Evaluation of inter-hospital transfers before and after

health reform plan in Iran

Babak Behzadi

, Abbas Yazdanpanah

*, Ramin Afshari

, Mohammad Hossein Pour

and Mohammad Reza Zarei

PhD Student of Health Services Management, Islamic Azad University, South Tehran Branch, Tehran, Iran

Assistant professor, Department of Healthcare Management, Marvdasht Branch, Islamic Azad University,

Marvdasht, Iran

Psychiatrist, Deputy chancellor for drug abuse and rehabilitation and head of the prevention of ce, Shiraz

University of Medical Sciences, Shiraz, Iran

M.Sc. in Nursing, Shiraz University of Medical Sciences, Shiraz, Iran

Master of Anatomy, Shiraz University of Medical Sciences, Shiraz, Iran

ABSTRACT

Health system reform and improving the quality of health care as one of its important results has always been

important. Health reform plan is considered as one of the fundamental changes in the health system of the Islamic

Republic of Iran and therefore requires the effective measures to enhance the status and improve the performance.

This study aimed to investigate the inter hospital transfers before and after health reform plan in Iran in 2013-2014.

This descriptive - analytic study was conducted in the second 6-month period of 2013 and 2014. The study population

consisted of all transfers from the hospitals in the city of Shiraz in Fars Province to the hospitals located in Shiraz.

The sample was based on the study population. Research Information were received from health care monitoring

center in Shiraz University of Medical Sciences. The statistical analysis was performed using the descriptive statistics

and chi-square and Wilcoxon tests and at a signi cance level p <0/05 and by software SPSS (22).The results showed

that the transfer cases in the second 6 months of 2013 (before transformation plan) were 427 and in the second 6

months of 2014 (after transformation plan) was 544. The results of this analysis showed that there is not a signi cant

difference in the rate of transfers before and after health reform plan (P> / 05). The statistical analysis also showed

that there’s a signi cant difference between before and after health reform plan in relation to the causes of sending

patients, in terms of the absence and lack of specialist, need for operating room, willingness to private hospitals and

not discharging and not sending the patient with personal satisfaction by the hospital (p </ 05). However, there was

a signi cant relationship between before and after health reform plan in terms of the lack of relevant department or

158

ARTICLE INFORMATION:

*Corresponding Author: abbas_yaz@miau.ac.ir

Received 30

Dec, 2016

Accepted after revision 29

March, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF : 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

Biosci. Biotech. Res. Comm. Special Issue No 1:158-163 (2017)

Babak Behzadi et al.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS EVALUATION OF INTER-HOSPITAL TRANSFERS BEFORE AND AFTER HEALTH REFORM PLAN IN IRAN 159

service and empty bed in the origin hospital and patients’  nancial distress (p> / 05).According to the study results,

the number of transfers was not signi cantly different before and after health reform plan and the transfers rate did

not diminish. With implementation of the health reform plan, it was expected that the transfers would decrease. But,

as the results showed the number of transfers had increased. In general, it should be noted that other variables that

were not examined in this study should not be considered off and their possible impact on increasing the inter-hos-

pital transfer can be considered. In any case, every  edgling national plan, especially in its  rst steps would require

the regular revisions and reforms.

KEY WORDS: HEALTH REFORM PLAN, TRANSFER, HOSPITAL

INTRODUCTION

The main mission of the health system is the promotion

of health and meeting the needs of people and society.

These needs in uenced by the economic, social, political

and environmental conditions are constantly changing.

On the other hand, the disease patterns and risky factors

are constantly changing. Especially in the current era

that the changes occur very fast in this sector. Respond-

ing to these changes is the most important argument that

based on it, the health system must be transformed and

upgraded (Health, 2011). Due to the constant changes in

the health system and pressure that is applied to the per-

sonnel of health staff in the health system which leads to

burnout and intention to leave, the health system reform

will be de nitely useful and effective for both the patients

and medical personnel, (NIKBAKHT, Salari, Hosseinpour,

& Yekaninejad, 2014). During the last health reforms

taking place in the country to implement the compre-

hensive health plan, the healthcare reform program has

been implemented in the country since mid-May 2014

(Health, 2014). In fact, the goal of health system reform

is the promotion of health, reduction of payment from

public funds, development and promotion of community

health indicators(Khodadadi, Vafaie, Aahmadi, & Raza-

vian, 2015). Studies show the gap between the objectives

and ideals of the health reform plan, (Zarezadeh, 2015).

