Evaluation of inter-hospital transfers before and after
health reform plan in Iran
Babak Behzadi
1
, Abbas Yazdanpanah
2
*, Ramin Afshari
3
, Mohammad Hossein Pour
4
,
and Mohammad Reza Zarei
5
1
PhD Student of Health Services Management, Islamic Azad University, South Tehran Branch, Tehran, Iran
2
Assistant professor, Department of Healthcare Management, Marvdasht Branch, Islamic Azad University,
Marvdasht, Iran
3
Psychiatrist, Deputy chancellor for drug abuse and rehabilitation and head of the prevention of ce, Shiraz
University of Medical Sciences, Shiraz, Iran
4
M.Sc. in Nursing, Shiraz University of Medical Sciences, Shiraz, Iran
5
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
th
Dec, 2016
Accepted after revision 29
th
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
© A Society of Science and Nature Publication, 2017. All rights
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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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