3.1 Literature review
The literature review extracted the models that were mainly designed to determine hospital bed capacity. In this step, 11 models and 14 key affecting factors considered by the models were included and extracted in another systematic review [22]. The identified factors were frequency of use, the average length of stay, bed occupancy rate, current bed numbers, admission rates, population, out-of-region use (inter-regional flows), Region of patient residence (sub-regional access), waiting time, hospitalization rates, patient transfer to other providers, disease prevalence, technology advances, funding level. The identified models were used to calculate the total number of hospital beds required. Some factors, such as admission rate, length of stay, and bed occupancy rate, were identified in most of the models. Demographic changes were included in the other models except for the Capacity Model and the Score Model. In most models, population composition was taken into account. The Capacity Model is the only model that considers external factors such as disease prevalence, technology advances, and funding level. Other models assume policies and technologies will not change, so the number of beds may be overestimated. The general characteristics of identified models and key affecting factors considered by the models are provided in Table 1.
Table 1. Key affecting factors considered by the identified models
Identified models
|
Key affecting factors considered by the models
|
Countries using these models
|
Trend Analysis
|
• Average length of stay
• Bed occupancy rate
• Admission rates
• Population
• Out-of-region use (inter-regional flows)
• Region of patient residence
|
Canada
|
The Greater Glasgow
|
• Bed occupancy rate
• Population
• Waiting time
• Patient transfer to other providers
|
Scotland
|
Michigan’s Bed Need Methodology
|
• Average length of stay
• Bed occupancy rate
• Admission rates
• Population
|
United States
|
The Swiss Health Observatory
|
• Average length of stay
• Bed occupancy rate
• Admission rates
• Population
• Out-of-region use (inter-regional flows)
|
Switzerland
|
Lausanne University Hospital (CHUV)
|
• Average length of stay
• Bed occupancy rate
• Admission rates
• Population
|
Switzerland
|
Basic scenario model
|
• Average length of stay
• Bed occupancy rate
• Admission rates
• Population
|
Switzerland
|
Current Use Projection
|
• Bed occupancy rate
• Population
• Region of patient residence (sub-regional access)
|
Canada
|
Capacity model
|
• Average length of stay
• Population
• Out-of-region use (inter-regional flows)
• Region of patient residence (sub-regional access)
• Patient transfer to other providers
• Disease prevalence
• Technology advances
• Funding level
|
New Zealand
|
Israeli Model
|
• Bed occupancy rate
• Admission rates
• Population
• Region of patient residence (sub-regional access)
|
Israel
|
Score Model
|
• Bed occupancy rate
• Admission rates
• Patient transfer to other providers
|
France
|
The Status Quo model
|
• Population
|
Canada
|
3.2 Interview
In this step, ten semi-structured interviews have been conducted to identify indicators and models for allocating CCU beds in Iranian hospitals and explore the challenges of allocating CCU beds. The number of beds required to provide quality healthcare depends on various factors. Fifty-eight factors affecting the allocation of CCU beds were identified through interviews. The influential factors were divided into ten categories. While the highest number of indicators was related to organizational and geographical determinants, the lowest number was associated with international and economic determinants. However, due to the lack of approved guidelines and standards for allocating CCU beds in Iran's health system, the political dimension plays a critical role in allocating CCU beds. The bargaining power of local politicians was the more important key factor. According to experts, the items associated with the organizational dimension, bed occupancy rate, bed rotation, admission rate, and average length of stay had a greater impact on bed distribution. In the geographical dimension, the patients' residency region, the referral hospital system, and travel time to referral levels was the most significant factor according to the key informants' expressions. Another effective dimension of the CCU bed distribution is the economic dimension, in which the health investors and donors in the Region play a critical role and have paramount significance on the issue. Among the demographic variables affecting the CCU bed allocation, the population age group had the most significant effect on the distribution of CCU beds (Table 2).
