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A benchmarking and evidence-informed gap analysis of the hemodialysis care provision in Iran

BMC Health Services Research volume 24, Article number: 1608 (2024) Cite this article

Abstract

Background

Patients with end stage renal disease (ESRD) are increasing worldwide. This is especially paramount in low and middle income countries in which ESRD patients are struggling to access specialist services e.g. hemodialysis (HD). Benchmarking analysis of the offered healthcare packages in several countries and comparison of the utilized alternative healthcare models for ESRD patients may be auspicious for institutional capacity-building in the existing healthcare facilities. Main aim of this study was to perform a benchmarking and evidence-informed gap analysis of the ESRD care provision in Iran and recognize the gaps that cause diversification in care quality for ESRD patients that hinder efforts for care quality improvement in the Iranian National Healthcare System.

Methods

Dimensions of the Australian Anglicare Southern Queensland Clinical and Care Governance Framework (ASQCGF) were utilized as corner stones of a comprehensive clinical care plan that is essential in responding to HD patients’ needs in Iran. An extensive literature search was performed at the next stage to recognize the gold standard core elements. The ascertained components were assigned to the five separate dimensions of the ASQCGF and a preliminary draft (comprehensive package of care for HD patients) was prepared. A checklist was developed at a later stage which was sent to a panel of expert consisting professional healthcare providers in nephrology and hemodialysis wards for their opinions. A gap analysis was conducted to evaluate current care processes of the Iranian HD patients align with the elements of the gold standard framework.

Results

The identified deficits were classified in five areas in accord with the elements of ASQCGF as follow: A) supply of resources, medical devices and equipment support B) recruitment and endorsement of clinics and general work force C) infection prevention and controlling procedures D) care effectiveness monitoring and quality improvement E) provision of safe environment for both HD patients and hospitals’ staff.

Conclusions

The study findings revealed considerable gaps in providing quality HD services to the Iranian HD patients that herald their therapeutic unmet needs and the shift that is needed to narrow down the widening organizational failure which fuels the current disenchantment among the both healthcare providers and HD patients.

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Introduction

Spreading sedentary lifestyle and population aging and the subsequent increase in the global prevalence of obesity, hypertension, diabetes and chronic kidney disease (CKD) posed an extra burden on the healthcare delivery systems (HCDs) across the world [1, 2]. This is specially paramount in low and middle income countries (LMICs) which already face with surge of demands for healthcare to meet unequivocal and implied clients' needs [3]. Healthcare institutions in many countries are under pressure from the beneficiaries, patients and social groups to provide high quality services where an inherent shortage of logistic, finance and skilled workforce hamper any quality improvement efforts [1,2,3]. Therefore, strengthening of existing structures is required to ensure their adequate performance and optimized utilization of available resources.

Complying with internationally agreed set of standard operating procedures (SOPs) is a crucial first step toward helping healthcare providers (HCPs) for successful task scheduling and execution. The priority is not properly addressed nor secured in many healthcare settings in LMICs [3,4,5]. The result is a widening gap between the healthcare demands for high-quality services and de facto performance standards.

Patients with end stage renal disease (ESRD) are increasing worldwide, with a growing burden on HCDs [4]. ESRD patients in many LMICs are struggling to access specialist services e.g. hemodialysis (HD), peritoneal dialysis and kidney transplantation but fairly a good proportion of them fail to receive their most needed life-saving care and eventually die prematurely from the consequent complications [5]. Those patients that have fortune to access their needed care for ESRD often complain of the low or deteriorating quality of the obtained care [6]. Unstable care quality and cross-center diversity of provided care to ESRD patients is well documented in the literature [7]. The reported healthcare variability in centers that provide specialist services to ESRD patients may stem from limitations of fiscal and administrative sources or simply from failure in organizational mindfulness or performance [7, 8]. Without having of a robust and globally agreed comprehensive plan of care for ESRD patients or in the case of its existence neglecting the SOPs precisely may also cause diverse care quality among the centers [9, 10]. Thus, obervation of disparate care qualities will be unavoidable even across centers in defined geographical regions and inside countries.

The International Society of Nephrology (ISN) in cooperation with a number of guideline developers, suggested appropriate set of care standards for HD patients with taking into account meagre availability of human and financial resources in many parts of the world [9].

Benchmarking analysis of the offered healthcare packages in several countries and comparison of the utilized alternative healthcare models for ESRD patients may be auspicious for institutional capacity-building in the existing healthcare facilities and minimize the current discordance in the quality of provided care [10]. Three important reasons were suggested for implementation of a benchmarking analysis in HCDs i.e. to control health care costs, for risk management and boosting care quality, and to meet patients’ unanswered needs [11].

