Clinical phenotypes of patients with acute stroke: a secondary analysis

INTRODUCTION

Stroke is a leading cause of mortality worldwide and a major cause of disability having a high burden on patients, society, and caregiving systems. This study was conducted to investigate the presence of clusters of in-hospital patients with acute stroke based on demographic and clinical data. Cluster analysis reveals patterns in patient characteristics without requiring knowledge of a predefined patient category or assumptions about likely groupings within the data.

METHODS

We performed a secondary analysis of open-access anonymized data from patients with acute stroke admitted to a hospital between December 2019 to June 2021. In total, 216 patients (78; 36.1% men) were included in the analytical dataset with a mean (SD) age of 60.3 (14.4). Many demographic and clinical features were included in the analysis and the Barthel Index on discharge was used for comparing the functional recovery of the identified clusters.

RESULTS

Hierarchical clustering based on the principal components identified two clusters of 109 and 107 patients. The clusters were different in the Barthel Index scores on discharge with the mean (SD) of 39.3 (29.3) versus 62.6 (29.4); t (213.87) = -5.818, P <0.001, Cohen's d (95%CI) = -0.80 (-1.07, -0.52). A logistic model showed that age, systolic blood pressure, pulse rate, D-dimer blood level, low-density lipoprotein, hemoglobin, creatinine concentration, the National Institute of Health Stroke Scale value, and the Barthel Index scores on admission were significant predictors of cluster profiles (all P ≤0.029).

CONCLUSION

There are two clusters in hospitalized patients with acute stroke with significantly different functional recovery. This allows prognostic grouping of hospitalized acute stroke patients for prioritization of care or resource allocation. The clusters can be recognized using easily measured demographic and clinical features.

Hospital Performance Evaluation Checklist in Context of COVID-19 Pandemic: Design and Validation

OBJECTIVE

Around the world, pandemics have been considered among the main hazards in the last 2 decades. Hospitals are 1 of the most important organizations responding to pandemics. The aim of this study was to design and develop a valid checklist for evaluating the hospitals' performance in response to COVID-19 pandemic, for the first time.

METHODS

This study is a mixed method research design that began in February, 2020 and was conducted in 3 phases: Designing a conceptual model, designing a primary checklist structure, and checklist psychometric evaluation. Known-groups method has been used to evaluate construct validity. Two groups of hospitals were compared: group A (COVID-19 Hospitals) and group B (the other hospitals).

RESULTS

The checklist's main structure was designed with 6 main domains, 23 sub-domains, and 152 items. The content validity ratio and index were 0.94 and 0.79 respectively. Eleven items were added, 106 items were removed, and 40 items were edited. Independent t-test showed a significant difference between the scores of the 2 groups of hospitals (P < 0.0001). Pearson correlation coefficient test also showed a high correlation between our checklist and the other. The internal consistency of the checklist was 0.98 according to Cronbach's alpha test.

CONCLUSIONS

Evaluating the hospitals' performance and identifying their strengths and weaknesses, can help health system policymakers and hospital managers, and leads to improved performance in response to COVID-19.

Budgeting in Healthcare Systems and Organizations: A Systematic Review

Background

Budgeting is the process resource allocation to produce the best output according to the revenue levels involved. Among the constraints that healthcare organizations, including hospitals, both in the public and private sectors, grapple with is budgetary constraints. Therefore, cost control and resource management should be considered in healthcare organizations under such circumstances.

Methods

We aimed to identify methods of budgeting in healthcare systems and organizations as a systematic review. To extract and analyze the data, a form was designed by the researcher to define budgeting methods proposed in the literature and to identify their strengths, weaknesses, and dimensions. The search was conducted in Google Scholar, Web of science, Pub med and Scopus databases covering the period 1990-2022.

Results

Overall, 33 articles were included in the study for extraction and final analysis. The study results were reported in four main themes: healthcare system budgeting, capital budgeting, global budgeting, and performance-based budgeting.

Conclusion

Each budgeting approach has its own pros and cons and requires meeting certain requirements. These approaches are selected and implemented depending on each country's infrastructure and conditions as well as its organizations. These infrastructures need to be thoroughly examined before implementing any budgeting method, and then a budgeting method should be selected accordingly.

