epidemiology and burden of Toxoplasma gondii in HIV-infected individuals in Iran.

METHODS

We searched the five English databases (Science Direct, PubMed, Scopus, Ovid, Embase, and Cochrane) and four Persian databases (Scientific Information Database (SID), Iran Medex, Iran Doc, and Magiran) with the terms of (Toxoplasma gondii OR "toxoplasmosis") AND (HIV OR "AIDS" OR immunodeficiency OR acquired immune deficiency syndrome) AND (Seroprevalence) AND (Seroepidemiologic Studies) AND (Elisa OR IgG) AND (PCR) AND (Iran) by two authors up to Feb 2021. Studies were included if they investigated people with HIV infection and presented data that allowed us to establish the prevalence of Toxoplasma gondii infection in Iran.

RESULTS

According to the inclusion/exclusion criteria, 15 studies were selected. A total number of 2275 HIV-infected individuals were tested and evaluated for toxoplasmosis from 2005 up to 2018 in different regions of Iran. The weighted overall prevalence of toxoplasmosis in HIV-infected individuals with Elisa was obtained using a random-effects model, which was estimated at 47% (95% CI = 31% - 62%). Also, the Weighted overall prevalence of toxoplasmosis in HIV-infected individuals with PCR was obtained using a random-effects model, which was estimated at 7% (95% CI = 3% - 12%).

CONCLUSION

According to the results of this study, it can be clearly understood that a large population of HIV patients living in Iran have toxoplasmosis. Therefore, due to the high susceptibility of these groups to toxoplasmosis, healthcare professionals must consider measures such as training in the ways of transmission and prevention of the infection to this high-risk group in order to reduce the risk of infection.

Cost-Effectiveness of Sacubitril/Valsartan Compared with Enalapril in Patients with Heart Failure with Reduced Ejection Fraction: A Systematic Review

Background

To assess the cost-effectiveness of sacubitril/valsartan compared with enalapril in patients with heart failure with reduced ejection (HFrEF).

Methods

A systematic literature search was conducted searching in major electronic databases from inception to January 1, 2021. All relevant full economic evaluation studies of sacubitril/valsartan versus enalapril for the treatment of patients with HFrEF were identified using ad hoc search strategies. Mortality, hospital admissions, quality-adjusted life years (QALYs), life-years (LYQs), annual drug costs, total lifetime costs, and incremental cost-effectiveness ratio (ICER) were considered as the outcomes. The quality of the included studies was assessed using the CHEERS checklist. This study was conducted and reported in accordance with the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines.

Results

The initial search yielded a pool of 1026 articles, of which 703 unique articles were screened, 65 full-text articles were assessed for eligibility and 15 studies finally included in the qualitative synthesis. Studies show that sacubitril/valsartan reduces mortality and hospitalization rate. The mean of death risk ratio and hospitalization were computed at 0.843 and 0.844, respectively. Sacubitril/valsartan produced higher annual and total lifetime costs. The lowest and highest lifetime costs for sacubitril/valsartan were found in Thailand ($4,756) and Germany ($118,815), respectively. The lowest ICER was reported in Thailand ($4857/QALY) and the highest in the USA ($143,891/QALY).

Conclusion

Sacubitril/valsartan is associated with better outcomes and may be cost-effective compared to enalapril for the management of HFrEF. However, in developing countries such as Thailand, sacubitril-valsartan costs must be reduced to yield an ICER below the threshold.

Hospitalization, major complications and mortality in acute myocardial infarction patients during the COVID-19 era: A systematic review and meta-analysis

Since the SARS-CoV-2 pandemic began, numerous studies have reported a concerning drop in the number of acute myocardial infarction (AMI) admissions. In the present systematic review and meta-analysis, we aimed to compare the rate of AMI admissions and major complication during the pandemic, in comparison with pre-pandemic periods. Three major databases (PubMed, Scopus, and Web of Science Core Collection) were searched. Out of 314 articles, 41 were entered into the study. Patients hospitalized for AMI were 35% less in the COVID-19 era compared with pre-pandemic periods, which was statistically significantly (OR = 0.65; 95% CI: 0.56–0.74; I² = 99%; p < 0.001; 28 studies). Patients hospitalized for STEMI and NSTEMI were 29% and 34% respectively less in the COVID-19 era compared with periods before COVID-19, which was statistically significantly (OR = 0.71; 95% CI: 0.65 –0.78; I² = 93%; p < 0.001; 22 studies, OR = 0.66; 95% CI: 0.58–0.73; I² = 95%; p < 0.001; 14 studies). The overall rate of in-hospital mortality in AMI patients increased by 26% in the COVID-19 era, which was not statistically significant (OR = 1.26; 95% CI: 1.0–1.59; I² = 22%; p < 0.001; six studies). The rate of in-hospital mortality in STEMI and NSTEMI patients increased by 15% and 26% respectively in the COVID-19 era, which was not statistically significant (OR = 1.15; 95% CI: 0.85–1.57; I² = 48%; p = 0.035; 11 studies, OR = 1.35; 95% CI: 0.64–2.86; I² = 45%; p = 0.157; 3 articles). These observations highlight the challenges in the adaptation of health-care systems with the impact of the COVID-19 pandemic.

Estimates, trends, and drivers of the global burden of type 2 diabetes attributable to PM2·5 air pollution, 1990-2019: an analysis of data from the Global Burden of Disease Study 2019

BACKGROUND

Experimental and epidemiological studies indicate an association between exposure to particulate matter (PM) air pollution and increased risk of type 2 diabetes. In view of the high and increasing prevalence of diabetes, we aimed to quantify the burden of type 2 diabetes attributable to PM2·5 originating from ambient and household air pollution.

METHODS

We systematically compiled all relevant cohort and case-control studies assessing the effect of exposure to household and ambient fine particulate matter (PM2·5) air pollution on type 2 diabetes incidence and mortality. We derived an exposure-response curve from the extracted relative risk estimates using the MR-BRT (meta-regression-Bayesian, regularised, trimmed) tool. The estimated curve was linked to ambient and household PM2·5 exposures from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, and estimates of the attributable burden (population attributable fractions and rates per 100 000 population of deaths and disability-adjusted life-years) for 204 countries from 1990 to 2019 were calculated. We also assessed the role of changes in exposure, population size, age, and type 2 diabetes incidence in the observed trend in PM2·5-attributable type 2 diabetes burden. All estimates are presented with 95% uncertainty intervals.

FINDINGS

In 2019, approximately a fifth of the global burden of type 2 diabetes was attributable to PM2·5 exposure, with an estimated 3·78 (95% uncertainty interval 2·68-4·83) deaths per 100 000 population and 167 (117-223) disability-adjusted life-years (DALYs) per 100 000 population. Approximately 13·4% (9·49-17·5) of deaths and 13·6% (9·73-17·9) of DALYs due to type 2 diabetes were contributed by ambient PM2·5, and 6·50% (4·22-9·53) of deaths and 5·92% (3·81-8·64) of DALYs by household air pollution. High burdens, in terms of numbers as well as rates, were estimated in Asia, sub-Saharan Africa, and South America. Since 1990, the attributable burden has increased by 50%, driven largely by population growth and ageing. Globally, the impact of reductions in household air pollution was largely offset by increased ambient PM2·5.