The first challenge was that there is no precise definition of a CCU bed and a patient who needs to receive services in a CCU bed, and the diagnosis of this need is based on a specialist's opinion. This can lead to supplier-induced demand. On the other hand, the needs of the population change due to various epidemiological, geographical, and demographic factors, as well as changes in the economic power of the people. So, the population's need for CCU services is very difficult to predict. The most suitable method for determining the need for special cardiovascular care is to measure the prevalence, occurrence, and geographical distribution of cardiovascular diseases in the country. As a result, the standard definition of CCU beds should be established and approved. Therefore, there is a need for a simple and practical scoring system for the admission of cardiovascular patients to the CCU, as well as a need to address organizational barriers, such as administrative policies that conflict with the available guidelines and recommendations. Also, managers and policymakers require information about the most effective strategies to reduce the need for CCU beds in the future. The most effective way of doing this appears to be through health promotion and CVD prevention.
The second challenge was the impact of social, economic, cultural, and political characteristics on the access and extent of people's use of CCU services. So developing a strategy to increase equity in accessing acute cardiovascular care and reducing the disparity is needed. The complete implementation of regionalization, referral system, and family physician can lead to justice in access to intensive cardiac care.
The third challenge was the lack of health literacy on the part of patients. Health literacy is an individual and social capacity to access, understand and evaluate health information and the optimal use of health services to promote the health of society. Inadequate health literacy is related to the individual's economic status, health status, improper use of drugs, improper nutrition, lack of knowledge about self-care activities, failure to follow doctor's orders, poor control of blood sugar and blood pressure, increased prevalence of cardiovascular diseases, and less acceptance of treatment. Therefore, improving the fundamental health literacy of cardiovascular patients by using different educational methods and training in a healthy lifestyle in a targeted and continuous manner is mandatory for patients with heart failure.
The fourth challenge was to evaluate the pattern of diseases leading to hospitalization in the CCU. Determining the rate and burden of cardiovascular diseases provides the most objective evidence for the policymaking, design, and management of CCU beds. However, due to their uncertainty, it is difficult to control factors outside the health system, such as disease patterns. So, an analysis of the social, economic, political, biological, and demographic trends affecting the increase in the need for CCU beds is recommended.
The fifth challenge was the increase in demand for exceptional care in CCUs. Related medical advancements and aging populations have increased the proportion of multi-comorbid patients. It means that many patients hospitalized in the CCU do not need the care of this unit and are admitted to be monitored and receive better quality services. Creating intermediate care units for patients who do not need intensive care in CCU but cannot be admitted to standard wards can reduce the need for ICU beds. Therefore, using more care facilities and equipment and engaging more skilled nursing staff in other wards is highly recommended by experts.
The sixth challenge was the deficiencies in current regionalization in Iran, including the emphasis on the concept of “admission rate” and “the average length of stay” instead of paying attention to the “population's needs” and “distribution of the population”. The absence of an efficient access system causes a low admission rate and length of stay. So, there is a need to be reviewed and enhanced the indices of bed allocation and attention to population needs in Iran's health regionalization.
The seventh challenge was the lack of guidelines and practical models for managing patients in the CCU and the lack of CCU admission criteria in Iran's health system. In addition, there is insufficient supervision in implementing the approved guidelines. Modification of clinical guidelines to empower care providers to involve patients in the care process and personalization of care were recommended. Furthermore, supervision planning must include the design of appropriate monitoring and evaluation systems. Due to the lack of necessary laws and an appropriate structure, physicians are not obliged to comply with clinical guidelines. So, the Iran health insurance system should be strengthened to supervise the implementation of the guidelines.
The eighth challenge was induced demand in bed allocation. Induced demand can lead to the misallocation of resources, which are spent on patients that do not require care. In Iran, physicians act as overseers and decision-makers, leading to their interests taking precedence over patients' interests. This is even though we have experts in the field of health policy, health economics, and health management in the country. Weak laws, ineffective implementation of health policies, and inadequate scientific capacity can also contribute to the rise in induced demand. The medicalization of Iranian society and the service delivery model in the country has created an environment where everything is defined and treated as a medical condition. It is better to choose health policy and health provision representatives who have a complete understanding of how to allocate the CCU beds.
The ninth challenge was that before any action to allocate CCU beds, no (cost-benefit) analysis and economic evaluation were done in Iran's health system. In university hospitals, requests for beds and medical equipment are made through faculty members and cardiologists, and the decision-makers of the type and amount of beds and equipment needed by hospitals are not health policymakers and medical economists. It is necessary to strengthen the health economics department in the country's hospitals and universities of medical sciences and emphasize their role in allocating beds.
