Publications by authors named "Mehrdad Askarian"

94 Publications

Resuming Breast Imaging Services in the Aftermath of the COVID-19 Pandemic: Safety and Beyond.

Clin Breast Cancer 2021 02 30;21(1):e136-e140. Epub 2020 Oct 30.

Medical Imaging Research Center, Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

As the Coronavirus disease 2019 (COVID-19) epidemic begins to stabilize, different medical imaging facilities not directly involved in the COVID-19 epidemic face the dilemma of how to return to regular operation. We hereby discuss various fields of concern in resuming breast imaging services. We examine the concerns for resuming functions of breast imaging services in 2 broad categories, including safety aspects of operating a breast clinic and addressing potential modifications needed in managing common clinical scenarios in the COVID-19 aftermath. Using a stepwise approach in harmony with the relative states of the epidemic, health care system capacity, and the current state of performing breast surgeries (and in compliance with the recommended surgical guidelines) can ensure avoiding pointless procedures and ensure a smooth transition to a fully operational breast imaging facility.
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http://dx.doi.org/10.1016/j.clbc.2020.10.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834332PMC
February 2021

Prevalence of non-reporting of hospital medical errors in the Islamic Republic of Iran.

East Mediterr Health J 2020 Nov 11;26(11):1339-1346. Epub 2020 Nov 11.

Department of Neurosurgery, University Hospital St. Marina, Medical University of Varna, Varna, Bulgaria.

Background: Medical errors frequently occur in health care facilities, jeopardizing patient safety and increasing associated costs.

Aims: This cross-sectional investigation examined the rates of and reasons for non-reporting of medical errors at Nemazee Hospital, Shiraz, Islamic Republic of Iran.

Methods: Self-administered questionnaires were completed by 283 staff members, including physicians, nurses and medical students. One-way analysis of variance, Fisher's least significant difference post hoc, Spearman correlation coefficient and intraclass correlation tests were used for statistical analyses.

Results: Almost all (95.8%) participants had observed at least 1 medical error during the previous year, with over half (50.5%) observing 3-10 errors. The preferred method for reporting medical errors among physicians and medical students was verbal and informal (40.3% and 41.8% respectively), while nurses preferred written forms (45.7%). The results indicated significant differences between groups concerning individual and organizational barriers in general, and among all sub-categories (P < 0.001).

Conclusion: Concerns of legal entanglements and confidentiality issues were recognized as the main barriers to reporting medical errors.
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http://dx.doi.org/10.26719/emhj.19.050DOI Listing
November 2020

Medical Error Reporting: Status Quo and Perceived Barriers in an Orthopedic Center in Iran.

Int J Prev Med 2020 17;11:14. Epub 2020 Feb 17.

Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Medical error reporting is fundamental for improving patient safety. We surveyed healthcare professionals to evaluate their experience of adverse events witness and reporting, knowledge about adverse events, attitude toward own and colleagues' errors, and perceived barriers in reporting errors.

Methods: This cross-sectional study was conducted on healthcare professionals from May to October 2017 at Chamran hospital, which is the largest referral orthopedic center in southern Iran. The self-administered questionnaire comprised 32 items covering five domains: (1) demographic and professional characteristics, (2) medical error witness and reporting, (3) actual and perceived knowledge regarding type of events and the status of completed training courses, (4) attitude toward reporting one's own and colleagues' errors, and (5) perceived barriers in error reporting. Questionnaire validity and reliability was proven in our previous study.

Results: From a total of 210 participants, 164 returned completed questionnaires (response rate = 78.1%); 87 (53%) were physicians and 77 (47%) were nurses. Underreporting was common, particularly among physicians. Out of physicians and nurses, 57.1% and 49.4% had poor knowledge, respectively. Participants reported their own or colleagues' errors alike, but physicians tended to only provide verbal warning to their colleagues (36.8%), and nurses stated they would report the colleagues' errors, if it was serious (32.4%). Fear of blame and punishment and fear of legal ramification were the most important perceived barriers.

Conclusions: Improvements in current medical error registry system, implementing effective educational courses, and modifying the curricula for students seem to be necessary to resolve the problem of underreporting and poor knowledge level.
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http://dx.doi.org/10.4103/ijpvm.IJPVM_235_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050265PMC
February 2020

Quality of Referral Letters Written by Family Physicians to Otologists -A Peer Assessment.

Iran J Otorhinolaryngol 2019 Nov;31(107):369-375

Department of Community Medicine, Medicinal and Natural Products Chemistry Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

Introduction: Otolaryngology is a field with a high referral rate; however, there is a dearth of research on the quality of referral letters written in this field. This study was carried out to explicitly assess the quality of referral letters, more specifically in the field of otology.

Materials And Methods: Two otologists assessed referral letters written by general practitioners or primary care physicians working as family physicians. They were asked to make independent assessment on different variables related to the quality of referral letters and their appropriateness. A "qualified referral letter" in the current study is defined as a letter with standard items, including, description of chief complaint, description of associated symptoms, relevant physical findings, past medical history, drug history, family history, and reasons for referral.