INTERPRETATION

Air pollution is a major risk factor for diabetes. We estimated that about a fifth of the global burden of type 2 diabetes is attributable PM2·5 pollution. Air pollution mitigation therefore might have an essential role in reducing the global disease burden resulting from type 2 diabetes.

FUNDING

Bill & Melinda Gates Foundation.

Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life Years for 29 Cancer Groups From 2010 to 2019: A Systematic Analysis for the Global Burden of Disease Study 2019

IMPORTANCE

The Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019) provided systematic estimates of incidence, morbidity, and mortality to inform local and international efforts toward reducing cancer burden.

OBJECTIVE

To estimate cancer burden and trends globally for 204 countries and territories and by Sociodemographic Index (SDI) quintiles from 2010 to 2019.

EVIDENCE REVIEW

The GBD 2019 estimation methods were used to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) in 2019 and over the past decade. Estimates are also provided by quintiles of the SDI, a composite measure of educational attainment, income per capita, and total fertility rate for those younger than 25 years. Estimates include 95% uncertainty intervals (UIs).

FINDINGS

In 2019, there were an estimated 23.6 million (95% UI, 22.2-24.9 million) new cancer cases (17.2 million when excluding nonmelanoma skin cancer) and 10.0 million (95% UI, 9.36-10.6 million) cancer deaths globally, with an estimated 250 million (235-264 million) DALYs due to cancer. Since 2010, these represented a 26.3% (95% UI, 20.3%-32.3%) increase in new cases, a 20.9% (95% UI, 14.2%-27.6%) increase in deaths, and a 16.0% (95% UI, 9.3%-22.8%) increase in DALYs. Among 22 groups of diseases and injuries in the GBD 2019 study, cancer was second only to cardiovascular diseases for the number of deaths, years of life lost, and DALYs globally in 2019. Cancer burden differed across SDI quintiles. The proportion of years lived with disability that contributed to DALYs increased with SDI, ranging from 1.4% (1.1%-1.8%) in the low SDI quintile to 5.7% (4.2%-7.1%) in the high SDI quintile. While the high SDI quintile had the highest number of new cases in 2019, the middle SDI quintile had the highest number of cancer deaths and DALYs. From 2010 to 2019, the largest percentage increase in the numbers of cases and deaths occurred in the low and low-middle SDI quintiles.

CONCLUSIONS AND RELEVANCE

The results of this systematic analysis suggest that the global burden of cancer is substantial and growing, with burden differing by SDI. These results provide comprehensive and comparable estimates that can potentially inform efforts toward equitable cancer control around the world.

Quality Assessment of Services in Primary Healthcare in Iran: A Systematic Review and Meta-analysis

Background

Primary healthcare (PHC) plays an important role in achieving universal health coverage (UHC). The SERVQUAL instrument is the tool for evaluating the quality of services in the health sector. The main purpose of this study is to evaluate the quality of services provided in PHC in Iran using the SERVQUAL instrument.

Materials and Method

We searched eight databases from January 2000 to September 2021. We analyzed the mean of various SERVQUAL instrument items using the DerSimonian-Laird approach via a random model with 95% confidence interval. Also, we used I2 to evaluate the heterogeneity of the studies.

Results

Finally, 17 studies were chosen for analysis in the present study. There were 8,767 study participants, out of which 8,237 were female and 530 were male. The mean dimensions of perception were as follows: Tangibles = 3.71, reliability = 4, responsiveness = 3.79, assurance = 3.83, and empathy = 3.86. For the expectation, the mean dimension were: Tangibles = 4.46, reliability = 4.46, responsiveness = 4.36, assurance = 4.36, and empathy = 4.36 respectively. The total gap quality between perception and expectation was -0.53.

Conclusion

All dimensions of quality based on SERVQUAL were negative, and the quality of service in PHC is not satisfactory. Therefore, policymakers must adopt serious and effective programs to improve services in this area. We also recommend that quality management of services in PHC in Iran should move toward comprehensive optimization in all areas, and quality in this area should be a priority.

Individual and institutional capacity-building for evidence-informed health policy-making in Iran: a mix of local and global evidence

Background

Providing valid evidence to policy-makers is a key factor in the development of evidence-informed policy-making (EIPM). This study aims to review interventions used to promote researchers’ and knowledge-producing organizations’ knowledge and skills in the production and translation of evidence to policy-making and explore the interventions at the individual and institutional level in the Iranian health system to strengthen EIPM.

Methods

The study was conducted in two main phases: a systematic review and a qualitative study. First, to conduct the systematic review, the PubMed and Scopus databases were searched. Quality appraisal was done using the Joanna Briggs Institute checklists. Second, semi-structured interviews and document review were used to collect local data. Purposive sampling was used and continued until data saturation. A qualitative content analysis approach was used for data analysis.

Results

From a total of 11,514 retrieved articles, 18 papers were eligible for the analysis. Based on the global evidence, face-to-face training workshops for researchers was the most widely used intervention for strengthening researchers’ capacity regarding EIPM. Target audiences in almost all of the training programmes were researchers. Setting up joint training sessions that helped empower researchers in understanding the needs of health policy-makers had a considerable effect on strengthening EIPM. Based on the local collected evidence, the main interventions for individual and institutional capacity-building were educational and training programmes or courses related to the health system, policy-making and policy analysis, and research cycle management. To implement the individual and institutional interventions, health system planners and authorities and the community were found to have a key role as facilitating factors.

Conclusion

The use of evidence-based interventions for strengthening research centres, such as training health researchers on knowledge translation and tackling institutional barriers that can prevent well-trained researchers from translating their knowledge, as well as the use of mechanisms and networks for effective interactions among policy-makers at the macro and meso (organizational) level and the research centre, will be constructive for individual and institutional capacity-building. The health system needs to strengthen its strategic capacity to facilitate an educational and training culture in order to motivate researchers in producing appropriate evidence for policy-makers.

Health Effects of Metabolic Risks in the United States From 1990 to 2019

Introduction

Metabolic risks including high body mass index, high fasting plasma glucose, high low-density lipoprotein cholesterol, high systolic blood pressure, kidney dysfunction and low bone mineral density, contribute heavy burden to the US health systems. We aimed to investigate the burden attributable to metabolic risks in the US from 1990 to 2019.

Methods

Using methodology of Global Burden of Disease Study, the deaths and DALYs attributable to metabolic risks were analyzed by age, gender, states, Socio-demographic Index (SDI) and diseases from 1990 to 2019 in the US.