Cost-Effectiveness of Remote Cardiac Monitoring With the CardioMEMS Heart Failure System: A Systematic Review

Background

Heart Failure (HF) imposes a relevant burden and a considerable health concern, with high prevalence and mortality rates. This study was conducted to assess the cost-effectiveness of remote cardiac monitoring with the CardioMEMS Heart Failure System.

Methods

In the present systematic review, several scholarly databases were searched and updated from inception up to September 20, 2022. The objective of the present review was formulated according to the patient/population, intervention, comparison and outcomes format. Mortality rate, hospitalization rate, quality-adjusted life year (QALY), total costs, and the incremental cost-effectiveness ratio regarding the use of the CardioMEMS System were the key outcomes of the present study. The quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS) checklist.

Results

Finally, 5 articles were retained and analyzed in the present systematic review. All studies employed the Markov and decision tree models. Results show that the CardioMEMS system reduced mortality and hospitalization rate and created a higher QALY. In all selected countries the CardioMEMS method is a more expensive method than the standard of care (SoC), with the highest cost in the United States (US) ($201,437) and the lowest cost in the United Kingdom ($25,963), respectively. the highest willingness to pay in the US and the lowest in Italy ($100,000 and $33,000 per QALY), respectively. Results showed that the most cost per QALY for the CardioMEMS system was in the US and the lowest was in the Netherlands ($46,622 and $26,615 per QALY), respectively.

Conclusion

In all selected countries, CardioMEMS is a cost-effective method for monitoring and managing pulmonary artery pressures in HF patients. Strategies such as CardioMEMS, which decrease the rate of hospitalization, are likely to be only more cost-effective in the future.

Association of Glasgow coma scale and endotracheal intubation in predicting mortality among patients admitted to the intensive care unit

BACKGROUND

We assessed predictors of mortality in the intensive care unit (ICU) and investigated if Glasgow coma scale (GCS) is associated with mortality in patients undergoing endotracheal intubation (EI).

METHODS

From February 2020, we performed a 1-year study on 2,055 adult patients admitted to the ICU of two teaching hospitals. The outcome was mortality during ICU stay and the predictors were patients' demographic, clinical, and laboratory features.

RESULTS

EI was associated with a decreased risk for mortality compared with similar patients (adjusted odds ratio [AOR], 0.32; P=0.030). This shows that EI had been performed correctly with proper indications. Increasing age (AOR, 1.04; P<0.001) or blood pressure (AOR, 1.01; P<0.001), respiratory problems (AOR, 3.24; P<0.001), nosocomial infection (AOR, 1.64; P=0.014), diabetes (AOR, 5.69; P<0.001), history of myocardial infarction (AOR, 2.52; P<0.001), chronic obstructive pulmonary disease (AOR, 3.93; P<0.001), immunosuppression (AOR, 3.15; P<0.001), and the use of anesthetics/sedatives/hypnotics for reasons other than EI (AOR, 4.60; P<0.001) were directly; and GCS (AOR, 0.84; P<0.001) was inversely related to mortality. In patients with trauma surgeries (AOR, 0.62; P=0.014) or other surgical categories (AOR, 0.61; P=0.024) undergoing EI, GCS had an inverse relation with mortality (accuracy=82.6%, area under the receiver operator characteristic curve=0.81).

CONCLUSIONS

A variety of features affected the risk for mortality in patients admitted to the ICU. Considering GCS score for EI had the potential of affecting prognosis in subgroups of patients such as those with trauma surgeries or other surgical categories.

A Systematic Review and Meta-Analysis of Health Care Quality in Iran Based on the Comprehensive Quality Measurement in Health Care Model

Background

Comprehensive assessment of health care quality is the first step in improving care and achieving health service goals. Therefore, this study aimed to conduct a systematic review and meta-analysis of health care quality in Iran based on the Comprehensive Quality Measurement in Health Care model.

Methods

In this study, the databases of PubMed, Scopus, Web of Science, Iranian Scientific Information Database (SID), MagIran, and Google Scholar were searched using English and Iran keywords without time limit. STATA 16 software and a random effect model were used for conducting meta-analysis.