Iran as a typical LMIC faces important challenges in providing quality care for ESRD patients [12]. There are several reports of drastically variable care quality in the HD centers with considerable impacts on the patients’ quality of life (QOL) [12,13,14]. One of the reason for such a rampant organizational turmoil is not using of a substantive and up-to-date care protocol for meeting the ESRD patients’ needs.

Main aim of this study was to perform a benchmarking and evidence-informed gap analysis of the ESRD care provision in Iran and recognize the gaps that cause diversification in care quality for ESRD patients. The paucity hinder efforts for care quality improvement (CQI) in the Iranian National Healthcare System (INHS). This study’s findings could shed light on major steps that is needed be taken towards a well-functioning HCDs in the country.

Methodology

Dimensions of the Australian Anglicare Southern Queensland Clinical and Care Governance Framework (ASQCGF) [15] were utilized as corner stones of a comprehensive clinical care plan (Fig. 1) for consolidation of best-practice components of a healthcare package that is essential in responding to HD patients’ needs in Iran. An extensive literature search was performed on several databases including PubMed, Scopus, Embase, ScienceDirect and also Google Scholar at the next stage from September 2020 up to April 2023 to recognize the gold standard core elements of an encompassing care protocol to cloak needs of the country’s HD patients in a tertiary care center.

Fig. 1
figure 1

Dimensions of an exemplar best practice clinical and care governance framework (adapted from the Australian Anglicare Southern Queensland Clinical and Care Governance Framework (ASQCGF) [15]

Full size image

The ascertained components were assigned according to the five separate dimensions of the ASQCGF [15] and a preliminary draft of an exemplar comprehensive package of care for HD patients (CPC-HD) in responding to their diverse needs was prepared. A checklist was developed at a later stage consisting of the care elements listed in the preparatory framework which was sent to a panel of expert (two nephrologists and three experienced nurses working in the HD wards) seperately for their approval in the first place and also their opinions about de facto status of the HD wards they are working in the next step. The number of experts were assumed to be satisfactory and representative of the country wide HCPs who work in the HD wards since, all the teching hospitals in Iran are working under the supervision of the Ministry of Health and Medical Education (MOHME) and almost face common institutional level logistic and operational constraints. The solicted experts verified inclusiveness of the provided checklist in terms of the listed care components and therefore, no further amendment was performed on the preliminary draft. The informants were asked to give their responses in a three Likert-type scale options (yes/no/somewhat) to indicate factual state of care provision to the HD patients in their wards. Based on the given feedbacks a gap analysis (GA) was conducted to evaluate the extent to which current care provision processes to the Iranian HD patients align with the elements of the suggested gold standard framework (Fig. 2). The analysis was performed by the researchers individually and any disagreement was resolved by consensus. The outlined National Accreditation Standards and Guidelines for Hospitals (NASGH) [16] were also examined in addition to the expert panel members’ feedbacks in conducting the GA to ensure legislative and regulatory inclusiveness of the wards’performance data.

Fig. 2
figure 2

Flow diagram of the steps used to perform a gap analysis of hemodialysis (HD) care provision in the Iranian hospitals

Full size image

This gap analysis process was implemented based on the collected data in one of the stages of a larger study that had been endorsed by the institutional level Medical Ethics Board of Trustees (MEBoT) affiliated to the Tabriz University of Medical Sciences (approval number: IRCT20171213037859N1). Partial findings of the conducted large-scale study were reported elsewhere [17, 18].

Results

The approached panelists’ feedbacks and findings from detailed assessment of the NASGH [16] were used to compare the list of procedures and already provided or assumed to be necessary care components to HD patients in Iran with elements of the devised CPC-HD. Thus, gaps in terms of important care segments and main insufficiencies of the HD wards in the Iranian hospitals were identified. The identified deficits were classified in five areas in accord with the elements of ASQCGF [15] as follow: A) supply of resources, medical devices and equipment support B) recruitment and endorsement of clinics and general work force C) infection prevention and controlling procedures D) monitoring of care effectiveness and quality improvement E) provision of safe environment for both HD patients and hospitals’ staff.

Detailed list of shortages in these five categories of deficits in care provision for the Iranian HD patients was provided in Table 1.

Table 1 Gap analysis of the current care provision processes for the Iranian HD patients compared to elements of the devised comprehensive package of care for HD patients (CPC-HD)
Full size table

As tabulated main shortages in the category of “supply of resources, medical devices and equipment support” were inadequacy of the physical space and devices relative to the number of patients, lack or limitation of physical space for isolation of HCV (hepatitis C virus) and HIV (human immunodeficiency virus) positive patients and fixed backup device, lack of adequate insurance coverage for all medication and pharmaceutical items, lack of a comprehensive financial/non-financial support and illness benefit scheme, shortage or lack of necessary equipment to be used during dialysis, home HD or kidney transplantation.