The inter-hospital transfer in the referral system is

one of the most important components of a country’s

emergency service system, so that in most developed

countries, a scienti c protocol has been de ned for it

(Ebadifarde Azar, 2002), (“Evaluate the performance of

the referral system in patients referred,” 2013), (system,

2002). Transferring patients from one medical facility to

another medical facility such as counseling, admission,

Parr clinic services or special services that require the

certain conditions including the patient preference, lack

of diagnostic and therapeutic facilities, or need for med-

ical treatment facilities in the speci c cases is called the

inter-hospital transfer (Bagust, Place, & Posnett, 1999).

The inter-hospital transfer is considered as part of

the patient’s treatment. The special laboratory tests, spe-

cialty or subspecialty care, lack of skilled manpower,

lack of diagnostic and therapeutic facilities, especially

the limitation of intensive care beds in distant centers

can be raised as reasons for sending patients (Armagan,

Al, Engindeniz, & Tokyay, 2004). One of the major chal-

lenges that have created many problems for the health

system during recent decades in Iran and shows the

need for further studies during the implementation of

plan is the inter-hospital transfers from small towns to

larger cities,(Bagheri Lankarani, 2015). Many patients in

deprived areas die or suffer the irreversible lesions due

to the lack of medical facilities in public hospitals or

lack of timely and adequate provision of services and

lack of specialists(Alidadi, Zaboli, & Sepandi, 2016).

But what is certain is that the inter-hospital transfers

that occur due to the absence of specialists and other

relevant factors will impose the additional costs to the

health system and patients. Therefore, by doing the tar-

geted researches in this  eld, the ef ciency and effec-

tiveness of the health system should be improved by

providing the scienti c solutions, and the efforts must

be made so that people have access to health services,

(Jabbari 2015).

Health reform plan aimed at improving the quality

of medical and health services follows the infrastructure

reforms. This plan has been operating for several years

and frequent and continuous assessments can be effec-

tive in identifying the weaknesses and improving the

performance. Therefore, this study was aimed to investi-

gate the rate of inter-hospital transfers before and after

health reform plan in the hospitals of Shiraz University

of Medical Sciences in the second half of 2013 and 2014.

MATERIAL AND METHODS

This study is applied and was conducted in descriptive -

analytic method at a point in time, between the second

half of 2013 and 2014. It is worth noting that the health

reform plan has been implemented since the second half

of 2014 and the collected data related to the inter-hos-

pital transfers in the  rst period of implementation of

the transformation plan, the second 6 months of 2014

(after health reform plan) were compared with the previ-

ous corresponding period, the second 6 months of 2013

(before health reform plan) in this study.

Babak Behzadi et al.

160 EVALUATION OF INTER-HOSPITAL TRANSFERS BEFORE AND AFTER HEALTH REFORM PLAN IN IRAN BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

The study population consisted of all deployments

made in all health services including surgery, obstetrics

and gynecology, pediatrics, neurology, neurosurgery,

orthopedics, cardiology, internal medicine, ear, nose and

throat or ENT, burn and ophthalmology in the hospi-

tals of Shiraz University of Medical Sciences. The hos-

pitals sending patients included all hospitals located in

the cities of Fars province and the hospitals receiving

patients were the hospitals located in the city of Shiraz.

In this study, according to the importance of sending

the patients, all of the study population was studied and

sampling was not performed. As a result, the sample is

identical with the study population.