Results: A total of 1000 referral letters written by 652 primary care physicians were investigated in the current study. The obtained results indicated that 74% of referral letters to otologists contained inadequate information regarding various items in the referral letters. Symptoms, diagnosis, and signs were only reported in 28.3%, 28.9%, and 3.6% of the letters, respectively. The findings showed that most common reasons for referrals were uncertainty in diagnosis (52.4%), persistence of the patient (32.6%), and failed therapy (32%). With regards to case-specific conditions, the highest referral rates were related to external otitis, otitis media with effusion, and acute otitis media.

Conclusion: According to the obtained results of the current study, the content of referral letters were insufficient or inappropriate. Therefore, it is recommended to improve otolaryngology syllabus and provide suitable courses for undergraduate students in order to become familiar with the importance of referral letter writing.
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http://dx.doi.org/10.22038/ijorl.2019.35908.2187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6914324PMC
November 2019

Adherence to American Heart Association and American College of Cardiology guidelines for exercise tolerance test in cardiovascular clinics.

J Cardiovasc Thorac Res 2019 24;11(4):305-308. Epub 2019 Oct 24.

Department of Cardiology, Shiraz University of Medical Sciences, Shiraz, Iran.

Considering the increased expenditure in public health sector, especially the increased cost in hospitals and clinics, there is an urgent need to control these costs mainly by ensuring adherence to clinical guidelines for diagnostic procedures. In this study we aim to investigate the adherence of heart clinics to guideline for exercise tolerance test. This cross-sectional study was performed on 308 patients who were referred for ECG exercise test in 3 clinics located in the city of Shiraz, Iran in 2018. Demographic and clinical data were recorded and the indications of exercise test for each patient was reviewed according to the ACC/AHA guideline for exercise tolerance test. Exercise tests were found to be inappropriately done in 121 (39.3%) participants. Among the patients for whom the test was done without indication 79 (65.3%) were women and the gender difference was statistically significant ( < 0.01); women were 18.5% more likely to undergo exercise test without indication. There was more inappropriate tests among nonanginal pain subsets comparing to other presenting symptoms ( < 0.001). Age, coronary risk factors, reason for performing exercise tests and private health system were not predictors of inappropriate use ( > 0.05). This study confirms that more than one third of exercise tests done in the participants are inappropriate. Wide availability of exercise test makes it vulnerable to overuse and additional unnecessary cost to health care systems.
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http://dx.doi.org/10.15171/jcvtr.2019.49DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6891037PMC
October 2019

Effect of a Smoking Cessation Program on Inpatients in the Largest Hospital in Southern Iran.

Int J Prev Med 2019 6;10:54. Epub 2019 May 6.

Department of Community Medicine, Medicinal and Natural Products Chemistry Research Center Shiraz University of Medical Sciences, Shiraz, Iran.

Background: There is evidence that cessation programs can be effective for hospital inpatients. Hence, the aim of this study was to investigate the effects of such programs and factors that may affect success.

Methods: This study was carried out on in-patient users of tobacco in Shiraz Hospital, Iran in 2015. After implementing the inclusion criteria, a study population was selected using a convenience sampling method. Participants were contacted monthly by study personnel concerning certain aspects of their tobacco cessation program. The study lasted 6 months. Data analyses involved survival analysis using Kaplan-Meier analysis, log-rank test, and multivariate Cox regression modeling.

Results: The study included 425 in-patient smokers of which 328 (77.2%) were male. Median follow-up time was 96 days (interquartile range: 20-150). Cessation survival rates were 76% at 1 month, 63% at 2 months, and 61% at 3 months. From the 4 month onward rates remained unchanged at 60%. Univariate analyses with variables such as time since last smoking, consumption type, interval between wake-up and consumption, the severity of dependence and interest in smoking cessation were statistically significant as to cessation survival rate ( < 0.05). After adjusting the confounding variables based on multivariable analyses, results indicated that consumption type, the severity of dependence and interest in smoking cessation were the most important predictors of cessation survival rates among in-patient smokers.

Conclusions: Findings indicated that application of the cessation program among our group of inpatients appears to have been an effective intervention that produced an extended period of no smoking.
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http://dx.doi.org/10.4103/ijpvm.IJPVM_57_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528428PMC
May 2019

Analysing cardiovascular risk factors and related outcomes in a middle-aged to older adults population in Iran: a cohort protocol of the Shiraz Heart Study (SHS).

BMJ Open 2019 04 3;9(4):e026317. Epub 2019 Apr 3.

Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran (the Islamic Republic of).

Introduction: The significant increase in the rate of morbidity and mortality due to cardiovascular diseases has become a health challenge globally. Lack of enough knowledge on the underlying causes in Iran and taking the unique characteristics of the Shiraz metropolitan city (the capital city of Fars Province) into consideration prompted us to conduct the Shiraz Heart Study. The aim of this study is to determine the predisposing elements leading to coronary heart disease, cerebrovascular disease and peripheral arterial disease.