Results

In 2019, the age-standardized death and DALY rates attributable to metabolic risks were 174.9 and 4738.7 per 100,000 people, accounting for 33.1% and 18.2% of death and DALY rates from all causes in the US, and there was a decrease by −32.5% and −21.2% in age-standardized death and DALY rates since 1990. The burden attributable to metabolic risks increased with age, and was higher in males than females. In addition, the burden varied widely across the states, generally in inverse proportion to the SDI levels, and the heaviest burden was observed in East and West South-Central of the US. Cardiovascular diseases carried heavy burden attributable to metabolic risks.

Conclusion

The burden attributable to metabolic risks remained major public health concerns in the US. Prevention of metabolic risks should be a high priority in the US.

The global burden of adolescent and young adult cancer in 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

In estimating the global burden of cancer, adolescents and young adults with cancer are often overlooked, despite being a distinct subgroup with unique epidemiology, clinical care needs, and societal impact. Comprehensive estimates of the global cancer burden in adolescents and young adults (aged 15-39 years) are lacking. To address this gap, we analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, with a focus on the outcome of disability-adjusted life-years (DALYs), to inform global cancer control measures in adolescents and young adults.

METHODS

Using the GBD 2019 methodology, international mortality data were collected from vital registration systems, verbal autopsies, and population-based cancer registry inputs modelled with mortality-to-incidence ratios (MIRs). Incidence was computed with mortality estimates and corresponding MIRs. Prevalence estimates were calculated using modelled survival and multiplied by disability weights to obtain years lived with disability (YLDs). Years of life lost (YLLs) were calculated as age-specific cancer deaths multiplied by the standard life expectancy at the age of death. The main outcome was DALYs (the sum of YLLs and YLDs). Estimates were presented globally and by Socio-demographic Index (SDI) quintiles (countries ranked and divided into five equal SDI groups), and all estimates were presented with corresponding 95% uncertainty intervals (UIs). For this analysis, we used the age range of 15-39 years to define adolescents and young adults.

FINDINGS

There were 1·19 million (95% UI 1·11-1·28) incident cancer cases and 396 000 (370 000-425 000) deaths due to cancer among people aged 15-39 years worldwide in 2019. The highest age-standardised incidence rates occurred in high SDI (59·6 [54·5-65·7] per 100 000 person-years) and high-middle SDI countries (53·2 [48·8-57·9] per 100 000 person-years), while the highest age-standardised mortality rates were in low-middle SDI (14·2 [12·9-15·6] per 100 000 person-years) and middle SDI (13·6 [12·6-14·8] per 100 000 person-years) countries. In 2019, adolescent and young adult cancers contributed 23·5 million (21·9-25·2) DALYs to the global burden of disease, of which 2·7% (1·9-3·6) came from YLDs and 97·3% (96·4-98·1) from YLLs. Cancer was the fourth leading cause of death and tenth leading cause of DALYs in adolescents and young adults globally.

INTERPRETATION

Adolescent and young adult cancers contributed substantially to the overall adolescent and young adult disease burden globally in 2019. These results provide new insights into the distribution and magnitude of the adolescent and young adult cancer burden around the world. With notable differences observed across SDI settings, these estimates can inform global and country-level cancer control efforts.

FUNDING

Bill & Melinda Gates Foundation, American Lebanese Syrian Associated Charities, St Baldrick's Foundation, and the National Cancer Institute.

Recommendations to improve insurance coverage for physiotherapy services in Iran: a multi criteria decision-making approach

BACKGROUND

High toll of traffic-related injuries, climate change, natural disasters, population aging, as well as chronic diseases have all made considerable demands on receiving physiotherapy services in Iran. Nevertheless, there is an assortment of complications facing utilization of such services, particularly poor insurance coverage. Therefore, the present study investigated and identified gaps in insurance coverage in order to inform future policy reforms and the design of a more comprehensive and universal benefits package for physiotherapy services in Iran.

METHODS

This project was carried out in Iran, using a mix-methods (viz. qualitative-quantitative) approach. Within the first phase, a qualitative study was completed to find policy recommendations. Such recommendations were then prioritized through the Analytical Hierarchy Process (AHP), in the second phase, based on effectiveness, acceptability, cost, fairness, feasibility, and time.

RESULTS

Within the first phase, a total number of 30 semi-structured interviews with health policy-makers, health insurers, faculty members, rehabilitation experts, and physiotherapists were completed. Several policy recommendations were also proposed by the study participants. Following the second phase, prioritized recommendations were provided to promote stewardship (e.g., informing policy-makers about physiotherapy services), collection of funds (e.g., placing value-added taxes on luxury goods and services), pooling of funds (e.g., moving allocated resources towards insurance (viz. third-party) mechanism), purchasing (e.g., using strategic purchasing), and benefit package (e.g., considering preventive interventions) as the main components of insurance coverage.

CONCLUSION

The study findings provided a favorable ground to improve insurance coverage for physiotherapy services in Iran. As well, decision- and policy-makers can place these recommendations on the agenda in the health sector to protect population health status, especially that of groups with disabilities.

Effect of COVID-19 on the Number of CT-scans and MRI Services of Public Hospitals in Iran: An Interrupted Time Series Analysis

Background

In February 2020, the Ministry of Health and Medical Education in Iran announced the first case of COVID-19. The aim of this study was to investigate the impact of COVID-19 on the number of CT-Scans and MRI services in public hospitals in western Iran.

Methods

We collected CT-scans and MRI services data from 18 public hospitals via Vice-Chancellor Office, Lorestan University of Medical Sciences from January 2017 to February 2021. Interrupted time series analysis (ITSA) was conducted to assess the impact of COVID-19 on CT-Scans and MRI services. More specifically, ITSA was conducted using ordinary least squares regression with the number of CT-Scans and MRI services per 1,000 registered persons per month as dependent variable.

Results

At the beginning of the observation period, the monthly rate of CT-Scans was constant (p for trend = 0.267) at 291.9 (from 95%CI 240.5 to 343.4) per 1,000 registered patients. The first case of COVID-19 coincided with an abrupt increase by 211.8 (from 95%CI 102.9 to 320.7) per 1,000 patients. Thereafter, the trend of CT-Scans did not change (p=0.576) compared to the pre-pandemic period. The rate of MRI services was 363.5 per 1,000 per registered patients per month (P = <0.0001) with a slightly decreasing trend (coefficient=-5; 95%CI, -6.9 to -3.1).

Conclusion

The findings of this study showed that crises such as COVID-19 can affect the service delivery process. Health policymakers and decision makers should work to prevent potential reductions in health care during events such as COVID-19.

Economic, Cultural, and Political Requirements for Medical Tourism Development in Iran: Insights from a Fuzzy Analytical Hierarchy Process Method

Background: According to the World Bank, the medical tourism industry in 2016 generated more than $100 billion revenue turnover for the destination countries. This study aims to investigate the developmental requirements of medical tourism industry in Iran to identify sustainable development strategies within this sector.

