Journal of Hayat

Value-based care and the necessity of economic evaluation of nursing services

Abbas Ebadi

Economic evaluation is an invaluable and important tool in healthcare decision- and policy-making. The volume-based paradigm has been a prominent tool to evaluate healthcare economy for consecutive decades. In this approach, the main focus is on volume of treated patients alongside to reduce healthcare costs. Despite this view and during recent years, there was a dramatic rising in healthcare costs without attaining excellence in quality and health outcomes. This status is escalating to the point at which governmental budgets, service providers, and patients are unwilling or unable to afford its related costs (1). There is a similar situation in high-income countries that spend several times more money on health than middle-income and low-income countries (2).
The experts believed that one of the most important and underlying causes of this situation is ineffective healthcare service models that resulted in fragmentation, lack of coordination, reduced quality of care, and finally increased health costs (3). It is assumed that the health service delivery models can seriously affect health costs. Accordingly, health economics does not only refer to health costs but also it includes quality improvement, access to, and equity of health services (4).
For the first time in 2006, “value-based care” was developed to evaluate healthcare economy (5). This paradigm which is also considered a kind of healthcare delivery model, is based on patient outcomes payment as an alternative for the fee-for-service model of payment. Based on this approach, healthcare providers such as physicians and nurses will be rewarded when their services improve the health of patients, reduce the complications, and help to make a healthier life for patients (6); while the population transition to old age and an increase in noncommunicable diseases which require behavioural approches for modifying risk factors in addition to acute care only, are also fueling the mandate for change. Therefore, 30% of healthcare payments in the US by the end of 2016 and 50% of payments by the end of 2018 were tied to the value-based care approach. Based on that, new institutions such as Accountability Care Organizations (ACOs), Advanced Primary Care and Integrated Care models were launched (7). The focus of these institutions is on effective care pathways which, along with the reduction in health care costs, lead to prevention and primary care (7). The principals of new payment model are greater teamwork and integration, more effective coordination of health providers across settings, greater attention to population-based healthcare, and providing information system to improve care for patients (7).
A report in 2011 entitled “The future of nursing: leading change, advancing health” asserted that despite the financial concerns, nursing service can on the one hand address the increasing demand for safer and high-quality healthcare and on the other hand, create equitable and affordable access to health services for societies (8).
The report believed that nursing practice covers a broad continium from health promotion, to disease prevention, to coordination of care, to cure-when possible-and to palliative care-when cure is not possible. Therefore, nurses have a direct and indirect effect on patient care. They can provide assessments and care in hospitals, nursing homes, clinics, schools, ambulatory settings, and workplaces and accordingly they can contribute to the provision of accessible, equitable, and high quality care in healthcare system.
From value-based model perspective, quality, access, and value are key indicators that are specific and sensitive to health service effects on health economics (1). Evidence reveals that nursing services can suprisingly affect these three indicators. However, there are few studies showing that the development of nursing services results in lower costs, along with increased service quality. Of course the evidence in favor of such a conclusion is growing. The current evidence on these indicators are as follows:
Nursing and health service quality
Although causation is difficult to prove, an emerging body of literature has revealed that the quality of care depends, in a large degree, on nurses. The association between nursing care and quality of hospital care such as patient outcomes, including lenghts of stay, mortality, pressure ulcer, deep vein thrombosis, and hospital-acquired infections has been published in several studies (9-11). Studies have shown the role of nurses in improving the quality and efficacy of hospital (12,13). However, the extent to which nursing care has an impact on health and life or death issues is still ambiguous (8) Also, the patient-centered nursing care has recently been disscussed as a cause of patient satisfaction which is an indicator of the delivered service quality in all over the world (14,15).
Nursing and access to health services
Evidence suggests that access to quality care can greatly be expanded by developing the use of nurses in primary, chronic, and transitional care from hospital to home. For example, If nurses are involved in special roles such as care coordinators or primary healthcare providers, that increase the level of access to services, the hospitalization and rehospitalization rates of patients will be reduced. A 52% reduction in emergency department (ED) visits with a cost per admission of at least $800 has been mentioned as a result of nursing postoperative visits and telephone follow-ups (16). In the coordination of transitional care from hospital, nursing visits during a three-month transition period in patients with heart failure showed the average savings of $4,845 per patient with a significant increase in survival and fewer readmissions (17). Also, performed activities such as self medication management and referral care coordination by nurses in community-based or ambulatory care settings can save $686 per patient in a 12-month period (18).
Nursing and value of health services
The value in healthcare is expressed as the physical health and sense of well-being achieved relative to the cost. There is little evidence at the macro level indicating that the development of nursing services results in cost savings to society while promoting outcomes and ensuring quality (19). For example, managing nursing work hours is dramatically associated with 1.5 million fewer hospital days, nearly 60,000 fewer inpatient complications, and 0.5 percent reduction in costs (20).
Overall, it seems that we need to conduct precise studies at macro-level to assess the net economic effects resulting from nursing care delivery models in order to seriously integrate them into health policy. Also, undrestanding the impact of nursing care on the health system requires the data to enable nurses have more effects on healthcare transformation.

