mohammadreza mobinizadeh

Rare diseases, characterized by low prevalence and high complexity, pose significant challenges to health systems due to the uncertainty surrounding the best diagnostic methods and availability of effective treatments.

This study aimed to introduce new methods for prioritizing orphan drugs, with a pilot application to hemophilia, spinal muscular atrophy (SMA), cystic fibrosis (CF), and multiple sclerosis (MS).

This quantitative research, conducted at Iran’s National Institute for Health Research from 2021 to 2023, employs multi-criteria decision-making models (MCDA) to evaluate the efficacy of health care technologies for "rare and hard to cure" diseases. A preliminary model was developed based on a pilot selection of seven medications, for which comprehensive data was extracted. The clinical efficacy was assessed using quality adjusted life years (QALY) as a metric. The model design was grounded on three critical factors: The annual cost of intervention per individual, the annual number of eligible patients for intervention, and the Proportion of expenses covered by the governmental budget. Additionally, the model incorporated various constraints and a regulatory coefficient, denoted as “w,” to enhance its robustness.

By running the model, the coverage of selected medications through model optimization, revealing the following percentages: Alemtuzumab (30%), ocrelizumab (30%), emicizumab (6%), dornase alfa (29%), tobramycin (2%), and spinraza (0.02%). Additionally, the corresponding monetary coverage in Iranian Rials is reported as follows: Alemtuzumab (27,144,000,000 IRR), ocrelizumab (109,645,200,000 IRR), emicizumab (17,360,490,000 IRR), dornase alfa (43,350,930,000 IRR), tobramycin (1,268,505,000 IRR), and spinraza (350,000,000 IRR).

This model has tried to solve the shortcomings of the existing models regarding the prioritization of orphan drugs by combining different factors to improve access to essential treatments for rare diseases, although it can be generally asserted that no unique model can answer all policymakers’ questions regarding budget allocation of rare diseases and orphan products.

Context: 

Evaluation of health policies and identification of their challenges are vital for improving and implementing reforms in the healthcare system. The present study was conducted to identify interventions aimed at improving primary healthcare (PHC) services in Iran.

Evidence Acquisition: 

This research utilizes a scoping review to examine reform interventions in PHC services across 10 selected countries: Qatar, Oman, Turkey, Georgia, Armenia, United Arab Emirates, Saudi Arabia, Bahrain, Kazakhstan, and Kuwait. The study covers areas such as the PHC delivery system, human resource management, financial mechanisms, and the framework of community participation and intersectoral collaboration from 2010 to 2022.

The main reform strategies for PHC systems in the reviewed countries included the establishment of family medical centers with nurse support as a comprehensive strategy for service provision in public health centers; providing comprehensive and quality healthcare service packages including maternal and child health, infectious disease immunization, chronic disease monitoring, and dental care services; health education; access to essential medications; improvement of electronic health services; implementation of health promotion and continuous prevention programs; capacity enhancement; and a greater focus on health screening programs and grading of healthcare centers.

The major findings from the reviewed countries indicate that healthcare policymakers focus on providing preventive care services, reducing maternal and child mortality, and increasing life expectancy. Programs such as referral systems, service grading, and the adoption of electronic health services are part of their reform agenda.

Context: 

Spinal muscular atrophy (SMA) is a rare genetic disorder that significantly impacts the quality of life. This paper aims to gather current understanding of the safety, efficacy, and economic aspects of common SMA treatments to assist Iranian policymakers in adopting these novel treatments for this vulnerable population.

This rapid health technology assessment (HTA) research was conducted in four steps: Database review, screening, data extraction, and thematic analysis. Inclusion criteria consisted of studies focused on assessing the safety, efficacy, and economic aspects of medical interventions in SMA patients compared to those who did not receive such interventions.

Based on current data, nusinersen was found to be the most effective treatment (increasing mobility achievements in SMA types 1 and 2) with the least side effects for SMA types 1 and 2. In terms of economic evaluations, none of the treatments were found to be cost-effective.