Results

Of the 750 articles found, 20 were finally included; 13 of which were related to service quality, five to customer quality, and four to technical quality. Overall mean score of service quality was 7.79 [95% CI 7.43-8.15, df = 12, I² = 98.48, P value < 0.000] out of 10, and overall mean score of customer quality was 73.20 ± 4.56 [95% CI 65.18-81.22, df = 5, I² = 99.34, P value < 0.001] out of 100. Among the 12 dimensions of service quality, the confidentiality dimension (9.55 ± 0.12) had the highest mean score and the group support dimension (5.92 ± 0.901) had the lowest score. In general, from the viewpoint of service receivers, the technical quality is relatively favorable.

Conclusions

According to the results of this study, the quality of health care in Iran is significantly far from ideal. Therefore, planning to improve providing health care is essential.

Cost-benefit analysis of Intensive Care Unit with Activity-Based Costing approach in the era COVID-19 pandemic: A case study from Iran

BACKGROUND

Providing intensive care to acute patients is a vital part of health systems. However, the high cost of Intensive Care Units (ICU) has limited their development, especially in low-income countries. Due to the increasing need for intensive care and limited resources, ICU cost management is important. This study aimed to analyze the cost-benefit of ICU during COVID-19 in Tehran, Iran.

METHODS

This cross-sectional study is an economic evaluation of health interventions. The study was conducted in the COVID-19 dedicated ICU, from the provider's point of view and within one-year horizon. Costs were calculated using a top-down approach and the Activity-Based Costing technique. Benefits were extracted from the hospital's HIS system. Benefit Cost ratio (BCR) and Net Present Value (NPV) indexes were used for cost-benefit analysis (CBA). A sensitivity analysis was performed to evaluate the dependence of the CBA results on the uncertainties in the cost data. Analysis was performed with Excel and STATA software.

RESULTS

The studied ICU had 43 personnel, 14 active beds, a 77% bed occupancy rate, and 3959 occupied bed days. The total costs were $2,372,125.46 USD, of which 70.3% were direct costs. The highest direct cost was related to human resources. The total net income was $1,213,314.13 USD. NPV and BCR were obtained as $-1,158,811.32 USD and 0.511 respectively.

CONCLUSION

Despite operating with a relatively high capacity, ICU has had high losses during the COVID-19. Proper management and re-planning in the structure of human resources is recommended due to its importance in the hospital economy, provision of resources based on needs assessment, improvement of drugs management, reduction of insurance deductions in order to reduce costs and improve ICU productivity.

Relationship between quality of work-life, resilience and burnout among nursing professionals during COVID-19 pandemic in Iran: A cross-sectional study

Background

The COVID-19 pandemic and the increased workload and stress associated with the disease prevalence have posed a high risk of burnout to nurses. The effects of the workplace and environmental factors on resilience and burnout among nursing professionals have not been investigated in Iran.

Objective

Present study aimed to assess a model linking quality of work-life to the resilience and various dimensions of burnout among Iranian nursing professionals based on the health service workplace environmental resilience model.

Methods

This was a cross-sectional study performed on 202 Iranian nurses employed in three educational hospitals. Maslach burnout inventory, Brooks' quality of nursing work-life survey, and an abbreviated version of the Connor-Davidson resilience scale were used to collect data. The correlation between the study variables was assessed by conducting path analysis in AMOS 22.

Results

The final model demonstrated adequate fit. The quality of working life indirectly affected burnout via a direct impact on nursing professionals' resilience (p <0.001, β = 0.39). In addition, resilience had negative, significant effects on all the dimensions of job burnout. The quality of work-life also had negative and significant effects on emotional exhaustion (p <0.001, β = -0.38) and reduced personal accomplishment (p <0.001, β = - 0.38).

Conclusion

Resilience and quality of work-life are protective variables against burnout in nursing professionals. Nursing managers can increase resilience and decrease burnout among nursing professionals by adopting policies that can improve the quality of work life.

Intensive Care Unit Risk Assessment: A Systematic Review

Background:

It is of paramount importance to reduce the probability of clinical risks to improve the quality of health care services, make the relationship between service providers and patients more effective, enhance patient satisfaction, and decrease the rate of complaints regarding medical errors in hospitals. This study aimed at detecting potential and unacceptable risks occurring in the hospital ICUs.