The age-standardized rate of female genital cancers in Iran: A systematic review and meta-analysis

Soheil Hassanipour

Background & Aim: Female genital cancers are the third most common type of malignancy among women. Considering the importance of these cancers, the present study was conducted to determine the age-standardized rate (ASR) of female genital cancers in Iran.
Methods & Materials: In this systematic review, six international databases (Medline/PubMed, ProQuest, Scopus, Embase, ScienceDirect, and Google Scholar), and four national databases (Scientific Information Database, MagIran, IranMedex, and IranDoc) were searched in 2017. Thereafter, Persian and English papers referring to the ASR of female genital cancers in Iran were included. The Joanna Briggs checklist was used to evaluate the quality of studies. Data were independently extracted by two reviewers.
Results: A total of 264 papers were found in the initial search of the databases, and 27 papers were included for final analysis. Based on the random-effect model, the ASR was 2.07 (95% CI, 1.83-2.31) for cervical cancer, 3.15 (95% CI, 2.75-3.54) for ovarian cancer, and 1.52 (95% CI, 1.32-1.73) per 100,000 for uterine cancer.
Conclusion: The ASR of female genital cancers in Iran was lower than other countries of the world. It should be noted that the results of this review must be judged with caution because of the high heterogeneity of the studies.

Effect of fall care behaviors training on fear of falling among the elderly people referred to health centers: A double-blind randomized clinical trial

Samira Samadzadeh

Background & Aim: Falling is a serious problem in the elderly population, with many physical, psychological, social and economic consequences. The fear of falling has been considered an activity limiting condition, which can lead to a reduction in the quality of life of the elderly people. The study aimed to determine effect of fall care behaviors training on fear of falling among the elderly people referred to health centers.
Methods & Materials: This double-blind randomized clinical trial was carried out on 110 elderly people referred to health centers in Ardabil in 2017. Participants were selected by the multi-stage random sampling and divided into intervention and control groups by random allocation. The data collection tools were consisted of demographic questionnaire, Mini-Mental State Examination: MMSE, Abbreviated Mental Test Score: AMTS and Fall efficacy scale international: FES-I. Data were analyzed using statistical tests on the SPSS software version 22.
Results: The mean and standard deviation of fear of falling in the intervention and control groups before the intervention were 33.91±12.03 and 31.22±14.76, respectively (P=0.29). Three months after the intervention, the mean and standard deviation of fear of falling were 22.32±4.45 and 30.85±15.03 (P<0.001). Also, ANCOVA was used for controlling pre-test scores and level of education compared to the post-test scores in the two groups (P<0.001).
Conclusion: The results showed that education on fall care behaviors reduces the fear of falling in the elderly people. Therefore, this education is suggested to be considered in the self-care program for elderly people.
Clinical trial registry: IRCT20180205038618N1

The level of happiness among nurses and its’ relation to some demographic factors in Zanjan province-2017

Kourosh Amini

Background & Aim: A desirable level of happiness among nurses is related to the quality of nursing care services. This study aimed to evaluate the level of happiness among nurses and its’ relation to some demographic factors in Zanjan province- 2017.
Methods & Materials: In this cross sectional study, 371 nurses employed in the hospitals affiliated to Zanjan University of medical sciences were participated. The Oxford happiness inventory was used to collect data. The data were analyzed using descriptive statistics and Chi-square test through the SPSS software version 16. A P<0.05 was considered statistically significant.
Results: The mean and standard deviation of age of samples were 32.2±7.08. Most nurses were female (86.79%) and married (68.46%). Most nurses had a bachelor’s degree (94.88%) and the rest of them had a master’s degree. The mean score of happiness in nurses was 43.1±13.3 (the range 0-87). Concerning the demographic and occupational variables, a statistically significant relationship was found between job satisfaction and happiness level (P=0.049).
Conclusion: According to the findings of the study, the level of happiness in the nurses was at an acceptable level. Considering the relationship between happiness and job satisfaction, and given the importance of job satisfaction in the motivation and retention of nurses in the profession, it is necessary to pay attention to this matter.