Methods: The present study was an applied-analytical study performed in a cross-sectional manner. A total of 25 experts, including policy experts, decision-makers, and managers with over 10 years of experience in the health system and familiar with the process of attracting medical tourists from foreign countries were asked to compare options for the development of the medical tourism. Expert opinions were analyzed using a fuzzy analytical hierarchy process using the open-source R Studio software.

Results: Out of the 5 items included in the questionnaire, the criterion of "government policy making and related entities" was ranked the first in terms of importance and prioritization for medical tourism development (0.249) through attracting domestic and foreign investments followed by advertising and marketing (0.241). Also, the criteria of "destination characteristics" and "facilities and status of service capacities with 0.111 and 0.185 weights had the lowest weight among the 5 items, respectively.

Conclusion: In general, governments play a key role in marketing and promoting the nascent medical tourism industry. Experts in the field believe that the role of government, policy and decision-makers in medical tourism can be an advantage for its prosperity and development.

Burden of Hypertensive Heart Disease in Iran during 1990-2017: Findings from the Global Burden of Disease study 2017

Background

Hypertension and its consequent end-organ damage including Hypertensive Heart Disease (HHD) are a major concern that impact health, resulting into impairment and reduced quality of life (QOL). The purpose of this study was to describe the burden of HHD in Iran and comparing it with the World Bank upper middle-income countries (UMICs) in terms of disability-adjusted life years (DALY), mortality and prevalence.

Methods

Using data from the Global Burden of Disease study 2017, we compared the number of DALYs, deaths and prevalence trends for HHD from 1990 to 2017 in all age groups for both sex in Iran, and compared the epidemiology and trends with UMICs and globally.

Results

The age-standardized DALY rate for HHD increased by 51.6% for men (95% uncertainty interval [UI] 305.8 to 436.7 per 100,000) and 4.4% for women (95% UI 429.4 to 448.7 per 100,000) in Iran. The age-standardized prevalence of HHD in Iran was almost twice times higher than globally and 1.5-times more than the World Bank UMICs. The age-standardized death rate for HDD increased by 60.1% (95% UI 17.3 to 27.7% per 100,000) for men and by 21.7% (95% UI 25.85 to 31.48 per 100,000) for women from 1990 to 2017. Age-standardized death rate in Iran was 2.4 and 1.9 times higher than globally and UMICs, respectively.

Conclusions

The higher prevalence and death rate in Iran in comparison with UMICs and globally should encourage health care provider to perform intensive screening activities in at risk population to prevent HHD and mitigate its mortality.

Financial Protection Indexes and the Iranian Health Transformation Plan: A Systematic Review

Background: On May 5, 2014, the Iranian Ministry of Health and Medical Education launched the Health Transformation Plan (HTP) as a major healthcare reform to curb out-of-pocket (OOP) expenses and protect people from catastrophic health expenditures (CHEs). Therefore, in this study, we conducted a comprehensive literature search with the aim of systematically investigating the impacts of HTP on OOP and CHE after the implementation of the plan. Method: Web of Science, PubMed, Scopus, Embase, and Iranian bibliographic thesauri and repositories such as MagIran, Elmnet, and Scientific Information Database were searched. Studies published between May 2014 and December 2020 that reported the impact of HTP on the financial indicators under investigation in this study (OOP and CHEs) that were conducted in Iran. Estimated pooled change both for OOP and CHEs was calculated as effect size utilizing meta-analytical techniques. Also, heterogeneity among studies was assessed with the I2 statistics. Results: Seventeen studies were included, nine of which evaluated the OOP index, six studies assessed the CHEs index, and two studies examined both the OOP and CHEs indexes. The OOP was found to decrease after the implementation of the HTP (with an estimated decrease of 13.02% (95% CI: 9.09-16.94). Also, CHEs experienced a decrease of 5.80% (95% CI: 3.85-7.74). Conclusion: The findings show that the implementation of HTP has reduced health costs. In this regard and in order to keep reducing the costs that many people are unable to pay, the government and other organizations involved in the health system should provide sustainable financial resources in order to continue running HTP. However, there remain gaps and weaknesses that can be solved through discussion with all the actors involved.

Burden of Respiratory Infection and Tuberculosis Among US States from 1990 to 2019

PURPOSE

To estimate the incidence, death, disability-adjusted life years (DALYs) and attributable risk factors for respiratory infection and tuberculosis (RIT) in the US from 1990 to 2019.

METHODS

Following the methodology framework and analytical strategies used in the Global Burden of Disease Study 2019, the incidence, death, DALYs and risk factors of RIT were examined by age, gender and states from 1990 to 2019 in the US. All estimates were calculated as counts, age-standardized rates per 100,000 people and percentage change, with 95% confidence intervals (CIs).

RESULTS

In 2019, the age-standardized incidence, death and DALY rates per 100,000 people of RIT were 339,703 (95% CI 303,184 to 382,354), 13.6 (95% CI 12.2 to 14.4) and 384.9 (95% CI 330.6 to 458.6), respectively. Among RIT causes, upper respiratory infection accounted for the large majority of RIT age-standardized incidence rate, while lower respiratory infection constituted the highest proportion of RIT age-standardized death and DALY rates. The age-standardized incidence, death and DALY rates of RIT in 2019 and their temporal trends since 1990 varied widely across states and socio-demographic index. Among all attributable risk factors, smoking was the leading one for age-standardized RIT deaths in 2019, followed by low temperature and alcohol use (the attributable fractions were 17.7%, 15.3% and 6.9%, respectively).

CONCLUSION

Our results suggest that RIT remained a major cause of health burden in the US, with large disparities persisting between US states. Intervention efforts for RIT hotspots, high-risk populations and modifiable risk factors are necessary.

Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Ending the global tobacco epidemic is a defining challenge in global health. Timely and comprehensive estimates of the prevalence of smoking tobacco use and attributable disease burden are needed to guide tobacco control efforts nationally and globally.

METHODS

We estimated the prevalence of smoking tobacco use and attributable disease burden for 204 countries and territories, by age and sex, from 1990 to 2019 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. We modelled multiple smoking-related indicators from 3625 nationally representative surveys. We completed systematic reviews and did Bayesian meta-regressions for 36 causally linked health outcomes to estimate non-linear dose-response risk curves for current and former smokers. We used a direct estimation approach to estimate attributable burden, providing more comprehensive estimates of the health effects of smoking than previously available.