Important identified deficits relating to the “recruitment and endorsement of clinics and general work force” aspect included lack of a devised program or not implementing of the mandatory 6-month probationary training course for nurses before their start of work in the HD wards, lack of professional dialysis nutritionists for recruitment to work in HD wards, shortage of HD machine technicians, and psychologists or psychiatrists to assess patients’ mental health regularly and shortage of social workers to support HD patients through a comprehensive network of social support services (that include peer and volunteer groups’ support or funds and facilities provided by certain non-governmental charities and organizations) to help vulnerable and disadvantaged HD patients.

Main pinpointed inadequacies in the “infection prevention and controlling procedures” and “provision of safe environment for both HD patients and hospitals’ staff” aspects comprised lack of a continuous monitoring program and strict precautionary measures regarding the use of personal protective equipment, low level of pneumococcal vaccine coverage among the patients and staffs and not performing routine nasal culture for identification of positive staphylococcus cases.

Consequential identified shortcomings related to the “monitoring of care effectiveness and quality improvement” aspect of HD services in the Iranian hospitals were lack of a robust protocol for assessment of protein-energy intake adequacy, not having a programmed screening and monitoring procedures to ensure achieving of Kt/V > 1.2 goal (measure of dialysis adequacy) in 90% of the patients, lack of accurate dry weight assessment tools, hemodiafiltration program and vascular access monitoring.

Discussion

Main aim of this study was to identify gaps in provision of ESRD care to HD patients in Iran based on a comparative analysis and benchmarking approach. The HD patients in Iran as a transitional LMIC do not receive the quality care they are deserving due to several organizational deficits including lack of updated and evidence–informed HD care protocol [12,13,14]. The study findings revealed considerable unmet needs of the Iranian HD patients in terms of the required resources supply, medical devices and equipment support, work force recruitment and endorsement, infection prevention and controlling procedures, care effectiveness and quality improvement monitoring and provision of safe environment for both HD patients and hospitals’ staff. These deficits herald the widening gap in the organizational knowledge and pefomance balance that is needed to narrow down since it fuels the current disenchantment among the both HCPs and HD patients.

Similar unmet needs of HD patients were reported from both developed and developing countries of the world [19,20,21,22,23]. Several infrastructural limitaions including shortage of manpower and financial resources have been reported as the main antecedents of substandard HD services in LMICs [24,25,26] however, critical role of political commitment and leadership embeddedness in enhancing organizational performance should not be underestimated.

Difficulties in recruitment of well-trained and proficient nursing staff to provide care for HD patients and building a sympathetic and caring partnership with each patient was pinpointed in this study. Such a restrain is a global phenomenon [19,20,21,22,23, 27] and can be associated with the nurses workload and their burnout in the HD units. But limited organizational positions and budgetary resources for hiring and keeping qualified and competent nursing staff from one hand and inability of the INHS in delination of an internationally acceptable and logical wage and salary for nursing staff in the HD units have aggrevated the problem in Iran. Such an inadequacy reveals its impacts on the HD patients’ overall wellbeing, quality of life, CKD related complications or mortality.

The amount of direct and indirect out-of-pocket payments that HD patients in Iran should make for use of HD services specially in the lower socioecomic gradients might not be bearable. Owing to a high consistent inflation rate in the country [28] which may cause an extra burden on the patients’ economy and quality of life, a higher level of social responsiveness and commitment to healthcare quality and excellence is required in the INHS. A balancing strategy to curb out-of-pocket payment by the HD patients in Iran could have positive consequences beyond merely financial circumstances of the patients and directly affects their accessibility and use of mostly required life-saving HD services.

To sum up, the basic challenges in providing quality care for HDs in Iran compared with an evidence-informed presumptive care delivery guideline can be classified in the following four dimensions.

  • 1. Insufficient physical space and medical equipments: Atleast a physical space of 4.5 m2 per patient equiped with cardiopulomonary resaciation facilities (CPR) was recommended for provosion of qulaity HD care for the patients [17, 18]. But securing such a space with the mentioned facilities in LMICs including Iran for HD units requires added investments in supply-chain and logistics that seems to be unachievalble in short term. The current limited physical space and shortage of medical equipments resulted to overcrowding of the HD units in Iran and a lower care quality for the HD patients. Another challenge is related to the current in use HD machines that are from different brands and producers therefore, maintaing their spare parts and monthly services is demanding.