The scope of the study includes the hospitals of Medi-

cal Sciences and Health Services, located in the city of

Shiraz in Fars province which did the inter-hospital

transfers in 2013 and 2014 that among them, it can be

named Ali Asghar Hospital in Bayram, Imam Khomeini

in Estahban, Imam Hassan in Darab, Vali Asr in Eghlid,

Imam Hussein in Sepidan, Imam Khomeini in Abade,

Imam Sadeq in Saadat Shahr, Vali Asr in Boanat, and

so on. The hospitals of Medical Sciences and Health

Services, located in Shiraz also admitted the patients in

2013 and 2014. These hospitals included Shahid Cham-

ran, Namazi, Ordibehesht (May), Shahid Rajai and Cen-

tral Hospitals. The basic information of this study was

obtained from the health care monitoring system of Shi-

raz University of Medical Sciences and in coordination

with deputy of treatment.

RESULTS

The results showed that the transfer cases were 427 in

the second 6 months of 2013 (before transformation

plan) and was 544in the second 6 months of 2014 (after

transformation plan). Moreover, 40 percent of inter-hos-

pital transfers were female and 60 percent were male

in 2013 (before transformation plan) and 43 percent

of inter-hospital transfers were female and 57 percent

were male in 2014 (after transformation plan). 263 cases

of transfers (62%) were occurred due to the lack of a

doctor in 2013 (before transformation plan). Also, 209

cases (38%) were occurred due to the lack of a doctor in

2014 (after transformation plan). 184 cases of transfers

(43%) were due to the lack of specialist in 2013 (before

transformation plan). The number of transfers occurred

due to the absence of specialist was 267 cases (49%) in

2014 (after transformation plan). The number of trans-

fers occurred due to the lack of related service or depart-

ment was 208 case (49%) in 2013 and 273 cases (50%) in

2014. The number of transfers occurred due to the lack

of available bed was 13 case (3%) in 2013 and 24 cases

(13%) in 2014.

The number of transfers occurred due to the need for

operating room was 66 case (15%) in 2013 and 46 cases

(8%) in 2014. The number of transfers occurred due to

willingness to private hospitals was 41 case (10%) in

2013 and 79 cases (14%) in 2014. The number of trans-

fers occurred because of the private patients’  nancial

distress was 16 case (4%) in 2013 and 11 cases (2%) in

2014. The number of transfers occurred due to the lack

of patient’s withdrawal from the transfer was 10 case

(2%) in 2013 and 17 cases (3%) in 2014. The number of

transfers occurred due to the cancellation of origin hos-

pital was 14 case (3%) in 2013 and 6 cases (1%) in 2014.

The number of transfers occurred because of DAMA (dis-

charge against medical advice) was 34 case (8%) in 2013

and 20 cases (3%) in 2014.

For inferential analysis of the data, it is used Chi-

square and Wilcoxon tests at a signi cance level of P </

05.The results of this analysis showed that there is not a

signi cant difference in the rate of transfers before and

after health reform plan (P> / 05).

The statistical analysis also showed that there’s a

signi cant difference between before and after health

Table 1. Summary of descriptive data

Frequency Percent

The number

of transfers

(dispatches)

2013 427 -

2014 544 -

Transfer patients’

gender

(Gender of

patients sent)

2013 Male 258 40

169 60

2014 Female 311 43

233 57

Withdrawal of

origin Hospital

2013 14 3

2014 6 1

DAMA 2013 34 8

2014 20 3

Lack of specialist 2013 263 62

2014 209 38

Absence of

specialist

2013 184 42

2014 267 48

Lack of ward 2013 208 49

2014 273 51

Lack of empty

bed

2013 13 3

2014 24 24

The need for

operating room

2013 66 15

2014 46 8

Willingness to

private hospital

2013 41 10

2014 79 14

Patients’  nancial

problems

2013 16 4

2014 11 2

Babak Behzadi et al.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS EVALUATION OF INTER-HOSPITAL TRANSFERS BEFORE AND AFTER HEALTH REFORM PLAN IN IRAN 161

reform plan in relation to the causes of sending patients,

in terms of the absence and lack of specialist, need for

operating room, willingness to private hospital and not

discharging and not sending the patient with personal

satisfaction by the hospital (p </ 05). However, there was

a signi cant relationship between before and after health

reform plan in terms of the lack of relevant department

or service and empty bed in the origin hospital and also

patients’  nancial problems (p> / 05).