FINDINGS

Globally in 2019, 1·14 billion (95% uncertainty interval 1·13-1·16) individuals were current smokers, who consumed 7·41 trillion (7·11-7·74) cigarette-equivalents of tobacco in 2019. Although prevalence of smoking had decreased significantly since 1990 among both males (27·5% [26·5-28·5] reduction) and females (37·7% [35·4-39·9] reduction) aged 15 years and older, population growth has led to a significant increase in the total number of smokers from 0·99 billion (0·98-1·00) in 1990. Globally in 2019, smoking tobacco use accounted for 7·69 million (7·16-8·20) deaths and 200 million (185-214) disability-adjusted life-years, and was the leading risk factor for death among males (20·2% [19·3-21·1] of male deaths). 6·68 million [86·9%] of 7·69 million deaths attributable to smoking tobacco use were among current smokers.

INTERPRETATION

In the absence of intervention, the annual toll of 7·69 million deaths and 200 million disability-adjusted life-years attributable to smoking will increase over the coming decades. Substantial progress in reducing the prevalence of smoking tobacco use has been observed in countries from all regions and at all stages of development, but a large implementation gap remains for tobacco control. Countries have a clear and urgent opportunity to pass strong, evidence-based policies to accelerate reductions in the prevalence of smoking and reap massive health benefits for their citizens.

FUNDING

Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Physical rehabilitation financing in Iran: a policy analysis using Kingdon's multiple streams

BACKGROUND

Adequate financing is a crucial function, securing that physical rehabilitation services (i.e., physiotherapy, occupational therapy, prosthetics and orthotics) are available with no financial hardship. Like many other countries, despite the adoption of various policies and strategies in recent decades, Iran enjoys no desirable physical rehabilitation financing (PRF). Accordingly, this qualitative study aimed to explore the PRF-related strategies and issues as well as their impacts on relevant policies in Iran.

METHODS

An analysis of PRF-related policies was conducted in Iran using semi-structured interviews and policy documents review. Purposive and snowball sampling techniques were employed to select key informants, including health-policy makers, civil society, rehabilitation-policy makers, university professors, and practitioners. Thematic analysis was used to analyze the collected data. The analysis was framed within Kingdon's multiple streams.

RESULTS

The hindering factors for desirable financing were weak insurance coverage, lack of sustainable financial resources, fragmented financing, lack of split between provider and financer, high-cost of physical rehabilitation services, low engagement of relevant experts in policy-making processes, and corrupt activities. In the policy stream, the following factors were highlighted: involvement of sustainable financial resources, the use of external revenue sources, allocated resources' earmarking, the integration of the current funds to have better pooling, the use of incentive and timely payment mechanisms, the implementation of strategic purchasing principals, and the employment of effective rationing strategies. Moreover, parliament support, changes in administrations, international effects, pressures from interest campaigns and NGOs, and international sanctions were found as factors affecting the politics stream.

CONCLUSION

The study findings revealed that a variety of national and international factors affect PRF-related issues in Iran. The recently enacted laws indicate that the PRF policies have already been on the national health political agenda. The study reflected the multifaceted nature of barriers to optimal PRF in Iran.

The impacts of health transformation plan on physiotherapy sector in Iran: a qualitative study using five control knobs

PURPOSE

To investigate physiotherapists', academics', and relevant decision- and policy-makers' experiences regarding the impacts of the Health Transformation Plan (HTP) on the physiotherapy sector in Iran.

MATERIALS AND METHODS

This qualitative study was conducted using in-depth semi-structured interviews. The participants were selected using both purposive and snowball sampling strategies with maximum diversity. The sampling procedure continued until data saturation was achieved. The collected data were analyzed using thematic content analysis in accordance with Braun and Clarke's methodology.

RESULTS

The findings showed that the physiotherapy sector has faced several challenges after the implementation of HTP in five control knobs: (1) financing (a decline in the government budget and insufficient health insurance coverage), (2) payment (delayed payments and setting a tight ceiling for reimbursements), (3) behaviors (a decrease in the motivation of physiotherapists, the tendency toward misbehaviors such as absenteeism and providers' unwillingness to cooperate with insurance companies), (4) organization (difficulty in clinical education and ignoring the preventive effects of physiotherapy interventions), and (5) regulation (absence of stakeholders in political processes and inconsistency of upstream documents).

CONCLUSION

HTP has posed various challenges on the physiotherapy sector in Iran. Promoting the policymakers' awareness and aligning the health reforms such as HTP with the current upstream documents would diminish the existing challenges.IMPLICATIONS FOR REHABILITATIONMore government budgets and better insurance coverage are needed to strengthen the physiotherapy sector.Timely payment and modification of limitations for reimbursements of physiotherapy services are recommended.It is recommended to adopt strategies to increase the motivation of physiotherapists and reduce the risk of professional misconduct in the physiotherapy sector.Problems in clinical physiotherapy training should be addressed by policy-makers, and the preventive effects of physiotherapy interventions deserve more attention.Enhanced participation of physiotherapy stakeholders in relevant legislative processes is recommended to improve their services.

Mapping Research Trends of Universal Health Coverage From 1990 to 2019: Bibliometric Analysis

Background

Universal health coverage (UHC) is one of many ambitious, health-related, sustainable development goals. Sharing various experiences of achieving UHC, in terms of challenges, pitfalls, and future prospects, can help policy and decision-makers reduce the likelihood of committing errors. As such, scholarly articles and technical reports are of paramount importance in shedding light on the determinants that make it possible to achieve UHC.

Objective

The purpose of this study is to conduct a comprehensive analysis of UHC-related scientific literature from 1990 to 2019.

Methods

We carried out a bibliometric analysis of papers related to UHC published from January 1990 to September 2019 and indexed in Scopus via VOSviewer (version 1.6.13; CWTS). Relevant information was extracted: the number of papers published, the 20 authors with the highest number of publications in the field of UHC, the 20 journals with the highest number of publications related to UHC, the 20 most active funding sources for UHC-related research, the 20 institutes and research centers that have produced the highest number of UHC-related research papers, the 20 countries that contributed the most to the research field of UHC, the 20 most cited papers, and the latest available impact factors of journals in 2018 that included the UHC-related items under investigation.

Results

In our analysis, 7224 articles were included. The publication trend was increasing, showing high interest in the scientific community. Most researchers were from the United States, the United Kingdom, and Canada, with Thailand being a notable exception. The Lancet accounted for 3.95% of published UHC-related research. Among the top 20 funding sources, the World Health Organization (WHO), the Bill and Melinda Gates Foundation, and the National Institutes of Health (NIH) accounted for 1.41%, 1.34%, and 1.02% of published UHC-related research, respectively. The highest number of citations was found for articles published in The Lancet, the American Journal of Psychiatry, and the Journal of the American Medical Association (JAMA). The top keywords were “health insurance,” “insurance,” “healthcare policy,” “healthcare delivery,” “economics,” “priority,” “healthcare cost,” “organization and management,” “health services accessibility,” “reform,” “public health,” and “health policy.”

Conclusions

The findings of our study showed an increasing scholarly interest in UHC and related issues. However, most research concentrated in middle- and high-income regions and countries. Therefore, research in low-income countries should be promoted and supported, as this could enable a better understanding of the determinants of the barriers and obstacles to UHC achievement and improve global health.