The challenges of the physiologic childbirth program from the perspective of service providers: A qualitative approach

Khadigeh Mirzaiinajmabadi

Background & Aim: The physiologic childbirth program in Iran is an emerging program that needs to be evaluated like any other program to improve its quality and process. Evidence suggests that the implementation of the physiologic childbirth program faces some challenges. The present research aimed to explore the challenges of the physiologic childbirth program from the perspective of service providers.
Methods & Materials: This qualitative research was carried out through a content analysis method in two mother-friendly hospitals of Ahwaz and Mashhad in 2016-2017. Data were collected through semi-structured interviews with 17 physiologic childbirth service providers. The content analysis method of Elo and Kyngas was used for qualitative data analysis.
Results: Data analysis led to five main categories: low motivation of midwives in performing physiologic childbirth; barriers related to manpower; medical interventions in physiologic childbirth; challenges from the environment and facilities; and educational barriers.
Conclusion: Different challenges in interaction with each other create a complex environment in which the implementation of physiologic childbirth program becomes more difficult. Therefore, policymakers, authorities, doctors, midwives and mothers need to work in a coordinated way to resolve the mentioned challenge.

Analysis of pretest-posttest studies with control group: Comparison of two types of effect sizes

Hamid Sharif Nia

The pre-post test study with control group is one of the most widely used methods to evaluate clinical research and educational designs. The data analysis of this design is done in a variety of ways. However, considering that the interaction between the pre-test score and intervention score is considered a threat for external validity in these types of study designs, the ANCOVA test is recommended for its control. Also, due to the importance of accurately estimating the effect size of intervention, it is necessary to assess the differences in the accuracy of its estimate among conventional methods. In this regard, the ANCOVA test, a common linear model that combines the analysis of variance and regression, estimates the effect size better than other common analyzes. In this article, the data of a hypothetical study were analyzed using these two tests to clarify the different results between the independent t-test and the ANCOVA test. The result showed that the obtained effect size from ANCOVA was greater than that from the independent t-test. Therefore, it is suggested that the ANCOVA test be used to analyze the data and estimate the effect size in the pre-post test designs with control group.

Perceived stress and its relationship with perceived social support in women undergoing chemotherapy for reproductive system cancers

Mina Hoseinzadeh

Background & Aim: Women with cancer face many stresses. Social support can facilitate coping skills and improve active coping strategies. The purpose of this study was to assess perceived stress and its relationship with perceived social support in women undergoing chemotherapy for genital cancers.
Methods & Materials: This descriptive, correlational study was conducted from March to May 2016 on 151 patients undergoing chemotherapy for gynecologic cancers in oncology wards of Alzahra and Shahid Ghazi hospitals in Tabriz. The perceived stress scale (PSS) and perceived social support scale (PRQ-85-part2) were completed through interviews with patients. Data analysis was performed using the Pearson correlation test, one-way ANOVA and independent t-test.
Results: Mean (and standard deviation) total score of perceived stress for women was 42.26 (3.97) in the score range of 0-56. Mean (and standard deviation) total score of perceived social support for women was 127.55 (16.64) in the score range of 25-175. Based on the Pearson correlation test, no statistically significant correlation was observed between perceived stress and perceived social support (P=0.324, r=0.08).
Conclusion: The findings indicated that the perceived stress score for women with genital cancers was high. Nevertheless, no relationship was observed between perceived stress and perceived social support. Therefore, further studies are needed in this area.

Identifying the fields of activity, challenges and positive outcomes of nursing prescription: A systematic review

Monir Nobahar

Background & Aim: Nursing prescription is an expanding category with many supporters and critics. The present research attempts to answer three questions: What are the fields of activity of nurse prescribers? What are the challenges of nursing prescription? and what are the positive outcomes of nursing prescription?
Methods & Materials: In the present systematic review, all relevant papers published until March 2017, were examined. Search was done in databases: SID, Iran Medex, Iran Doc, Magiran, Science Direct, Medline/PubMed, Web of Science, Scopus, ProQuest, Google Scholar, Cochrane Library and with keywords: nursing prescription, nurse prescribing, nurse prescriber, independent prescribing, supplementary prescribing and their equivalent terms in persian. Inclusion criteria were articles in English or persian, quasi experimental, questionnaire based study, qualitative study and relevant to the objectives of the study. Exclusion criteria were review articles, posters, presentation, and letter to the editor.
Results: A total of 72 articles that were included in the systematic review, showed extensive nurse prescribing activity in the fields of diabetes, mental health, rheumatology, dermatology, primary care, elderly care, epilepsy, pain, asthma, hypertension, constipation, emergency, hemodialysis, glaucoma and elderly. Challenges included: the critical look of the care team and lack of support, lack of attention to professional competence assessment, legal constraints, and lack of community awareness of the role of nurse purscribers. The positive outcomes of nursing prescription were classified in three areas related to the patient, the nurse and the organization.
Conclusion: Nurse prescribing activity is changing, and identifying its challenges and outcomes will help it progress.