Methods:

In this systematic review, all studies examining the risk assessment of ICUs in hospitals using Failure Mode and Effect Analysis method were reviewed. Google scholar, PubMed, Scopus, SID, Magiran and Web of Science databases were searched to find relevant articles published from 1980 to 2019.

Results:

The most frequent failures detected in the reviewed articles consisted of high risk of infection inwards for medical and nursing operations, high infection rates inwards for medical devices’ operation within the unit, and early discharge. Moreover, the processes through which potential high-risk Failures were examined in these studies were injection or prescription process, suction process, the process of inserting or removing endotracheal tubes, the process of transferring patients from the operation room to the unit or vice versa, pressure ulcers, and processes related to the medical devices’ operation.

Conclusion:

There are many possible reasons for failure occurring throughout these processes, and the failure modes occurring in these processes are more probable to cause serious damages to patients, have high repeatability with low probability of failure detection as the failures cannot be discovered by the personnel.

Determinants of Hospital Inpatient Costs in the Iranian Elderly: A Micro-costing Analysis

Objectives

Aging is assumed to be accompanied by greater health care expenditures. The objective of this retrospective, bottom-up micro-costing study was to identify and analyze the variables related to increased health care costs for the elderly from the provider’s perspective.

Methods

The analysis included all elderly inpatients who were admitted in 2017 to a hospital in Tehran, Iran. In total, 1288 patients were included. The Mann-Whitney and Kruskal-Wallis tests were used.

Results

Slightly more than half (51.1%) of patients were males, and 81.9% had a partial recovery. The 60-64 age group had the highest costs. Cancer and joint/orthopedic diseases accounted for the highest proportion of costs, while joint/orthopedic diseases had the highest total costs. The surgery ward had the highest overall cost among the hospital departments, while the intensive care unit had the highest mean cost. No statistically significant relationships were found between inpatient costs and sex or age group, while significant associations (p<0.05) were observed between inpatient costs and the type of ward, length of stay, type of disease, and final status. Regarding final status, costs for patients who died were 3.9 times higher than costs for patients who experienced a partial recovery.

Conclusions

Sex and age group did not affect hospital costs. Instead, the most important factors associated with costs were type of disease (especially chronic diseases, such as joint and orthopedic conditions), length of stay, final status, and type of ward. Surgical services and medicine were the most important cost items.

Designing a model for critical thinking development in AJA University of Medical Sciences

INTRODUCTION

In the new concept of medical education, creativity development is an important goal. The aim of this research was to identify a model for developing critical thinking among students with the special focus on learning environment and learning style.

METHODS

This applied and cross-sectional study was conducted among all students studying in undergraduate and professional doctorate programs in Fall Semester 2013-2014 in AJA University of Medical Sciences (N=777). The sample consisted of 257 students selected based on the proportional stratified random sampling method. To collect data, three questionnaires including Critical Thinking, Perception of Learning Environment and Learning Style were employed. The data were analyzed using Pearson's correlation statistical test, and one-sample t-test. The Structural Equation Model (SEM) was used to test the research model. SPSS software, version 14 and the LISREL software were used for data analysis.

RESULTS

The results showed that students had significantly assessed the teaching-learning environment and two components of "perception of teachers" and "perception of emotional-psychological climate" at the desirable level (p<0.05). Also learning style and two components of "the study method" and "motivation for studying" were considered significantly desirable (p<0.05). The level of critical thinking among students in terms of components of "commitment", "creativity" and "cognitive maturity" was at the relatively desirable level (p<0.05). In addition, perception of the learning environment can impact the critical thinking through learning style.

CONCLUSION

One of the factors which can significantly impact the quality improvement of the teaching and learning process in AJA University of Medical Sciences is to develop critical thinking among learners. This issue requires providing the proper situation for teaching and learning critical thinking in the educational environment.

The extent of inappropriate use of magnetic resonance imaging in low back pain and its contributory factors

BACKGROUND

Magnetic resonance imaging (MRI) is an expensive and commonly used technology with a variety of indications in patient diagnosis and treatments. The aim of this study is to identify a comprehensive list of indications and contraindications for MRI in patients with low back pain (LBP) and to determine the appropriateness of using this technology in these patients on the basis of this list.