The tenth challenge was the pressure of local politicians and the bargaining power of local politicians to allocate CCU beds without considering the actual needs of the regions. These pressures increase when health donors finance CCU beds or equipment. For the equitable distribution of CCU beds, comprehensive management should be established that considers all influential factors and indicators. This comprehensive management must be able to withstand political pressure.
The eleventh challenge was the political nature of policymaking processes that tend to advocate for curative interventions and invest in building large hospitals and wards since they perceive it as the best way to foster health and wellbeing. However, the healthcare system has other tasks such as prevention, health promotion, health education, and early disease detection even before one becomes ill and requires a hospital visit. Thus, the health policy focus must shift to upgrading the healthcare system to become more proactive, comprehensive, and integrated. The challenges and solutions identified by experts are summarized in Table 3.
Table 2. Key factors affecting coronary care units beds allocation
Dimensions
|
Variables
|
Demographic factors
|
Population (density, growth rate, size, age distribution)
|
The pattern of population change
|
Population over 60 years old
|
Birth and death rate
|
Immigrability and floating populations
|
Geographical factors
|
Geographical position or Region of patient residence
|
The roads and communications status
|
Suitable road accessibility
|
Travel time to referral levels
|
Industrial areas
|
Existence of other centers providing cardiac services and their status
|
Travel time to the nearest cardiac intensive care center
|
Transportation status to nearest provinces
|
Being the referral center of the province
|
Air pollution
|
Epidemiological factors
|
Prevalence of cardiovascular diseases
|
The ratio of cardiovascular patients to the general population
|
Regional disease patterns
|
The needs of the population
|
Reduction in physical activity of the community
|
Morbidity rate, the burden of cardiovascular disease
|
The health status of vulnerable groups in society
|
cultural factors
|
Culture, religion, and language of the Region
|
lifestyle (improper nutrition or inactivity)
|
Real health literacy
|
Customer Service Culture
|
Political factors
|
Political parties and coalitions of groups
|
Political pressure, conformity pressure, and officials acting on political
|
Power and political influence of the petitioner
|
Bargaining power of local politicians
|
Justice and solidarity in priority setting in health care
|
Improving the quality of special cardiac care services as an agenda setting
|
Economic factors
|
Budget allocation
|
The economic status of the people of the Region
|
Presence of healthy donors and investors in the Region
|
Organizational factors
|
National health policies and strategies in services delivery
|
Rationing rules for CCU
|
General hospitals or specialty cardiac hospitals
|
Hospital bed productivity
|
Bed occupancy rate and bed rotation
|
The rate of admission and discharge of cardiovascular patients
|
Average waiting time for cardiovascular patients
|
Number of heart surgeries
|
The average length of stay of patients in the CCU
|
Per capita allocated to the CCU
|
The level of urgency and complexity of service delivery
|
Dedicated space of the cardiac intensive care unit
|
Structural factors
|
The number of cardiologists and other heart physicians in the hospital
|
Distribution of cardiologists in the country
|
Resources requested by cardiology professors and their students in teaching hospitals
|
Number of trained nurses in the Region
|
Infrastructure factors
|
The ratio of cardiac intensive care beds to hospital beds
|
Technological factors
|
Diagnostic and therapeutic technological advances
|
The existing technologies status (angiography, imaging, …)
|
Dependence of special cardiac care services on medical equipment
|
Management, maintenance, and protection of equipment related to unique cardiac beds
|
International factors
|
Global standards in CCU bed allocation
|
Table 3. The main challenges and solutions in CCU bed allocation in Iran.
No
|
Challenges
|
Solutions
|
1
|
Definition of a CCU bed and also a patient who needs to receive services in a CCU bed
|
-Measure the prevalence, occurrence, and geographical distribution of cardiovascular diseases.
- Established and approved the standard definition of CCU beds.