The decision regarding reimbursement for such medical drugs should not focus solely on their cost-effectiveness but rather on creating access to essential care, meeting patient needs, and considering national budget limitations. Managed entry agreements (MEAs) are flexible tools that service providers or payers can use to negotiate and reduce the financial burden for both patients and payers.

In the context of Persian traditional medicine, there are several therapeutic strategies for managing diseases, ranging from lifestyle changes to herbal remedies.

Given the application of Persian traditional medicine in the management of chronic diseases, the burden of chronic illnesses, and the public’s recourse to traditional medicine specialists, this study aimed to assess the cost-effectiveness of traditional medicine dietary regimens for the treatment of non-alcoholic fatty liver disease from the perspective of the payer.

In this study, we investigated the cost-effectiveness of providing nutrition counseling for lifestyle modification (changes in the aforementioned Setteh-e-Zarurieah) by a traditional medicine specialist compared to receiving counseling from a nutritionist for nonalcoholic fatty liver disease from the payer’s perspective. The outcomes measured were changes in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) enzymes, body mass index (BMI), and the grade of fatty liver. Cost and effectiveness data were entered into Excel software, and the ICER ratio was calculated.

The results indicated that the dietary regimen prescribed by Persian traditional medicine when compared to the nutritionist’s recommended diet, resulted in a lower decrease in AST and ALT enzymes but led to a greater decrease in BMI (mean change = 0.42) and a significant change in the grade of fatty liver (OR = 9.75). Since the costs of tests, ultrasounds, and visits were equal in both groups, the cost difference was zero. In the first scenario, where traditional medicine is considered an alternative therapy and liver enzymes are the
primary focus, providing nutritional counseling services by Persian traditional medicine may not be cost effective. However, if we consider the grade of fatty liver and BMI as the primary variables, providing nutritional counseling services by Persian traditional medicine may be cost-effective.

Based on the available evidence, the treatment of fatty liver using Persian traditional medicine can be considered an effective and cost-effective complementary (or alternative) intervention. Considering the long-term costs imposed by the health system and insurance organizations, it is predicted that adding visits to Persian traditional medicine specialists may reduce overall healthcare system costs.

National comprehensive cancer control programs combat cancer through different measures, including primary prevention, early detection, treatment, and palliative and supportive care. Among the others, early detection programs seem to be a promising intervention and lead to lower cancer mortality. We define research priorities for the early detection of cancers in Iran.

We applied the multiple criteria decision-making (MCDM) tools using three key attributes, including “5-year prevalence”, “mortality to incidence ration as severity of disease,” and “economic burden,” to rank different cancers for research priorities. The priorities were ranked based on four scenarios based on the weighting of the attributes. We also used the differences in the 5-year survival between localized and advanced tumors as the effect of early detection and incorporated it as the decision rule into the priority-setting model.

Gastric cancer and cancers of the brain and nervous system ranked first in all the proposed scenarios. The most and least 5-year survival differences between localized and advanced cancers were observed for the kidney (80.5%) and the brain (3.3%) cancers. The top 10 priorities for early cancer detection in Iran were gastric, prostate, breast, lung, colorectal, ovarian, kidney, bladder, and cervical cancers.

We used a quantitative method and demonstrated the priority areas for research in the early detection of cancer in Iran. Researchers and government may use these results to optimize their research strategies for cancer prevention in Iran.

 Trauma-related deaths increase yearly. The distribution of trauma cases is increasing in middle- and low-income countries, and therefore, a national trauma registry system is needed. This study aimed to prioritize the research domains using the data recorded in the National Trauma Registry of Iran (NTRI). This study used three stages of qualitative and quantitative research methods. First, a detailed literature review was conducted to identify the research domains. Then, appropriate criteria for the priority setting of the study were determined. Finally, scientists and experts of the NTRI ranked the research areas. The data provided by NTRI experts were analyzed based on five scenarios.  By literature search, 14 main domains using trauma registry data were identified, and six criteria were included in the final modeling phase to prioritize the mentioned domains. According to the NTRI expert opinion, the priority of criteria from highest to lowest was: “effectiveness of interventions performed on patients,” “improving the quality of medical services,” “prevention of trauma,” “Improving economic indicators of the health sector,” “feasibility,” and “importance in science and knowledge production” respectively. Finally, using the multi-criteria decision-making (MCDM) model, “investigating trauma incidence in children and adolescents” and “investigating the relationship between trauma registry data and hospital care protocols” had the highest and lowest average scores, respectively.  The results of this study show that, based on the data recorded in NTRI and according to experts’ views, “trauma incidence in children and adolescents, and distribution of trauma based on demographic information” were the most critical areas of research. A complete trauma registry system with an assessment of mentioned domains should be a priority for policymakers.