Cost-effectiveness analysis of mitral valve repair with the MitraClip delivery system for patients with mitral regurgitation: a systematic review

To assess the cost-effectiveness of mitral valve repair with the MitraClip delivery system for patients with mitral regurgitation and heart failure, a systematic literature search was conducted in various electronic databases to January 3, 2020. Eligibility criteria are the population (patients with mitral regurgitation (MR)), intervention (transcatheter mitral valve repair using the MitraClip), comparator (conventional medical treatment), outcomes, and designs (Model-based or trial-based full economic evaluations).The quality of included studies was assessed using the CHEERS checklist. Mortality and survival rate, quality-adjusted life year (QALY), life years gained (LYG), total cost, and the incremental cost-effectiveness ratio (ICER) regarding the use of MitraClip System were considered as the key outcomes. Eight articles were eligible for full-text assessment. Ultimately, a total of seven studies were considered in the current systematic review. Results demonstrated that MitraClip reduces mortality rate and increases survival rate. The mortality rate at 1 year and 10 years was 16.7% versus 29.77% and 70.9% versus 98.8%, respectively. Total cost data based on 2019 USD show that the MitraClip has the highest cost in the USA ($121,390) and the lowest cost in Italy ($33,062). The results showed that in all selected countries, willingness-to-pay (WTP) thresholds are upper than the cost per QALY; also, the highest ICER for the MitraClip is in the USA ($55,600/QALY) and the lowest in Italy ($10,616/QALY). To conclude, evidence from this systematic review suggests that MitraClip Delivery System improved both life expectancy and QALY compared with medical treatment in patients at high surgical risk and it was also a cost-effective treatment option for patients with mitral regurgitation.

One health approach to tackle brucellosis: a systematic review

Background

Brucellosis is the most significant and common bacterial zoonosis and is recognized as a re-emerging and neglected disease. Tackling zoonosis is very important for the health and the economy. One Health is an approach characterized by the integration of human and animal health, plants, and ecosystems and encourages joining local, national, and global multidisciplinary efforts to achieve optimal levels of health and collaboration among different disciplines to address complex health problems.

Objectives

The present study aimed to review published scientific literature related to the use of the One Health approach to tackle human brucellosis.

Methods

Web of Science (WoS), PubMed, Scopus, The Cochrane Library, and Embase databases were searched from inception until 30 January 2020. The reference lists of all relevant papers were hand-searched. Two authors extracted data from published studies independently. The Joanna Briggs Institute tool was used to assess the quality of studies.

Results

Of 2297 studies, 10 studies were deemed eligible, which were conducted between 2013 and 2019. Studies were performed in Uganda, Malta, Serbia, Greece, Mongolia, Azerbaijan, Israel, India, Ethiopia, and the USA. All studies suggested that brucellosis is still a major public health problem and that the most important aspect of the One Health approach is the interdependence of humans, ecosystems, and animals .Some studies have focused on livestock vaccination as the most effective way to prevent disease, and others have focused on the biology of Brucella infection and its transmission patterns. Some studies have pointed to the effectiveness of the One Health approach in all the phases of disease management as well as to its role in reducing health costs.

Conclusion

The success of the approach depends on the willingness of the decision-makers to implement the necessary policies. Due to the heterogeneity of current practices, and organizations involved in One Health approach-based programs, it will be incomplete without proper planning. To better implement the approach, strategies should be appraised and disseminated by experts and relevant stakeholders.

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages.

METHODS

Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0-100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target-1 billion more people benefiting from UHC by 2023-we estimated additional population equivalents with UHC effective coverage from 2018 to 2023.

FINDINGS

Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2-47·5) in 1990 to 60·3 (58·7-61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9-3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010-2019 relative to 1990-2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6-421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0-3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5-1040·3]) residing in south Asia.

INTERPRETATION

The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people-the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close-or how far-all populations are in benefiting from UHC.

FUNDING

Bill & Melinda Gates Foundation.

Estimating global injuries morbidity and mortality: methods and data used in the Global Burden of Disease 2017 study

BACKGROUND

While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria.

METHODS

In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced.

RESULTS

GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes.

CONCLUSIONS

GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.

Burden of injury along the development spectrum: associations between the Socio-demographic Index and disability-adjusted life year estimates from the Global Burden of Disease Study 2017

BACKGROUND

The epidemiological transition of non-communicable diseases replacing infectious diseases as the main contributors to disease burden has been well documented in global health literature. Less focus, however, has been given to the relationship between sociodemographic changes and injury. The aim of this study was to examine the association between disability-adjusted life years (DALYs) from injury for 195 countries and territories at different levels along the development spectrum between 1990 and 2017 based on the Global Burden of Disease (GBD) 2017 estimates.

METHODS

Injury mortality was estimated using the GBD mortality database, corrections for garbage coding and CODEm-the cause of death ensemble modelling tool. Morbidity estimation was based on surveys and inpatient and outpatient data sets for 30 cause-of-injury with 47 nature-of-injury categories each. The Socio-demographic Index (SDI) is a composite indicator that includes lagged income per capita, average educational attainment over age 15 years and total fertility rate.

RESULTS

For many causes of injury, age-standardised DALY rates declined with increasing SDI, although road injury, interpersonal violence and self-harm did not follow this pattern. Particularly for self-harm opposing patterns were observed in regions with similar SDI levels. For road injuries, this effect was less pronounced.

CONCLUSIONS

The overall global pattern is that of declining injury burden with increasing SDI. However, not all injuries follow this pattern, which suggests multiple underlying mechanisms influencing injury DALYs. There is a need for a detailed understanding of these patterns to help to inform national and global efforts to address injury-related health outcomes across the development spectrum.

Global injury morbidity and mortality from 1990 to 2017: results from the Global Burden of Disease Study 2017

BACKGROUND

Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries.

METHODS

We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs).

FINDINGS

In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505).

INTERPRETATION

Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care.

Morbidity and mortality from road injuries: results from the Global Burden of Disease Study 2017

BACKGROUND

The global burden of road injuries is known to follow complex geographical, temporal and demographic patterns. While health loss from road injuries is a major topic of global importance, there has been no recent comprehensive assessment that includes estimates for every age group, sex and country over recent years.

METHODS

We used results from the Global Burden of Disease (GBD) 2017 study to report incidence, prevalence, years lived with disability, deaths, years of life lost and disability-adjusted life years for all locations in the GBD 2017 hierarchy from 1990 to 2017 for road injuries. Second, we measured mortality-to-incidence ratios by location. Third, we assessed the distribution of the natures of injury (eg, traumatic brain injury) that result from each road injury.