METHODS

A cross-sectional study was conducted in four radiographic centers in Tehran, Iran. A list of MRI indications and contraindications for LBP was developed by review of documents and expert panel. A pre structured checklist was designed and incorporated into a structured form. All 100 consecutive patients referring to four radiographic centers for performing MRI regarding LBP completed the questionnaire. Chi-square, Fisher's Exact Test and logistic Regression were used to assess statistical significance.

RESULTS

In this study, 187 patients (46.7%) had an indication for MRI, but 186 patients (46.5%) had no indication, 18 patients (4.5%) had indication and contraindication at the same time and nine patients (2.3%) had contraindication. Moreover, 71 patients (17.8%) underwent MRI for LBP during the past 2 years, of which 14 (19.7%) had normal results. Patients with complementary private insurance had a history of previous MRI about 20% more than other patients (P = 0.018). There was a statistically significant relationship between complementary private insurance coverage and number of MRI performed (P = 0.006).

CONCLUSIONS

About half of the patients referring to radiographic centers with LBP for MRI had no indication for this test.

Indications and overuse of computed tomography in minor head trauma

Background:

Computed Tomography (CT) is a useful diagnostic technology, particularly in accident and emergency departments.

Objectives:

To identify a comprehensive list of indications for application of CT in patients with minor head trauma (MHT) and to determine appropriateness of its use on the basis of this list.

Materials and Methods:

A cross-sectional study was conducted in three Imaging centers in Tehran. A panel of experts developed a list of CT indications for MHT by reviewing documents. A pre-structured checklist was designed and incorporated into a structured form. Four hundred consecutive patients referring to three imaging centers for performing CT due to MHT completed the questionnaire.

Results:

Of 400 patients who underwent CT after MHT, 187 (46.8%) patients had Glasgow coma scale (GCS) score of 13 or 14 at two hours post-trauma and 37 (19.8%) of these patients did not have any indication of imaging. In addition, 213 (53.2%) patients had GCS score of 15 out of which 110 (51.6%) patients did not have any indication of imaging. Patients with a GCS score of 15 had a noticeably lower proportion of abnormal CT results in comparison to patients with a GCS score of 13 or 14, (odds ratio, 19.07; 95% confidence interval, 6.74-54.00; and P < 0.001). There was a statistically significant association between abnormal CT results and the presence of indications including vomiting, dangerous mechanism of injury, visible signs of trauma above the clavicles, signs of skull base fracture, and suspected skull fracture (P < 0.001).

Conclusions:

On average, about 37% of the patients with MHT referring to the emergency departments had no indication of CT and approximately 86.5% of CT results were normal. Improving this situation can result in a significant saving in health care costs.

Equity in Distribution of Health Care Resources; Assessment of Need and Access, Using Three Practical Indicators

BACKGROUND

Equitable distribution of health system resources has been a serious challenge for long ago among the health policy makers. Conducted studies have mostly ever had emphasis on equality rather than equity. In this paper we have attempted to examine both equality and equity in resources distribution.

METHOD

This is an applied and descriptive study in which we plotted Lorenz and concentration curves to describe graphically the distribution of hemodialysis beds and nephrologists as two complementary resources in health care in relation to hemodialysis patients. To end this, inequality and inequity were measured by calculating Gini- coefficient, concentration and Robin Hood indices. We used STATA and EXCEL software to calculate indicators.

RESULTS

The results showed that inequality was not seen in hemodialysis beds in population level. However, distribution of nephrologists without considering population needs was accompanied with some sort of inequality. Gini- coefficient for beds and nephrologists distribution in population level was respectively 0.02 and 0.38. Hence, calculation of concentration index for distribution of hemodialysis beds and nephrologists with regard to population needs indicated that unlike beds distribution, equity gap between nephrologists distribution against patients distribution among the provinces was considerably significant again.

CONCLUSION

Our results imply that although hemodialysis beds in Iran have been distributed in connection with the population need, nephrologists' distribution is not the same as hemodialysis beds one and this imbalance in complementary resources, can affect both efficiency and equitable access to services for population.