Context: 

Health systems’ main mission is to improve society’s well-being and fulfill their health needs.

This study aimed to describe the intrinsic and extrinsic events that had influenced Iran’s health system over the previous decade, as well as to identify the possible factors influencing it until 2025 and investigate their positive/negative impacts.

To determine previous driving forces, a systematic review of electronic databases was conducted up to December 2018. Then the most frequent contributing factors were extracted and discussed in expert panels, and finally, scenarios were composed. After identifying the internal and external driving forces as well as their effects, an input-output model was designed by using a sequence of events’ scenarios. Finally, findings were presented using a scenario-based expert system model.

The most important driving forces affecting health system’s policies included “demographic changes”, “economic changes”, “natural disasters”, “changes in population’s health status”, and “changes in the health system’s management.” Furthermore, other events such as “risks associated with emerging technologies”, “cold wars”, and “changes in personal vehicle utilization rates” may have, directly or indirectly, affected the benefits from health services, status, costs, and out-of-pocket payments.

In sum, it was found possible to implement the most effective crisis management system, eliminate the negative effects of these uncertainties, and reap the most considerable benefits by identifying the factors influencing health system, determining their interrelationships and effects, as well as designing separate scenarios for all possible outcomes.

In the first stage of viral replication, Covid-19 may cause a remarkable inflammatory response in patients. Molnupiravir is an oral antiviral medicine which functions through inhibiting the viral replication of RNA viruses including Corona virus (SARS-CoV-2). The present study intends to help the policymakers decide on using of this medication in Iran. This study is conducted on Jan. 22, 2022 (from Jan. 2014 -the year of molnupiravir production for treatment of RNA virus diseases), using a rapid review of evidence as well as reviewing reliable databases including the Cochrane library, PubMed and Google scholar. The inclusion criteria were the randomized controlled trials that investigated the safety and efficacy of Molnupiravir at different doses in patients with Covid-19, comparing with placebo or other routine care methods (Population: Covid-19 patients, Intervention: molnupiravir, Control: placebo or other routine care methods, Outcome: Safety, Efficacy and Economic status, Study design: the randomized controlled trials or HTA reports). Prescription for oral administration in 800 mg dose twice daily for 5 days to inpatients and outpatients with mild, moderate or severe symptoms in the early stages of the disease (viral phase) had the most desirable level of efficacy. This medicine has no serious side effects; since the mutations caused by this medication have not been clarified yet, it is not recommended during pregnancy and/or for women planning to become pregnant. According to the manufacturing company, in the United States, each drug package is priced at $712 for a 5-day treatment period. Molnupiravir can be used in outpatients and inpatients (Over 18 years old) with moderate or severe symptoms in the early stages of the disease. But it is not recommended during pregnancy and/or for women planning to become pregnant.

This study aimed to investigate the economic evaluation of remote monitoring of type 2 diabetic patients for controlling glycosylated hemoglobin compared to routine care for type 2 diabetics.

Economic evaluation was carried out to calculate the unit cost of the remote monitoring technology and the routine treatment for type 2 diabetics, incremental cost-effectiveness ratio, and sensitivity analysis using the key variables such as population size and cost items (in five categories of equipment and devices, building, staff, overhead costs, and consumables costs).