DISCUSSION

As the results showed there is not a signi cant dif-

ference in the rate of transfers before and after health

reform plan. It seems that the health reform plan could

not change the rate of transfers with its eight-fold pack-

ages and this is while the rate of transfers had been sig-

ni cantly reduced due to the lack of specialists before

and after health reform plan which indicates that the

reform plan has been partly successful in its resident

and retention package and this is while the absence of a

specialist after health reform plan has been higher than

before, which indicates that despite the existence of

various specialists in the cities, their physical presence

has been reduced in the city for various reasons that

requires more monitoring units surveillance to assess the

presence of specialists. The lack of specialists in the hos-

pitals located in cities of Fars province was one of the

concerns that was evaluated in this study after health

reform plan. The researches that had been discussed the

absence of specialist in the hospitals before the health

reform plan reported a great dissatisfaction, (Moradi

2014 and Mahdavi 2014 ).

In the previous researches, it was reported the reluc-

tance and lack of motivation to attend specialist in the

cities, especially the more deprived areas (Armagan et al.,

2004). The studies have shown that increasing the use

of skilled manpower cannot only be effective in reduc-

ing transfer but also the proper planning to provide the

needed experts,  tting the number of doctors, hospital

equipment and other specialized facilities with the needs

of a region, making culture of changing patient attitudes,

increasing the physical space and improving the environ-

ment of health centers can affect the patient’s morale and

reduce the patients’ negative opinions about the inability

of medical centers in providing the quality services and

also prevent the waste of organizations’ human-economic

resources, imposing the heavy costs and the problems

caused by the patient transfer(Alidadi et al., 2016).

Comparing the hospitals in the cities in terms of the

inter-hospital transfer due to the lack of related ser-

vice or department was another variable examined. The

number of transfers occurred due to the lack of related

service or department has increased after transformation

plan. However, the transfer percent has not decreased

compared with before the transformation plan due to an

increase in the number of transfers. But it was expected

that the transfer of patients reduced due to the lack of

related service or department after transformation plan

and that no signi cant difference was found in the

transfer of patients before and after transformation plan.

In other words, the reform plan has not been effective

on the inter-hospital transfer due to the lack of relevant

department or service.

Accordingly, it can be examined the relationship

between “the presence of specialist and lack of related

service or department despite decreasing the lack of spe-

cialist” in future researches and based on these results,

the practical strategies are offered more decisively in

this regard. In addition, as a possibility, a lack of related

service or department can be one of the reasons for the

absence of specialist in the hospital. As a result, a com-

parative study can be used to examine the relationship

between these two factors. Several studies show that the

main reason for the transfers is the shortage of specialists

and super-specialists, diagnostic services and lack of clin-

ical departments(Watts, Fountain, Reith, & Schep, 2004).

Another variable examined was the transfer due to

the lack of available bed that had not a signi cant differ-

ence before and after health reform plan. In Hashemian

and Moeini Pour’s study, it was found that enhancing

the operation of public hospital beds in deprived areas

was not considerable. Instead, the public hospitals in

the provincial capital has seen a signi cant increase in

bed performance index(Hashemian M, 2014). Since this

study was done in the early months of health develop-

ment plan and the creation of hospital beds is time-con-

suming, judging the impact of the health reform plan on

increasing the hospital beds seems a bit hasty.

Another reason for sending the patients was a need

for operating room that there was a signi cant differ-

ence between before and after the health reform plan.

The 15% of transfers were occurred because of the need

for operating room before health reform plan. This rate

has signi cantly decreased after the health reform plan

since the rate has increased to 8 percent after the health

reform plan.Of course, this depends on the existence of

operating room or presence of the equipment in it and

also the presence of relevant specialists.

In assessing the health reform plan, one of the things

that can determine the desirability of improving the indi-

cators is the patients’  nancial problems. A signi cant

difference was seen in the transfers due to the patients’

 nancial problems before and after health reform plan.