Methods And Analysis: In this population-based, prospective study, family physician clinics will become the executive arms. Participants aged 40-70 years old will be recruited to achieve a sample size of 10 000. Socioeconomicta and anthropometric indices supplemented by physical activity, nutritional and psychological questionnaires, as well as routine blood laboratory tests, medical history and electrocardiographic records, will be collected at enrolment in clinics. In addition, blood samples will be obtained to explore the possible role of genetics in outcome occurrence. Follow-up with blood sampling, completion of a lifestyle questionnaire and evaluation of clinical risk factors will be carried out five times in a 2-year interval for all participants. Advanced statistical methods such as mixed model and time-to-event models will be used for data analysis.

Ethics And Dissemination: This study is in accordance with the Helsinki Declaration and has been approved by the Research Ethics Committee of Shiraz University of Medical Sciences (No: 2017-358). Signing a written informed consent is the preliminary step. Participants are free to withdraw on their request at any time. Collected data are kept encrypted in a software with authorities' access only. Findings of the study will be published at a national or international scale through peer-reviewed journals.
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http://dx.doi.org/10.1136/bmjopen-2018-026317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500324PMC
April 2019

Causes of medical errors and its under-reporting amongst pediatric nurses in Iran: a qualitative study.

Int J Qual Health Care 2019 Aug;31(7):541-546

School of Medicine, Western Sydney University, Locked Bag 1797, Penrith NSW, Australia.

Objectives: To explore the causes of medical errors (ME) and under-reporting amongst pediatric nurses at an Iranian teaching hospital.

Design: A qualitative study, based on individual, in-depth, semi-structured interviews and content analysis approach.

Settings: The study was conducted at the Pediatric Department of the largest tertiary general and teaching hospital in Shiraz, southern Iran.

Participants: The study population was all pediatrics nurses who work at Pediatric Department and they had been trained on ME, as well as methods to report them through the hospital's ME reporting system. Purposive sampling was used by selecting key informants until data saturation was achieved and no more new information was obtained. Finally, 18 pediatric nurses were interviewed.

Main Outcome Measure(s): Pediatrics nurses' views on the causes of ME and under-reporting.

Results: We found five main factors causing ME and under-reporting: personal factors, workplace factors, managerial factors, work culture and error reporting system. These factors were further classified into proximal and distal factors. Proximal factors had direct relationship with ME and distal factors were contextual factors.

Conclusion: Causes of ME and under-reporting amongst pediatric nurses are complex and intertwined. Both proximal and distal factors need to be simultaneously addressed using context-specific approaches. Further research on other groups of healthcare workers and using a quantitative approach will be beneficial to elucidate the most appropriate interventions.
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http://dx.doi.org/10.1093/intqhc/mzy202DOI Listing
August 2019

Reply to: Web-Based Error Reporting Surveillance System.

Authors:
Mehrdad Askarian

Arch Iran Med 2018 02 1;21(2):85. Epub 2018 Feb 1.

Medicinal and Natural Products Chemistry Research Center, Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, IR Iran.

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February 2018

Social Determinants of Health and Attempt to Change Unhealthy Lifestyle: A Population-based Study.

Int J Prev Med 2017 1;8:88. Epub 2017 Nov 1.

Department of Community Medicine, Medicinal and Natural Products Chemistry Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: A healthy lifestyle is important because of its long-term benefits; however, there is a paucity of information concerning health choices among Iranians. We evaluated personal health behaviors, attempts to change unhealthy behaviors, and factors affecting attempts at change.

Methods: The design of this cross-sectional study was to assemble a representative cadre of >18-year-old adults in Shiraz, Iran, using a multistage cluster sampling technique. Validated questionnaires collected participant's demographic information, such as weight, height, cigarette smoking history, physical activity, and attempts at lifestyle changes during the previous year. To determine predictors of attempts to change unhealthy lifestyle and to identify confounders, we applied single and multivariable logistic regression methods, respectively. A confidence interval of 95% was calculated for each odds ratio.

Results: The prevalence of attempts to change unhealthy lifestyle was 42%, 64.8%, and 27.8%, respectively, for losing weight, being more physically active, and smoking cessation. Unemployment, low levels of education, and decreased socioeconomic status have important roles in attempts to change lifestyle conditions. Low socioeconomic status was a risk factor for quitting smoking. Occupation (unemployed/homemaker) and low level of education were two significant factors for being more physically active.

Conclusions: The prevalence of inadequate physical activity and being overweight or obese was considerable in Shiraz, Iran. Attempts to change unhealthy lifestyle were less than ideal. Social determinants of health factors including unemployment and low levels of education and socioeconomic status play important roles in attempts to change current lifestyles.
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http://dx.doi.org/10.4103/ijpvm.IJPVM_106_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686921PMC
November 2017

Evaluation of a Web-based Error Reporting Surveillance System in a Large Iranian Hospital.

Arch Iran Med 2017 Aug;20(8):511-517

Shiraz University of Medical Sciences, Shiraz, IR Iran.

Background: Proper reporting of medical errors helps healthcare providers learn from adverse incidents and improve patient safety. A well-designed and functioning confidential reporting system is an essential component to this process. There are many error reporting methods; however, web-based systems are often preferred because they can provide; comprehensive and more easily analyzed information. This study addresses the use of a web-based error reporting system.