Considering the incremental cost-effectiveness ratio in the base-case model and in comparison with routine treatment of type 2 diabetes, remote type 2 diabetes monitoring system was placed in the second quarter (more effective and affordable technology) of the graph as the most dominant alternative (RPM vs. Routine care: Total annual cost difference: -38476.477 US$ / “Unit- reduction in HbA1C” difference: 0.488).  The results of the sensitivity analysis revealed that in all scenarios, RPM was dominant compared to the routine treatment (The optimum ICER: -610.128 US$ per “Unit reduction in HbA1C” for the scenario with A 10% increase in the costs of the control and intervention group).

Remote patient monitoring is a dominant alternative compared to routine treatment. Results indicated that remote type 2 diabetes monitoring interventions play an effective role in reducing HbA1c, which may be considered the rationale for policymakers to use this technology.

To review the research dimensions of trauma registry data on health policy making.

PubMed and EMBASE were searched until July 2020. Keywords were used on the search process included Trauma, Injury, Registry and Research, which were searched by using appropriate search strategies. The included articles had to: 1. be extracted from data related to trauma registries; 2- be written in English; 3- define a time period and a patient population; 4- preferably have more details and policy recommendations; and 5- preferably have a discussion on how to improve diagnosis and treatment. The results obtained from the included studies were qualitatively analyzed using thematic synthesis and comparative tables.

In the primary round of search, 19559 studies were retrieved. According to PRISMA statement and also performing quality appraisal process, 30 studies were included in the final phase of analysis. In the final papers’ synthesis, 14 main research domains were extracted and classified in terms of the policy implication and research priority. The domains with the highest frequency were “The relationship between trauma registry data and hospital care protocols for trauma patients” and “The causes of Disability Adjusted Life Years (DALYs) due to trauma”.

Using trauma registry data as a tool for policy-making could be helpful in several ways, namely increasing the quality of patient care, preventing injuries and decreasing their number, figuring out the details of socioeconomic status effects, and improving the quality of researches in practical ways. Also, follow-up of patients after trauma surgery as one of the positive effects of the trauma registry can be the focus of attention of policy-making bodies.

Various studies have used multiple attribute decision making (MADM) techniques to assess and rank health technologies.  The goal of the present study was to prioritize health technologies using various techniques of MADMs in combination with decision rules.

The study is an applied research using multi-attribute decision making (MADM) methods. This study extracted the attributes related to health technology assessment from global literature and experts’ opinions. In this study, two different types of experts were consulted: the first type, including three experts in the field of the decision-making techniques, on the subject of setting priority on health focusing on MADM; and the second one consists of seven experts in the field of HTA, asked about the selection of attributes and determination their importance. Candidate health technologies were individually weighted and ranked using TOPSIS, SAW and VIKOR by the weight and decision matrix. The results obtained from various techniques were combined and ranked using Copeland’s technique to obtain the final ranking of health technologies. To determine HTA type reports, decision rules were defined. All models were designed via MS Excel.

This study chose eight technologies according to six tradeoff attributes. These attributes included health benefits at the population level, vulnerable population size, availability of alternative technologies, budget impact, financial protection, and quality of evidence. Their exact weights were 0.25, 0.121, 0.146, 0.132, 0.167 and 0.181, respectively. Also, safety and uncertainty about the cost-effectiveness were considered as the veto and decision rules respectively. Copeland’s method was therefore used to combine the methods Whereas HT2 (The technology for treating patients suffering from varicose) was ranked the highest priority and HT3 (The palliative method for patients who suffer from various cancers) was ranked the lowest (for preventing from any ethical issue, the exact name of each technology wasn’t mentioned).

Finally, in accordance with decision rules which are based on various conditions of “uncertainty about the cost-effectiveness”, it is recommended that full health technology assessment report be performed on three technologies, rapid health technology assessment report be performed on four others, and, finally no prioritizing for health technology assessment be made on one of them.

The health system is facing limited financial resources in all countries. Resource allocation is one of the tasks of the health system. Prioritizing interventions is one of the strategies that can help health policymakers in allocating financial resources. Rare diseases require more attention than other diseases due to their high cost and complex treatments. The countries use different policies to determine the effectiveness of interventions in the field of rare diseases. The purpose of this study is to refer to some policies in the field of allocating resources for rare diseases and to explain the importance of determining the threshold of cost-effectiveness for rare diseases in Iran.