This can be considered by the relevant authorities. In

this study, the patient’s withdrawal from the transfer

was compared between before and after the transforma-

tion plan. It is necessary to mention that this case may

Babak Behzadi et al.

162 EVALUATION OF INTER-HOSPITAL TRANSFERS BEFORE AND AFTER HEALTH REFORM PLAN IN IRAN BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

be occurred for reasons such as not being able to attend

the patient’s family in the provincial capital or the rea-

sons such as these. In these circumstances, if the neces-

sity of sending patient is con rmed by the medical staff,

he will stay away from treatment.

In this study, there was not a signi cant difference

between before and after transformation plan based

on the patient’s withdrawal from the transfer. In other

words, the transformation plan has not decreased the

patients’ withdrawal from the transfer.Hospital cancel-

lation of sending the patient was one of the factors that

leaded to cancel the process of sending patients. When a

hospital gets the admission in one of the hospitals in the

provincial capital for reasons including the lack of avail-

able bed and so on and then does not send the patient,

it seems that the problem (for example, the empty bed)

is solved.

The willingness of patients to private hospitals has

increased after the health reform plan. In other words,

the number and percentage dispatched to a private hos-

pital after the health reform plan has increased. There

are signi cant differences in the rate of transfer based

on the desire to a private hospital before and after the

health reform plan in this study. Sending patients to the

private hospitals can reduce the proliferation of patients

in the hospitals, particularly teaching. On the other hand,

the patients will incur heavier expenses. Designing the

programs can be considered to improve or enhance the

hospital environment and necessary resource for medi-

cal team in teaching and non-private hospitals and also

to balance the costs in the private hospitals.

This issue is interesting from another perspective.

If the private hospitals place less  nancial burden on

the patient and the measures are taken by the relevant

organizations in this regard, the volume of patients

admitted to the hospitals so-called state will be reduced

and the quality of services provided in these hospitals

also will be more effective.

In this study, two steps before and after transforma-

tion plan were compared based on the DAMA or dis-

charging the patients with personal satisfaction that had

a signi cant difference and rose slightly. In other words,

the transformation plan has failed to reduce the rate of

DAMA. The patients who were not transferred due to

DAMA were among those whose transfer necessity had

been identi ed, but the patients or their families refused

further treatment with personal satisfaction before being

admitted to hospital in Shiraz. The patient whose trans-

fer necessity has been identi ed more likely has not a

stable and non-traumatic situation however refuses fur-

ther treatment and such cases can be followed by the

of cials since some of these DAMA may be occurred

because of the marginal problems arisen in the origin

hospital.

In the study of Razavian et al, entitled “Comparing

the rate and reasons for discharge with personal prefer-

ences before and after health reform plan”, it was found

that the DAMA after health reform plan has decreased.

These results are inconsistent with the results of our

study(Rezvanian 2015). DAMA may occur in some

patients whose families feel that their patients can be

discharged, but the medical teams are looking for more

stable condition or more evaluation of patient to prepare

him for discharge. In such cases, the patient discharge

may cause risks for him. However, the hospital will

not be responsible for possible problems, but in some

cases, the clinical supervisor can give instructions to the

patient’s family and prevent the DAMA and potential

problems somewhat.

CONCLUSION

The results showed that the number of transfers are not

signi cantly different before and after health reform

plan and the rate of transfers has not diminished. With

regard to the implementation of the health reform

plan, it is expected that the transfers would decrease.

But as the results showed the number of transfers has

increased. In general, it should be noted that other vari-

ables that were not examined in this study should not be

considered off and their possible impact on increasing

the transfer of the hospital can also be considered. In

any case, all  edgling national plans, especially in its

 rst steps require the regular revisions and reforms. This

is well re ected in this study.

ACKNOWLEDGMENTS

It is necessary to sincerely thank and appreciate treat-

ment deputy of Shiraz University of Medical Sciences,

outstanding professors and all the colleagues who par-

ticipated in the preparation of this study.

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