Methods: This interventional study involved the application of an in-house designed "voluntary web-based medical error reporting system." The system has been used since July 2014 in Nemazee Hospital, Shiraz University of Medical Sciences. The rate and severity of errors reported during the year prior and a year after system launch were compared.

Results: The slope of the error report trend line was steep during the first 12 months (B = 105.727, P = 0.00). However, it slowed following launch of the web-based reporting system and was no longer statistically significant (B = 15.27, P = 0.81) by the end of the second year. Most recorded errors were no-harm laboratory types and were due to inattention. Usually, they were reported by nurses and other permanent employees. Most reported errors occurred during morning shifts.

Discussion: Using a standardized web-based error reporting system can be beneficial. This study reports on the performance of an in-house designed reporting system, which appeared to properly detect and analyze medical errors. The system also generated follow-up reports in a timely and accurate manner. Detection of near-miss errors could play a significant role in identifying areas of system defects.
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August 2017

Awareness and Observance of Patient Rights from the Perspective of Iranian Patients: A Systematic Review and Meta-Analysis.

Iran J Med Sci 2017 May;42(3):227-234

Department of Community Medicine, Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Recipients of healthcare services have rights, which must be acknowledged and protected. Such rights include observance of acceptable patient physical, mental, spiritual, and social needs guided by commonly accepted rules and regulations. The objective of this study was to conduct a systematic review and meta-analysis of awareness rates and observance of patient rights in Iran from the perspective of the patient.

Methods: In this study, various references such as Medline (PubMed), Scopus, Scientific Information Database (SID), Google scholar, Magiran, and IranMedex were searched (from August to December 2015). Heterogeneity was assessed using the Q statistic. English and Persian search keywords and combinations included terms such as "patient bill of rights, patient rights, Iranian patient bill of rights, and Persian patient rights." A meta-analysis of the primary search sources was accomplished using STATA (version 11.0).

Results: Initial review included 20 articles of which 12 assessed observance rates of patient rights and three described service awareness rates of recipients concerning their personal rights. Five articles covered both topics and had an estimated 54.2% coverage based on the results of meta-analysis and the random-effects model with the heterogeneity.

Conclusion: An Observance rate of patient bills of rights was considered somewhat adequate. However, contradictions in findings noted in this study suggest deficiencies do exist and need to be resolved. There appears a need to better describe and increase awareness rates of healthcare services by patients concerning their own bill of rights.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5429490PMC
May 2017

Neonatal Screening: Cost-utility Analysis for Galactosemia.

Iran J Public Health 2017 Jan;46(1):112-119

Dept. of Health Services Management, School of Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Galactosemia is a congenital metabolic disorder that can damage the health of a newborn. Screening is an important step to prevent and treat this condition. Due to increasing health care costs and limited financial resources of health systems, the most suitable economic analysis tool should be applied. The aim of this study was to analyze the cost-utility of neonatal screening program for diagnosing galactosemia in Fars province, Iran.

Methods: In this cross-sectional study and cost-utility analysis in the cost of screening for galactosemia and its financial effects, decision tree model and society's viewpoint were used. The population of study was 81837 infants referred to Neonatal Screening Laboratory (Nader Kazemi Clinic) affiliated to Shiraz University of Medical Sciences (SUMS), Iran, in 2010. Quality of life in two groups of patients was evaluated by using the time trade-off. The best intervention option was selected by using the Incremental Cost-effectiveness Ratio.

Results: The estimated cost of diagnosed through screening and without screening were 43519911 and 130011168 Iranian Rails (4222.00 $ and 12615.00 $), respectively. Therefore, there was a saving of 201443240.99 Iranian Rails (19641.00 $), for each patient annually.

Conclusion: The screening program can improve both the qualitative and quantitative lifestyle of people and increase savings in health care system. Policymakers could use the results to design new policies based on the necessity of screening.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5401919PMC
January 2017

Comparing knowledge and self-reported hand hygiene practices with direct observation among Iranian hospital nurses.

Am J Infect Control 2017 Jun 18;45(6):e65-e67. Epub 2017 Apr 18.

Department of Community Medicine, Medicinal and Natural Products Chemistry Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

We compared knowledge and self-reported hand hygiene practices with direct observations among Shiraz Nemazee Hospital nurses. Overall hand hygiene compliance was low (39.6%). Use and appreciation for alcohol-based handrubs were suboptimal. Some reluctance was due to religious concerns. Most nurses self-reported performing proper hand hygiene more than 75% of the time, whereas direct observation indicated much lower levels of compliance. It appears that additional training and improved monitoring are needed.
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http://dx.doi.org/10.1016/j.ajic.2017.03.007DOI Listing
June 2017

Economic Burden of Avoidable Hospitalizations among Patients with Cancer at Namazi Hospital in Shiraz, 2013

Asian Pac J Cancer Prev 2017 01 1;18(1):177-182. Epub 2017 Jan 1.