This research is a review study. First, a study was conducted on how to prioritize health interventions in the world and the thresholds of cost-effectiveness in different countries. Articles related to the research topic were then searched in accessible databases in Iran such as SID, Google Scholar and Medline. Finally, the obtained articles were screened and analyzed based on a thematic approach.

The World Health Organization (WHO) has set a threshold for determining the cost-effectiveness of health system interventions, that is determined and calculated based on the per capita GDP of each country. There are many differences between countries on policies related to the treatment of rare diseases, medicines, health care budgets and patient access.

Due to the very high cost of treating rare diseases, it is impossible to use the threshold used for general disease interventions in rare diseases and it is necessary to use a higher threshold for rare diseases. In addition to cost-effectiveness, budget, justice, feasibility, and other criteria that are considered important at the national level should be considered.

In recent years, health technology policy-making science has gone beyond just a health technology assessment or systematic review or economic evaluation study and the science of operational research in decision making, i.e. multi-attributes and multi-objective decision-making has been included. Hence, currently, health technology policy-making follows a seven-step process. After a technology undergoes these steps and is proven that it is useful for the health system, it must be determined how many of it is needed in the health system. Determining the required number of health technologies is a challenge that remains to be considered. Therefore, this study was designed to overcome this problem. The authors intend to introduce a multi-objective decision-making methodology considering the limited budget, to determine the number of technologies required to complete for the health technology policymaking cycle.

 Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appeared for the first time in December 2019 in Wuhan, China. Due to the lack of unified and integrated evidence for favipiravir, this study was conducted with the aim of rapid reviewing the existing evidence to help evidence-based decision-making on the therapeutic potential of this drug in the treatment of COVID-19 patients.

 This study is a rapid health technology assessment (HTA). By searching pertinent databases, the research team collected relevant articles and tried to create a policy guide through a thematic approach. This rapid review was done in four steps: 1) searching for evidence through databases, 2) screening the evidence considering eligibility criteria, 3) data extraction, and 4) analyzing the data through thematic analysis.

 After applying the entry criteria, four studies were finally found (a clinical trial that "the publisher temporarily removed the article from the journal's site" and three review studies). After searching the sources mentioned in the mentioned articles, two ongoing clinical trials were found in China. Also, by searching the clinical trial site, www.clinicaltrials.gov, five clinical trial studies were found during the search. The result of the search in the clinical trial registration system in Iran was a study that is in the process of patient’s recruiting. A limited number of other articles have been found, mostly in the form of reflections from physicians or researchers and letters to the editors who have predicted the drug's performance on the SARS-CoV-2 virus, which needs further clinical study for being approved

With the available evidence, it is not possible to make a definite conclusion about the safety and efficacy of this drug in the treatment of patients with COVID-19.

This study aimed to identify the public preference in health services, the principles that Iranian people consider important, and the aspects of trade-offs between different values in resource allocation practices.

This quantitative study was conducted to investigate public preferences on Health Insurance Benefit Package (HIBP) in 2017. A structured questionnaire was used for data collection, including the preferences of the people who live in Tehran, were above 18 year, and were covered by basic insurance for the HIBP contents and premium. The sample size was calculated 430 subjects and SPSS Statistics was used for data analyzing.

81.6% of the sample population agreed with government allocating more money to the health sector compared to other sectors and organizations and 55% were willing to pay higher premiums for expanding the HIBP coverage. The highest and lowest score regarding prioritization of budget allocation between health services was related to hospitalization services (28.6%) and rehabilitation services (1.6%), respectively. The first priority of respondents regarding health care and life cycle, was "prevention in newborns" (15.9%), the second priority was "prevention in children" (14.6%), the third priority was "prevention in adults" (9.5%), and the last priority was "short-term care in newborns" (0.9%).

Iranian people believe that not only the principle of health maximization but also equal opportunities to access health care and a fair allocation of resources should be considered by authorities for effective health insurance policymaking. In this case, given the scarcity of resources, setting priorities for alternative resources is inevitable.