- Identification and weighting of all factors affecting the prevalence and occurrence of cardiovascular diseases to predict the need for CCU beds.
|
2
|
The impact of social, economic, cultural, and political characteristics on the access and extent of people's use of CCU services.
|
-complete implementation of regionalization, referral system, and family physician.
|
3
|
The lack of health literacy on the part of patients
|
-Improving the fundamental health literacy level of society.
|
4
|
Evaluation of environmental changes, nutritional changes, and changes in the pattern of diseases leading to hospitalization in CCU
|
-An analysis of the social, economic, political, biological, and demographic trends affecting the increase in the need for CCU beds.
|
5
|
The increase in demand for exceptional care in CCU
|
-Creating intermediate care units
-Using more care facilities and equipment and engaging more skilled nursing staff in other wards
|
6
|
Much emphasis on "admission rate" and "the average length of stay" indicators
|
-Reviewed and enhanced the indices of bed allocation and attention to population needs in Iran's health regionalization.
|
7
|
the lack of guidelines and practical models for managing patients in the CCU and the lack of CCU admission criteria in Iran's health system.
|
-Strengthening supervision of the implementation of guidelines.
|
8
|
Induced demand in bed allocation and The medicalization of Iranian society and service delivery model in the country.
|
-Choosing health policy and health provision representatives who have a complete understanding of how to allocate CCU beds.
|
9
|
No cost-benefit analysis and economic evaluation are done in Iran's health system before allocating CCU beds
|
-Strengthen the health economics department in the country's hospitals and universities of medical sciences and emphasize their role in allocating beds.
|
10
|
the pressure local politicians and the bargaining power of local politicians to allocate CCU beds without considering the actual needs of the regions
|
-Creating comprehensive management that considers all factors and indicators effective in allocating CCU beds.
|
11
|
The political nature of policymaking processes that tend to advocate for curative interventions
|
- The health policy focus must shift to upgrading the healthcare system to become more proactive, comprehensive, and integrated
|
3.3 Policy analysis
We applied the “policy analysis triangle” as a framework to examine what the policy entailed, where the key ideas originated, why the policy process was activated, who the key actors were, and the main consequences.
Various social, economic, environmental, and political factors affected the CCU bed allocation shown in Table 2. The geographical distribution of CCU beds is critical for access to special cardiovascular care. On the other hand, environmental changes, air pollution, nutritional changes, lifestyle changes, and disease patterns increase the need for CCU beds. As CCU beds are an essential indicator to estimate the need for other resources such as specialists, trained nurses, and specialized medical equipment, equity in the distribution of CCU beds is implicitly essential for the distribution of other resources. Despite the national development plans of Iran and, recently, the health transformation plan, which has mainly focused on equity in access to healthcare services, only focusing on equitable bed distribution could not be effective. Simultaneous interventions in public health (including primary care, family physicians, and strengthening self-care), health networks, and curative services (strengthening the referral system) need to be taken into account, aiming to meet the demand for special cardiovascular care. Moreover, local and national policymakers should design and implement a comprehensive surveillance system for tracking and allocating CCU beds, both qualitatively and quantitatively.
Formal and informal criteria were used to set bed allocation. Formal criteria are objective criteria that, at least on paper, the Ministry of Health and Medical Education (MHME) claims to use in bed allocation. Informal criteria refer to subjective considerations influencing allocation practices in MHME and hospitals. CCU bed allocation in Iran is greatly influenced by two main factors, the population and the bargaining power of local politicians. Therefore, formal criteria such as population needs and regional epidemiology of cardiovascular diseases have received lower attention in CCU bed allocation. Also, the leading health criteria used in CCU bed allocation in Iran was the perceived medical need in the hospital by specialists.
The content of the policy includes a set of goals and actions planned in national allocation plans. The national documents generally attempt to present guidelines for equitable resource allocation in the country. The purpose of all these documents was the fair distribution of resources, full access to health services, and encourage the private sector to develop.
During the last decades, Iran’s government and parliament have developed several policies to equitable resource allocation. Due to the importance of hospital bed utilization in Iran, research about hospital beds efficiency had been conducted by MHME in 1994 to 1996 and put bed allocation on the agenda in Iran. With the approval of Article 193 of the Third Development Plan in 2000, a plan for inpatient bed distribution was developed to improve fair access to inpatient facilities and to prevent unnecessary investments. Afterward, the country was divided into geographical regions (provincial, university, regional). So, any construction, creation, development, and equipping of the country's inpatient services were announced following the health resources allocation priorities.