Department of Health Service Administration, School of Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran. Email:

Introduction: Hospitalization of patients with cancer has a significant economic impact and avoidance where unnecessary has great potential for significant cost savings for patients, individual hospitals and the health system in general. Methods: Demographic, clinical and economical data were collected from medical records in our hospital retrospectively. Oncology clinicians reviewed medical records to categorize each hospitalization as “potentially avoidable” or “not avoidable.” Patient demographic and clinical data were abstracted and quantitative and qualitative analyses were performed to identify patient characteristics and outcomes associated with potentially avoidable hospitalizations. Finally data on the cost of the latter were estimated. Results: Of 451 hospitalizations, medical oncologists identified 55 (12.2%) as potentially avoidable. Avoiding these and caring for the patients in alternative locations would save some $ US 641,240 yearly. Among patients with avoidable hospitalization, 70.9% were males and the median age and median length of stay was 55 years and 4.7 days. Most of them had general signs (83.6%) and a fever body temperature lower than 38.5’C (96.4%). Lung, kidney and urinary tract cancers were the most common diagnoses (10.9%). The majority of avoidable hospitalized patients had local cancer (85.5%) and poor performance status (43.6%). The most prevalent procedure for patients with avoidable hospitalization was sonography and the least frequent were laboratory tests and MRI. Most cases received no treatment. Conclusion: Avoidable hospitalizations are common in patients with cancer. Age, final results of hospitalization and length of stay were established as significant variables for patients with avoidable hospitalization.
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http://dx.doi.org/10.22034/APJCP.2017.18.1.177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5563097PMC
January 2017

Cost-Effectiveness of Intensive Vs. Standard Follow-Up Models for Patients with Breast Cancer in Shiraz, Iran

Asian Pac J Cancer Prev 2016 12 1;17(12):5309-5314. Epub 2016 Dec 1.

Department of Health Service Administration, School of Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Breast cancer is the most common type of cancer amongst women throughout the world. Currently, there are various follow-up strategies implemented in Iran, which are usually dependent on clinic policies and agreement among the resident oncologists. Purpose: A cost-effectiveness analysis was performed to assess the cost-effectiveness of intensive follow-up versus standard models for early breast cancer patients in Iran. Materials and methods: This cross sectional study was performed with 382 patients each in the intensive and standard groups. Costs were identified and measured from a payer perspective, including direct medical outlay. To assess the effectiveness of the two follow-up models we used a decision tree along with indicators of detection of recurrence and metastasis, calculating expected costs and effectiveness for both cases; in addition, incremental cost-effectiveness ratios were determined. Results: The results of decision tree showed expected case detection rates of 0.137 and 0.018 and expected costs of US$24,494.62 and US$6,859.27, respectively, for the intensive and standard follow-up models. Tornado diagrams revealed the highest sensitivity to cost increases using the intensive follow-up model with an ICER=US$148,196.2. Conclusion: Overall, the results showed that the intensive follow-up method is not cost-effective when compared to the standard model.
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http://dx.doi.org/10.22034/APJCP.2016.17.12.5309DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5454675PMC
December 2016

Relationship between Family-Work and Work-Family Conflict with Organizational Commitment and Desertion Intention among Nurses and Paramedical Staff at Hospitals.

Int J Community Based Nurs Midwifery 2016 Apr;4(2):107-18

Department of Health Management, School of Management and Medical Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: High turnover intention rate is one of the most common problems in healthcare organizations throughout the world. There are several factors that can potentially affect the individuals' turnover intention; they include factors such as work-family conflict, family-work conflict, and organizational commitment. The aim of this research was to determine the relationship between family-work and work-family conflicts and organizational commitment and turnover intention among nurses and paramedical staff at hospitals affiliated to Shiraz University of Medical Sciences (SUMS) and present a model using SEM.

Methods: This is a questionnaire based cross-sectional study among 400 nurses and paramedical staff of hospitals affiliated to SUMS using a random-proportional (quota) sampling method. Data collection was performed using four standard questionnaires. SPSS software was used for data analysis and SmartPLS software for modeling variables.

Results: Mean scores of work-family conflict and desertion intention were 2.6 and 2.77, respectively. There was a significant relationship between gender and family-work conflict (P=0.02). Family-work conflict was significantly higher in married participants (P=0.001). Based on the findings of this study, there was a significant positive relationship between work-family and family-work conflict (P=0.001). Also, work-family conflict had a significant inverse relationship with organizational commitment (P=0.001). An inverse relationship was seen between organizational commitment and turnover intentions (P=0.001).

Conclusion: Thus, regarding the prominent and preventative role of organizational commitment in employees' desertion intentions, in order to prevent negative effects of staff desertion in health sector, attempts to make policies to increase people's organizational commitment must be considered by health system managers more than ever.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4876779PMC
April 2016

Assessment of Three "WHO" Patient Safety Solutions: Where Do We Stand and What Can We Do?

Int J Prev Med 2015 9;6:120. Epub 2015 Dec 9.

Department of Community Medicine, Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Most medical errors are preventable. The aim of this study was to compare the current execution of the 3 patient safety solutions with WHO suggested actions and standards.