Access and the use of information and communication technology, especially mobile phones, have expanded significantly in recent years; therefore, we aimed to rank the potential applications of mobile apps in the Iranian health system. Study Design: A multi-attribute decision making design.

First, the main applications of apps and also the related attributes for prioritization were extracted from a systematic and comparative review of studies. Then, the weight of these attributes was extracted using the Shannon Entropy method. The values of attributes for each application were questioned by the 11 experts. By having the decision matrix and the weight of attributes, the applications were separately weighted and ranked using four MADM techniques. Finally, using the Copeland technique, the results of different techniques were combined, and a final ranking was achieved.

Based on the results extracted from the studies and the opinions of experts, 8 main applications, and, 14 attributes were determined and entered into the modeling phase. The most significant weight obtained was related to “the feasibility of monitoring activities” (weight=0.220), and the least was related to “the feasibility of access to apps in any location” (weight=0.017).

The apps related to the physicians' access to patients’ health information had the highest priority, and the apps related to the selection of proper health behavior patterns had the least priority.

From the first year of implementation, the Health Transformation Plan (HTP) has had many effects on the practice of health system actors. The present study was designed to investigate the effect of the HTP on the implementation processes, rules, and regulations of the basic health insurance organizations. This qualitative study was conducted using semi-structured interviews and document analysis. Data were analyzed using qualitative content analysis with an inductive approach. The interviews were analyzed using MAXQDA version 11 software. The research population consisted of experts and senior managers of the health insurance sector selected using purposive sampling. Four topics and 11 themes were identified, including population coverage, service coverage, cost of services, process of arranging and manipulating documents, the process of paying claims, the impact of HTP packages, the interactions of insurance companies with the Ministry of Health and hospitals, rules and regulations, structures, and workload of insurance agencies. They all constituted 75 subthemes. The experience of implementing the HTP in Iran shows that primary access to healthcare services for all is an achievable goal for any middle-income country although there are always questions about their sustainability and quantity. Major reforms in the financing of plans need changes that require government investment and long-term commitment to overcome challenges.

Many health problems and the slow progress of development plans root in the absence of indicators to measure and monitor the achievement of the goals. This study aimed to identify the categorized indicators for monitoring and assessment of goal achievement in the Sixth Development Plan in the health sector. This qualitative applied study was conducted in the following stages: Identifying the goals of the Sixth Development Plan in the health sector; identifying the inputs and outputs of the programs; initial compilation of indicators; evaluation of the indicators, and designing a conceptual model for health policy assessment. During the implementation of the study, the qualitative methods including high-level documents examination, literature review, and expert consensus were used. After being analyzed, the content of the development plan was divided into 12 topics. Then, a set of indicators were determined for each topic, which led to the emergence of 80 indicators after the final analysis. The highest score was related to the maternal and child health indicators (giving the scores of more than 63 out of 70). Concerning its generalities and details, the progress evaluation of the sixth development plan can be done using small to large-scale indicators. The optimal mode is to compile indicators for each level individually and professionally.

Implementation of the Health Transformation plan (HTP) has had many effects so far. The analysis of these impacts can help policymakers and planners to continuously improve the health system's ultimate goals. Considering that, health financing is one of the most impressive of health system functions from the HTP, the present study examines the effect of the HTP on supplementary health insurance as part of financial providers in the health system in Iran.

This is a descriptive study carried out using secondary data in 2017. Data were gathered using information systems of health insurance organizations and the statistical yearbook of central insurance of the country. Data analysis was performed using Excel and SPSS software. To analyze and report these data, descriptive statistics and analytical tests were used.

The effect of the HTP on the share of health care providers has shown that in private financing, the share of households is the highest, and during the period 2002-2004, the average share of households from the total private sector share was 86.5%. During the period of 2002-2003, the share of the domestic government as the public sector was 54% on average. Findings in relation to supplementary health show that the net loss has been ascending and premium rate has been increasing.