RESULTS

Globally, 1 243 068 (95% uncertainty interval 1 191 889 to 1 276 940) people died from road injuries in 2017 out of 54 192 330 (47 381 583 to 61 645 891) new cases of road injuries. Age-standardised incidence rates of road injuries increased between 1990 and 2017, while mortality rates decreased. Regionally, age-standardised mortality rates decreased in all but two regions, South Asia and Southern Latin America, where rates did not change significantly. Nine of 21 GBD regions experienced significant increases in age-standardised incidence rates, while 10 experienced significant decreases and two experienced no significant change.

CONCLUSIONS

While road injury mortality has improved in recent decades, there are worsening rates of incidence and significant geographical heterogeneity. These findings indicate that more research is needed to better understand how road injuries can be prevented.

The 'Health Transformation Plan' in Iran: A policy to achieve universal health coverage in slums and informal settlement areas

Universal health coverage (UHC) is one of the strategies that health decision- and policy-makers worldwide are implementing to guarantee a good health status to everyone. Living in slums is characterized by several issues, including homelessness and malnutrition, environmental challenges, lack of sanitation and access to safe, healthy drinking water, waste disposal problems, widespread social disruptions, job insecurity, feelings of dissatisfaction and inadequacy. In Iran, the 'Health Transformation Plan' (HTP), despite its weaknesses, has had good effects on the health level of people living in slums, ensuring insurance coverage and reducing many economic, social and cultural problems, with a dramatic decline in out-of-pocket expenditures. Good governmental financial support and an adequate revision of the initial packages of health services and provisions have resulted in a higher access rate to healthcare. The HTP has been, indeed, a major step towards reaching UHC in Iran. If policy- and decision-makers can further improve the present situation and provide more and better-quality services to these people, it can be expected that health indicators in suburbs will be significantly improved. Researchers should monitor the impact of HTP and examine its effects on health indicators, specifically among particularly vulnerable groups such as children, women and the elderly.

Cost-effectiveness of allopurinol versus febuxostat in the treatment of gout patients: A systematic review

Background: In recent years, increased longevity, poor dietary habits, and the rising prevalence of metabolic syndrome and hypertension have increased the prevalence of gout. Gout significantly increases direct and indirect costs and reduces the quality of life. Allopurinol and febuxostat are the most commonly used drugs for reducing uric acid levels and controlling this disease with different cost-effectiveness. The present systematic review compares the cost-effectiveness of these drugs. Methods: This was a systematic review of economic evaluations. Cochrane CENTRAL, Web of Science, PubMed, Embase, and the Cost-Effectiveness Analysis (CEA) Registry were searched up to April 30, 2018, based on the specific search strategy of each database. Keywords used in the search include gout, cost-effectiveness, allopurinol, and febuxostat in MeSH and free-text forms. Screening of identified studies, data extraction, and quality assessment were done independently by 2 reviewers. The quality of studies was assessed based on Drummond Checklist. Finally, a qualitative analysis was done to analyze the results. Results: A total of 94 studies were identified through database search and the review of references. After screening the titles, abstracts, and full-texts, 6 economic evaluations were included in the review. The majority of the studies had been conducted in the US using the Markov model, within a 5-year horizon, and from the payer's perspective, with the quality of life as a measure of effectiveness. In most studies, the incremental cost-effectiveness ratios (ICERs) of febuxostat per quality-adjusted life year (QALY) were below the threshold (10 000$/QALY and 30 000€/QALY). Conclusion: Febuxostat has been shown to be more cost-effective than allopurinol in all treatment sequences in studies that have used uric acid levels as the measure of effectiveness. Furthermore, in studies with the quality of life as the measure of effectiveness, febuxostat has been shown to be very cost-effective as the second-line treatment.

Mapping geographical inequalities in access to drinking water and sanitation facilities in low-income and middle-income countries, 2000-17

BACKGROUND

Universal access to safe drinking water and sanitation facilities is an essential human right, recognised in the Sustainable Development Goals as crucial for preventing disease and improving human wellbeing. Comprehensive, high-resolution estimates are important to inform progress towards achieving this goal. We aimed to produce high-resolution geospatial estimates of access to drinking water and sanitation facilities.

METHODS

We used a Bayesian geostatistical model and data from 600 sources across more than 88 low-income and middle-income countries (LMICs) to estimate access to drinking water and sanitation facilities on continuous continent-wide surfaces from 2000 to 2017, and aggregated results to policy-relevant administrative units. We estimated mutually exclusive and collectively exhaustive subcategories of facilities for drinking water (piped water on or off premises, other improved facilities, unimproved, and surface water) and sanitation facilities (septic or sewer sanitation, other improved, unimproved, and open defecation) with use of ordinal regression. We also estimated the number of diarrhoeal deaths in children younger than 5 years attributed to unsafe facilities and estimated deaths that were averted by increased access to safe facilities in 2017, and analysed geographical inequality in access within LMICs.

FINDINGS

Across LMICs, access to both piped water and improved water overall increased between 2000 and 2017, with progress varying spatially. For piped water, the safest water facility type, access increased from 40·0% (95% uncertainty interval [UI] 39·4-40·7) to 50·3% (50·0-50·5), but was lowest in sub-Saharan Africa, where access to piped water was mostly concentrated in urban centres. Access to both sewer or septic sanitation and improved sanitation overall also increased across all LMICs during the study period. For sewer or septic sanitation, access was 46·3% (95% UI 46·1-46·5) in 2017, compared with 28·7% (28·5-29·0) in 2000. Although some units improved access to the safest drinking water or sanitation facilities since 2000, a large absolute number of people continued to not have access in several units with high access to such facilities (>80%) in 2017. More than 253 000 people did not have access to sewer or septic sanitation facilities in the city of Harare, Zimbabwe, despite 88·6% (95% UI 87·2-89·7) access overall. Many units were able to transition from the least safe facilities in 2000 to safe facilities by 2017; for units in which populations primarily practised open defecation in 2000, 686 (95% UI 664-711) of the 1830 (1797-1863) units transitioned to the use of improved sanitation. Geographical disparities in access to improved water across units decreased in 76·1% (95% UI 71·6-80·7) of countries from 2000 to 2017, and in 53·9% (50·6-59·6) of countries for access to improved sanitation, but remained evident subnationally in most countries in 2017.

INTERPRETATION

Our estimates, combined with geospatial trends in diarrhoeal burden, identify where efforts to increase access to safe drinking water and sanitation facilities are most needed. By highlighting areas with successful approaches or in need of targeted interventions, our estimates can enable precision public health to effectively progress towards universal access to safe water and sanitation.

FUNDING

Bill & Melinda Gates Foundation.

Zonisamide add-on therapy for focal epilepsy

BACKGROUND

The majority of people with epilepsy have a good prognosis, and their seizures can be well controlled with the use of a single antiepileptic agent, but up to 30% develop dug-resistant epilepsy, especially those with focal seizures. In this review, we summarised the evidence from randomised controlled trials (RCT) of zonisamide, used as an add-on treatment for focal epilepsy uncontrolled by one or more concomitant antiepileptic drug. This is an updated version of the Cochrane review previously published in 2018.