Methods: Data collection forms and direct observation were used to determine the status of implementation of existing protocols, resources, and tools.

Results: In the field of patient hand-over, there was no standardized approach. In the field of the performance of correct procedure at the correct body site, there were no safety checklists, guideline, and educational content for informing the patients and their families about the procedure. In the field of hand hygiene (HH), although availability of necessary resources was acceptable, availability of promotional HH posters and reminders was substandard.

Conclusions: There are some limitations of resources, protocols, and standard checklists in all three areas. We designed some tools that will help both wards to improve patient safety by the implementation of adapted WHO suggested actions.
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http://dx.doi.org/10.4103/2008-7802.171391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4736056PMC
February 2016

Adherence to practice guidelines for coronary artery bypass graft surgery in Shiraz, Iran.

ARYA Atheroscler 2015 Nov;11(6):370-3

Professor, Anesthesiology and Critical Care Research Center AND Department of Community Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: There is an increasing tendency to use evidence-based medicine (EBM) and guidelines among physicians. This is also true for concordance of coronary artery bypass graft (CABG) surgery and guidelines; therefore, we aimed to address the adherence to 2011 American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) guideline for CABG.

Methods: In this cross-sectional study, we assessed 246 patients who underwent CABG in Shiraz, Iran, during 2011-2012, using a data collecting form provided through studying ACCF/AHA guideline 2011. The patients were categorized into clinical subgroups and then grouped into appropriate, in-appropriate and uncertain classes. Chi-square was used to compare categorical variables and t-test was used for continuous variables.

Results: Of the 246 patients, 70.3% were grouped into "class I," 12.6% into "class IIa," 6.9% into "class IIb" and 10.2% into "class III." Therefore, 82.9% of the patients were grouped into "appropriate," 6.9% into "uncertain," and 10.2% into group "inappropriate."

Conclusion: We suggest that more attention is needed to be paid to these guidelines. Using these guidelines may help surgeons to have a uniform approach for patients.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4738048PMC
November 2015

Using Queuing Theory and Simulation Modelling to Reduce Waiting Times in An Iranian Emergency Department.

Int J Community Based Nurs Midwifery 2016 Jan;4(1):11-26

Department of Community Medicine, Shiraz Nephro-urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Hospital emergencies have an essential role in health care systems. In the last decade, developed countries have paid great attention to overcrowding crisis in emergency departments. Simulation analysis of complex models for which conditions will change over time is much more effective than analytical solutions and emergency department (ED) is one of the most complex models for analysis. This study aimed to determine the number of patients who are waiting and waiting time in emergency department services in an Iranian hospital ED and to propose scenarios to reduce its queue and waiting time.

Methods: This is a cross-sectional study in which simulation software (Arena, version 14) was used. The input information was extracted from the hospital database as well as through sampling. The objective was to evaluate the response variables of waiting time, number waiting and utilization of each server and test the three scenarios to improve them.

Results: Running the models for 30 days revealed that a total of 4088 patients left the ED after being served and 1238 patients waited in the queue for admission in the ED bed area at end of the run (actually these patients received services out of their defined capacity). The first scenario result in the number of beds had to be increased from 81 to179 in order that the number waiting of the "bed area" server become almost zero. The second scenario which attempted to limit hospitalization time in the ED bed area to the third quartile of the serving time distribution could decrease the number waiting to 586 patients.

Conclusion: Doubling the bed capacity in the emergency department and consequently other resources and capacity appropriately can solve the problem. This includes bed capacity requirement for both critically ill and less critically ill patients. Classification of ED internal sections based on severity of illness instead of medical specialty is another solution.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709818PMC
January 2016

Cost-Utility of "Doxorubicin and Cyclophosphamide" versus "Gemcitabine and Paclitaxel" for Treatment of Patients with Breast Cancer in Iran.

Asian Pac J Cancer Prev 2015 ;16(18):8265-70

Department of Health Administration, School of Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran E-mail :

Purpose: A cost-utility analysis was performed to assess the cost-utility of neoadjuvant chemotherapy regimens containing doxorubicin and cyclophosphamide (AC) versus paclitaxel and gemcitabine (PG) for locally advanced breast cancer patients in Iran.

Materials And Methods: This cross-sectional study in Namazi hospital in Shiraz, in the south of Iran covered 64 breast cancer patients. According to the random numbers, the patients were divided into two groups, 32 receiving AC and 32 PG. Costs were identified and measured from a community perspective. These items included medical and non-medical direct and indirect costs. In this study, a data collection form was used. To assess the utility of the two regimens, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core30 (EORTC QLQ-C30) was applied. Using a decision tree, we calculated the expected costs and quality adjusted life years (QALYs) for both methods; also, the incremental cost-effectiveness ratio was assessed.

Results: The results of the decision tree showed that in the AC arm, the expected cost was 39,170 US$ and the expected QALY was 3.39 and in the PG arm, the expected cost was 43,336 dollars and the expected QALY was 2.64. Sensitivity analysis showed the cost effectiveness of the AC and ICER=-5535 US$.