In the country's third to sixth development programs, fair access to health services in the form of equitable allocations of health budgets to geographical areas of a health system has been developed. Furthermore, several policy documents were found, directly or indirectly, related to allocating hospital beds and resources. The established document in 2011 pointed directly to the CCU bed allocation (Table. 4).
Furthermore, the government and MHME have developed various strategies to improve equity of resource allocation, including; establishing the Ministry of Welfare and Social Security (MWSS) in 2005, incorporating all health insurance organizations under MWSS to separate the health care providers/MOHME from the financiers [23], and establish the Technology Assessment Unit within MOHME in 2007 [24]. Despite these efforts, the extent to which evidence from economic analyses is used to inform CCU bed allocation in national strategic planning and decision-making remains unclear.
Despite the existence of policies to support the private sector, the government’s incentives were not valuable in encouraging the private sector to develop in deprived areas of Iran because the activities of the private sector in health care were always based on the principle of profit. However, health donors played a significant role in distributing and equipping CCU beds in the regions.
Table 4. History of key policy documents
Year
|
Policy document
|
1970
|
Treatment Planning Council
|
1979
|
The Constitution of the Islamic Republic of Iran, Principles 29 and 43.
|
2000
|
Third Five-year Development Plan, Article 193
|
2003
|
Iran's 1404 Vision Policy
|
2004
|
Fourth Five-year Development Plan, Article 89 and 90
|
2006
|
Land-use planning, Article 104, 160, 215, 228
|
2010
|
Fifth Five-year Development Plan, Article 32 and 215
|
2010
|
Comprehensive science map of the country
|
2011
|
Road map for the treatment sector till 2025
|
2017
|
Sixth Five-year Development Plan, Article 72 and 74
|
- Actors
This study phase showed different stakeholders in Iran's bed allocation decisions and policymaking processes. In addition, the position, power, interest, and influence level of the identified stakeholders were varied. Recognizing the critical stakeholders and their roles can be necessary to develop, adopt, and implement effective policy solutions [25]. CCU bed allocation and its policy-led implementation is an inherently cross-sectoral field. The key actors were:
- Central Government: The Ministry of Health and Medical Education (MOHME), Universities of Medical Sciences, Iran Health Insurance Organization (IHIO), Planning and Budget Organization, the Parliament, and Governorate/municipality
-Local Government: Regional health administrators, Deputy for the curative affair, Members of Parliament, and politicians.
-Voluntary and community groups: including the healthy donors and incorporating many local campaigning groups across the Region.
Table 5 demonstrates the estimated position, power, interest, and influence of the stakeholders involved in the CCU beds allocating related decision- and policymaking processes.
Table 5. Rating the stakeholders according to position, power, interest, and influence
-Policy Process
The absence of a reliable, comprehensive process for allocating CCU beds leads to increased political pressures on bed allocation. Nevertheless, in general, the process of allocating CCU beds in Iran is as follows. The process of allocating CCU beds starts based on the need declared by regional hospitals or specialists. The requests are investigated by the province's universities of medical sciences, and if approved, they are sent to the MOHME. The department of allocating of the MHME has investigated the universities' demands, and if it complies with the official rules and formal indicators, it will be approved. The issued permits are financed by the Planning and Budget Organization.
3.4 Delphi
In the Delphi phase, full explanations were given to all the critical informants regarding the components of the model and the key factors affecting each model. Then each individual scored each model in nine perspectives of importance and applicability. In this section, the individuals' scores from 1 and 2 that disagree and items 3 and 4 agree were given to each perspective. In the information analysis step of this section, the scores were sorted from right to left. For example, the number 4 in “very high” was considered, and the number 1 in “very low” was considered. Then, the Content Validity Index (CVI) was computed for each model in scale (I-CVI) as well as for the overall scale (S-CVI). Kappa was used to determine the inter-rater agreement among the raters. The I-CVI for all models was under 0.76, except for the trend analysis model (0.83). Ultimately, the Trend Model was accepted as a well-suited model for Iranian hospital settings (Table 6).
Table 6. Content validity index