OBJECTIVES

To evaluate the efficacy and tolerability of zonisamide, when used as an add-on treatment for people with focal epilepsy uncontrolled by one or more concomitant antiepileptic drugs.

SEARCH METHODS

For the latest update, we searched the Cochrane Register of Studies (CRS Web) and MEDLINE Ovid (September 2019). In addition, we contacted Eisai Limited (makers and licensees of zonisamide) and experts in the field, to seek any ongoing or unpublished studies.

SELECTION CRITERIA

Randomised controlled trials, in which add-on zonisamide was compared with placebo or another antiepileptic drug in people with focal epilepsy, uncontrolled by one or more concomitant antiepileptic drugs.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, assessed for risk of bias using the Cochrane 'Risk of bias' tool, and assessed the certainty of the evidence, using the GRADE approach. The primary outcome was at least a 50% reduction in total seizure frequency; the secondary outcomes were (1) tolerability; and (2) adverse effects. We used an intention-to-treat approach for our primary analyses. We estimated summary risk ratios (RRs) for each outcome. We displayed a summary of the estimates of effects and certainty of the evidence for each outcome in a 'Summary of findings' table.

MAIN RESULTS

We did not find any new studies since the last version of this review. We included eight studies (1636 participants) from previous versions of this review. The overall RR with 95% confidence interval (CI) for at least a 50% reduction in seizure frequency for 300 mg to 500 mg/day of zonisamide compared to placebo was 1.90 (95% CI 1.63 to 2.22; 7 trials, 1371 participants; moderate-certainty evidence). The RR for 50% reduction in seizure frequency compared to placebo for any dose of zonisamide (100 mg to 500 mg/day) was 1.86 (95% CI 1.60 to 2.17; 7 trials, 1429 participants; moderate-certainty evidence). The number needed to treat for an additional beneficial outcome was six (95% CI 4.1 to 6.8). Two trials provided evidence of a dose-response relationship for this outcome. The RR for treatment withdrawal for 300 mg to 500 mg/day of zonisamide compared to placebo was 1.59 (95% CI 1.18 to 2.13; 6 trials, 1099 participants; moderate-certainty evidence), and for 100 mg to 500 mg/day was 1.44 (95% CI 1.08 to 1.93; 6 trials, 1156 participants; moderate-certainty evidence). The number needed to treat for an additional harmful outcome was 15 (95% CI 9.3 to 36.7). The following adverse effects were more likely to be associated with zonisamide than with placebo: ataxia (RR 3.85, 99% CI 1.36 to 10.93; 4 trials, 734 participants; low-certainty evidence); somnolence (RR 1.52, 99% CI 1.00 to 2.31; 8 trials, 1636 participants; moderate-certainty evidence); agitation (RR 2.35, 99% CI 1.05 to 5.27; 4 trials, 598 participants; low-certainty evidence); and anorexia (RR 2.74, 99% CI 1.64 to 4.60; 6 trials, 1181 participants; low-certainty evidence). Across the eight studies, we rated risk of bias domains at low or unclear risk of bias, apart from two studies, which we rated at high risk of attrition bias. Five of the eight studies were sponsored by the drug companies that produced zonisamide.

AUTHORS' CONCLUSIONS

When used as an add-on treatment in people with focal epilepsy, uncontrolled by one or more concomitant antiepileptic drugs, moderate-certainty evidence found that zonisamide was more successful than placebo at reducing the frequency of seizures by at least 50%. We were unable to identify minimum effective and maximum tolerated doses. The included trials evaluated a maximum stable-dose phase of 18 weeks, so results cannot be used to confirm longer periods of efficacy in seizure control. The results cannot be extrapolated to monotherapy, or to people with other seizure types or epilepsy syndromes.

Prevalence of self-medication in university students: systematic review and meta-analysis

Background

Self-medication can lead to serious consequences but its overall prevalence in students is not known.

Aims

The aim of this study was to determine the prevalence of self-medication in students through a systematic review and meta-analysis of studies on the prevalence of self-medication in students across the world.

Methods

PubMed/MEDLINE, EMBASE, ISI/Web of Science and Google Scholar were searched up to October 2017. Studies reporting the prevalence of self-treatment in university students were selected. Data recorded included year of publication, country where the study was conducted, sample size, prevalence of self-medication, sex and mean age of students, and faculty of students (medical or non-medical). A random-effect model was used to determine effect size with a 95% confidence interval (CI). Heterogeneity across studies was assessed with the I² test. A sensitivity analysis assessed stability of the findings.

Results

A total of 89 studies were included in the analysis, which comprised 60 938 students. The overall prevalence of self-medication in university students was 70.1% (95% CI: 64.3-75.4%). Female students self-medicated more often than male students: odds ratio = 1.45 (95% CI%: 1.17-1.79). The prevalence of self-medication in medical students (97.2%) was higher than in non-medical students (44.7%). The I² test indicated high, statistically significant heterogeneity. The sensitivity analysis showed that the results were stable.

Conclusion

The prevalence of self-medication among students worldwide is high. Programmes on the risks of self-medication and increasing control and monitoring of the sale of drugs are recommended. Facilitating students' access to doctors and health centres could reduce self-medication in students.

Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000-17: analysis for the Global Burden of Disease Study 2017

BACKGROUND

Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea.

METHODS

We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates.

FINDINGS

The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1-65·8), 17·4% (7·7-28·4), and 59·5% (34·2-86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage.

INTERPRETATION

By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health.

FUNDING

Bill & Melinda Gates Foundation.

The barriers to the full implementation of strategic purchasing and the role of health policy and decision-makers: past, current status, ethical aspects and future challenges

Healthcare systems are complex, multi-level, highly integrated organizations, comprising of different professional figures, institutions, and resources. Such breadth and complexity reflect the multi-dimensionality of the concept of health, which implies the adoption of a holistic approach. Health, rather than merely being the absence of disorders or infirmity, is a highly dynamic state, which represents the abilities of an individual to cope with adverse social, physical and emotional/psychological events and conditions, continuously adapting to them. Ensuring an adequate health state is one of the most important concerns, and the healthcare systems are called to renew themselves in order to meet with the new challenges and health needs. Throughout the last decades, due to demographic shifts and transitions, epidemiological and societal changes, technological achievements and scientific advancements, healthcare systems have undergone an extensive series of reform plans. Therefore, health policy- and decision-makers have made efforts to develop and implement initiatives for preserving the quality of the healthcare provisions. Strategic purchasing is an approach of purchasing that takes into account several health-related issues such as a proper, comprehensive planning of service delivery, the design and selection of the best packages of services and provisions, the appropriate selection of providers and the allocation of economical and financial incentives to provide better services and to motivate managers to adopt appropriate policies to implement strategic purchasing. Here, we intend to consider the various dimensions and aspects that can be effective in strategic purchasing, as well as the main barriers and obstacles that hinder its full implementation.