Conclusions: Overall, the results showed that AC to be superior to PG in treatment of patients with breast cancer, being less costly and more effective.
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http://dx.doi.org/10.7314/apjcp.2015.16.18.8265DOI Listing
October 2016

Shiraz medical students' perceptions of their colleagues' professional behavior.

J Adv Med Educ Prof 2015 Jul;3(3):111-6

Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.

Introduction: Today, development of professionalism is a critical aim of medical schools. Studies have demonstrated that medical students' perceived level of professionalism is inadequate worldwide. This study aimed to investigate the medical students' perceptions of their colleagues' professional behavior.

Methods: This study is a cross-sectional study with 280 medical students at Shiraz University of Medical Sciences in their fifth to seventh year of study as the sample. The study was performed during one month in 2013, using stratified random sampling method. The instrument of the study was the Persian version of the questionnaire of the American Board of Internal Medicine (ABIM).The questionnaire includes demographic information, questions about the meaning of the professionalism, history of medical ethics education programs and 12 behavioral questions. The data were analyzed using student t-test and Pearson correlation test. The significance level was set as 0.05.

Results: Forty percent of respondents did not know the meaning of professionalism. The mean±SD score of behavioral questions was 5.91±1.2 on a scale from 0 to 10. The mean±SD score of excellence questions was 4.94±1.7. It was 7.05±1.9 for 'honor/integrity', and 6.07±2.1 for 'altruism/respect' questions. There was a significant association between gender and excellence score (p=0.007).

Conclusion: Medical students assessed their colleagues' professional behavior as poor. They did not have proper information about professionalism. Medical students are future general practitioners and respecting medical ethics by them is very important in a perfect health system. Universities should emphasize the importance of teaching professionalism to medical students and faculty members, using innovative education methods.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530001PMC
July 2015

Knowledge, attitudes, and practices of health care personnel concerning hand hygiene in Shiraz University of Medical Sciences hospitals, 2013-2014.

Am J Infect Control 2015 09 23;43(9):1009-11. Epub 2015 Jun 23.

Department of Community Medicine, Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

This study evaluated knowledge and self-reported attitudes and practices concerning hand hygiene among hospital workers in Shiraz, Iran, using a 68-question survey divided into 4 sections: demographics, knowledge, attitudes, and practices. Work experience had a correlation with practices and knowledge (P < .05), and knowledge and practices scores were positively correlated (P < .05). Participants appear to have sufficient knowledge and proper attitudes regarding hand hygiene; however, compliance practices were suboptimal.
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http://dx.doi.org/10.1016/j.ajic.2015.05.002DOI Listing
September 2015

The Prevalence of Risk Factors of Coronary Artery Disease in the Patients who Underwent Coronary Artery Bypass Graft, Shiraz, Iran: Suggesting a Model.

Int Cardiovasc Res J 2014 Dec 1;8(4):139-42. Epub 2014 Dec 1.

Department of Community Medicine, Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran.

Background: Cardiovascular diseases are the main cause of 40% of deaths in Iran annually. Many patients undergoing coronary artery bypass graft surgery have previous cardiovascular risk factors which could be prevented.

Objectives: The present study aimed to assess the prevalence of cardiovascular risk factors in the patients undergoing coronary artery bypass graft surgery.

Materials And Methods: In this cross-sectional (descriptive - analytical) study, a data collecting form was used. A total of 246 patients were selected from six hospitals of Shiraz using random stratification. Descriptive statistics were presented through figures and tables and t-test was used to analyze the continuous variables. All the statistical analyses were performed using the SPSS statistical software (version 15.0). Besides, P < 0.05 was considered as statistically significant.

Results: Among the study patients, only 11.67% had no risk factors and 88.33% had one or more risk factors. The most common risk factors observed in the patients were hypertension, obesity and overweight, hyperlipidemia, and diabetes mellitus. The results showed a significant difference between males and females regarding the prevalence of hypertension (P = 0.001), diabetes (P = 0.028), hypercholesterolemia (P = 0.020), and cigarette smoking (P = 0.001). In addition, the patients' mean levels of cholesterol, LDL, triglyceride, and fasting blood sugar were higher than the acceptable level, while that of HDL was lower than the accepted level.

Conclusions: These patients are recommended to be trained regarding lifestyle changes. Also, prevention strategies can play an important role in reducing patient morbidity and mortality.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4302499PMC
December 2014

Adherence to informed consent standards in Shiraz hospitals: matrons' perspective.

Int J Health Policy Manag 2015 Jan 26;4(1):13-8. Epub 2014 Oct 26.

Department of Community Medicine, Shiraz Nephrourology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Informed consent is an important part of the patients' rights and hospitals are assigned to obtain informed consent before any diagnostic or therapeutic procedures. Obtaining an informed consent enables patients to accept or reject their care or treatments and prevent future contentions among patients and medical staff.