The share of households in health expenditures has decreased since the implementation of the HTP, but the average pocket spending in the public and private sector has not decreased by more than 10%. The goal of creating competition and improving the quality of the public sector with the private sector and increasing the incentive for people to go to the public sector has largely been met by changing the frequency of contributions made by the financiers. In the long run, with the continuation of the implementation of the health system reform plan and the elimination of the way in which supplementary health insurers benefit from health subsidies, a high percentage of supplementary health insurance funds in the private sector is consumed, while it is better to adopt measures for the use of this resource in the public sector.

Context: The mitral valve conducts blood flow from the left atrium to the left ventricle. Mitral regurgitation occurs when the valve couldn’t be closed properly at the end of ventricular filling. Mitraclip, a catheter-based device that can reduce mitral regurgitation without requiring open surgery, is routinely used for patients with unacceptable risk of conventional mitral valve repair or replacement. The purpose of this study is assessing the safety, efficacy, and economic aspects of Mitraclip treatment for mitral regurgitation.
Evidence Acquisition: The Cochrane Library, the TRIP database, and Google Scholar have been searched through appropriate strategies. Seven studies were included in the final phase based on the inclusion and exclusion criteria. Data collected from these studies were analyzed based on four main themes; applications, safety, efficacy, and economic evaluation.
The most potential side effects were related to an improper transfer of catheters and low durability of the device. One of the included studies showed that improved outcomes of the New York Heart Association (NYHA) was more in the clip group with better quality of life that were observed after 1 to 12 months in 192 patients and also one-year mortality rate after using clip ranged between 10% and 24%. This included study found that 72% to 100% of patients with Mitraclip have been successfully treated and the duration of hospital stays in these patients was between 5 to 10 days. The cost-effectiveness of the procedure still needs more robust evidence.
Given the lack of high quality evidence and relatively high cost of Mitraclip, it seems that until further robust evidence is produced; it should be used in research and in high risk patients selected after detailed examination with strict indications and appropriate opinions of cardiologists.

The financial protection against catastrophic and impoverishing health expenditures is one of the main aspects of the universal health coverage. This study aimed to present a clear picture of the financial protection situation in Iran from 2003-2014.
Study design: This is an analytical study on secondary data of Statistical Center of Iran (SCI). The study has some policy implications for policy makers; therefore, it is an applied one.
Data related to the Iranian rural and urban household payments on health expenditures was obtained from annual surveys of the SCI. WHO researchers’ approach was used to calculate the Fairness of Financial Contribution Indicator (FFCI), the headcount and overshoot ratios of catastrophic and impoverishing health expenditures. A logistic regression was conducted to identify the determinants of probability of occurrence of catastrophic health expenditure among Iranian households in 2014.
The mean of FFCI for rural and urban households was 0.854 (0.41) and 0.867 (0.32), respectively. The average headcount ratios of catastrophic and impoverishing health expenditures were 1.32% (0.24) and 0.33% (P=0.006) for rural households and 1.4% (0.6) and 0.28% (P=0.001) for urban households. Concerning rural households, the overshoot of catastrophic and impoverishing health expenditures was 14.94% (P=0.001) and 7.22% (0.53); it was 15.59% (1.54) and 7.76% (0.52) for urban households.
No significant and considerable change was found in the headcount ratios of catastrophic and impoverishing health expenditure and in their overshoot or gap amounts. This suggested a lack of well-designed and effective schemes for materializing the financial protection in Iran.

The most important issues in the process of implementation is stakeholder analysis and identify their interests to effective implementation. This study intends to examine policy content of family physicians and referral system from the medical perspective as the main stakeholders the project.
This cross-sectional descriptive-analytic study was conducted in 2013. Data collection using the questionnaire developed by the researchers based on version 02 family physician instructions that its validity and reliability were tested. Data were analyzed with SPSS software.
Over 60% of sample were female and aged less than 40 years. They also were under 5 years of experience and more than %50 of physicians were working in the line (health teams).
Establishing referral system in the country is a huge revolution in the delivery of health services. To implementation of this, and access to health services costs associated with the management. Infrastructure and health reforms in other sectors including health information systems, and training of related human resource, improve culture of the society, guidelines related to the payment system and how service delivery is required.