Methods: This survey was carried out during 2011-2. We assessed adherence of 33 Shiraz hospitals (governmental and non-governmental) to informed consent standards defined by Joint Commission International (JCI) Accreditation, USA. The questionnaire was designed using the Delphi method and then filled out by hospital matrons. We calculated valid percent frequency for each part of the questionnaire and compared these frequencies in governmental and non-governmental hospitals using analytical statistics.

Results: Considering 63% of the hospitals that filled out the questionnaire, no statistically significant difference was observed between the governmental and non-governmental hospitals in adherence to informed consent standards.

Conclusion: This study shows a relatively acceptable adherence to standards about informed consent in Shiraz hospitals but the implementation seems not to be as satisfactory.
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http://dx.doi.org/10.15171/ijhpm.2014.104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4289032PMC
January 2015

WITHDRAWN: An overview of the present status of hospital waste management in Kerman, Iran.

J Infect Public Health 2014 Aug 30. Epub 2014 Aug 30.

Department of Medical Lab Technology, and Proteomics Research Center, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Electronic address:

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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http://dx.doi.org/10.1016/j.jiph.2014.07.007DOI Listing
August 2014

The geographical clusters of gastrointestinal tract cancer in fars province, southern iran.

Int J Prev Med 2014 Jul;5(7):857-64

Department of Non-Communicable Diseases, Deputy of Health, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran.

Background: Gastrointestinal tract cancer (GI.C) is one of the common cancers in world-wide. The incidence rate of it is different in various geographical regions. This study was performed to assess spatial clusters of the occurrence of GI.C in Fars Province.

Methods: In this cross-sectional study, the new cases were 4569 cases from 2001 to 2009. The crude incidence rates were standardized based on world population for both sexes. The spatial analysis was conducted using the geographical information systems. We used the local Indicators of spatial association measure, in order to identify local spatial clusters.

Results: From a total of the new cases, 62.8% cases were male. The most common GI.Cs were stomach and colorectal cancer in men and women respectively. The significant cluster patterns were discovered from 2002 to 2007. The common type of spatial clustering was a high-high cluster, that to indicate from North-west to South-east of Fars Province.

Conclusions: Analysis of the geographical distribution of GI.C will provide opportunities for policymakers for applying preventive measures. Furthermore, it could be helpful for researchers for future epidemiological studies for investigation of etiological agents in regions with significant spatial clustering of high incidence of cancer.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4124563PMC
July 2014

Iranian healthcare workers' perspective on hand hygiene: a qualitative study.

J Infect Public Health 2015 Jan-Feb;8(1):72-9. Epub 2014 Jul 2.

Department of Community Medicine, Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

Background: Hand hygiene (HH) has been identified as one of the simplest, but most important, methods to prevent cross-infection in healthcare facilities. In spite of this fact, the HH compliance rate remains low among healthcare workers (HCWs). Several factors may affect HH behavior. In this study, we aimed to assess various aspects of HH from the perspective of HCWs.

Method: This qualitative study was conducted in two hospital settings in Shiraz, Iran. Eight focus group discussions (FGDs) and six in-depth interview sessions were held with ICU and surgical ward nurses, attending physicians, medical and nursing students and supporting staff. Each FGD and interview was transcribed verbatim, open codes were extracted, and thematic analysis was conducted.

Results: Three themes emerged from the thematic analysis including: "the relationship between personal factors and HH compliance," "the relationship between environmental factors and HH compliance" and "the impact of the health system on HH adherence, including the role of adequate health systems, administrative obligations and the effect of surveillance systems."

Conclusion: Several factors played a significant role in improving HCWs HH compliance, such as the regular adherence to health system tenets. HH compliance may be improved through application of realistic policies and better supervision. In addition, appropriate education may positively affect HH behavior and attitudes.
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http://dx.doi.org/10.1016/j.jiph.2014.05.004DOI Listing
September 2015

Barriers to standard precautions adherence in a dental school in Iran: a qualitative study.

Am J Infect Control 2014 Jul;42(7):750-4

Department of Community Medicine, Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

Background: Setting up good infection control practices in educational institutions is crucial in shaping future health professionals. The implementation of standard precautions (SPs) in Iranian dental schools has not been explored qualitatively to identify barriers to good practice.

Methods: Twelve focus group discussions and 8 semistructured interviews were conducted with students, residents, and staff members (n = 83) of the Shiraz University of Medical Sciences Dental School. The interview guide addressed performance, subjective norms, and behavioral control domains of SP-related behaviors. Thematic analysis was performed manually to identify barriers to SP practices.

Results: Proximal factors of poor SP adherence were a lack of knowledge and technical difficulties. These factors were compounded by intermediate factors in the work environment: lack of facilities, heavy workload, patient expectations, interprofessional conflicts, and lack of good role models. Two underlying distal factors were financial issues and unsupportive organizational culture. The social constructionism theory was useful in analyzing the situation and suggesting an educational approach as part of the solution.

Conclusion: Complex and intertwined barriers of SP adherence were found in this dental school. A social construction approach may assist in addressing these problems by shifting the culture through education to construct a contextual new knowledge. Further research in medical sociology of SP practices would be useful.
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http://dx.doi.org/10.1016/j.ajic.2014.04.001DOI Listing
July 2014