  • 2. Inadequacies of infection prevention and control measures: Infected patients with HCV or HIV are recommended to be dialyzed according to the endorsed protocol for infected pateints with hepatit B virus i.e. connection to separate and dedicated HD machines to prevent cross-infection [17, 27]. This is while, according to the Iranian NASGH [16], isolation of infected patients with HCV or HIV is unnecessary in HD units.

  • 3. Availability and capability of purchasing the required medication: Paying for costs of the essential medicines such as Sevelamer and Erythropoietin which are relatively expensive was another pinpointed problem with potential to pose an extra burden on HD patients in LMICs [29]. HD patients in Iran have different health insurance coverages with diverse policies in reimbursing medications cost. Inability of the HD patients in payment of full or partial prices of their required medications for a successful HD treatment is one of the main reasons for medication nonadherence among the HD patients [30].

  • HD patients are generally require help in commuting to the dialysis center, performing their daily life activities and payment of ordinary living costs due to variety of reasons including lossing job or their illness-related reduction of income [18]. Such a need for financial support among HD patients is not limited to the LMICs but it is also reported from upper income countries (UICs) of the world [3, 31, 32]. Providing opportunities for HD patients to work from home or finding a prefered home job are strtaegies that can be liaised or advocated through social work partenerships [33]. A mix of financial and other non-fiscal supports can be obtained by the HD patients in Iran from a number of charities, NGOs and government run organizations e.g. Iranian Welfare Organizations (IWO) or Ministry of Cooperatives, Labour, and Social Welfare (MoCLSW). But these supports are generally not sufficient to cover all of the disease-related or general life expenses of the HD patients.

  • Functional capabilites of the HD patients due to physical weakness and reduced exersice capacities are diminished therefore, the risk of falling and fractures increases. Provision of excersice facilities for HD patients to do exertion under supervision of trained staff is recommended and needed measure [24]. There are ample amount of evidence that indicated a combination of aerobic and resistance exercise may pose significant improvement on HD patients’ depression symptoms and QOL [34, 35]. Despite the benefits of performing regenerating and recreational exercise acitivities on overall wellbeing and prevention of a number of certain life threatening complications in HD patients no advice or recommendation nor a detailed guideline for preparation of facilities for HD patients’ regular execise were given in the current NASGH [16].

  • 4. Recruitment and endorsement of clinics and general work force

  • Recruitment and presence of specialist workforce in HD units that should include nephrologists, trained staff, technicines, social workers, nutritionists, psychologists and psychiatrists is a basic requisite to provide quality care for the patients and maintain their safety [17, 18, 36]. Shortage of professional staff in HD units inevitably could pose as a major obstacle in care provision. Difficluties in recruitment and maintaining the required number of professional staff to work in HD units and their contionous training for providing desired quality care to HD patients is another pinpointed organizational challenge in Iran that need to be addressed [32]. Lack of a trained resident technician to check the performance of reverse osmosis (RO) and fix the defects of HD machines [17], a dialysis nutritionist to check the protein-energy status and support the patients with information about dietary restrictions and liquid consumption are examples of the workforce inadquacies in the INHS.

  • Preparation and provision of informational materials to HD patients or scheduling peer support opportunities to empower patients and attract their full participation and cooperation in HD sessions was indicated to increase possibility of HD success rate [18, 26]. Despite being emphasized in the literature and the MOHME’s policy documents, no regular and coherent program to prepare useful e-educational contents, pre-dialysis education, training of the HD patients’ companions, building of peer support groups, or other empowerment activities are in place to boost HD success rate and decrease failures or HD-related complications. Routine examination of mental health status is not performed for all HD patients and only those with depressive symptoms are visited by physchatrists. This might hamper efforts of other medical staff in provision of successful healthcare and boosting QOL among the HD patients.

  • Prevention of cross-contamination in HD units is a major endeavor for working staff with remarkable impact on HD patients’ safety while being dialysed. All HD centers should have strict measures to prevent the risk of cross-infection among HD patients [31]. It is recommended that nurses and all assistants should wear masks, gowns, gloves and protective glasses when dealing with patients, especially when starting or stopping treatment [29, 32]. Despite the national and international directives, the protective equipment application is not fully complied with in the country due to the lack of strict supervision, regular monitoring and unavailability of the protective appliances.

  • Immunization of HD patients is recommended for influenza, pneumococcal and COVID-19 in addition to hepatitis B [33]. Based on the accreditation document, all required vaccines except pneumococcal vaccine (due to financial burden) are provided to the Iranian HD patients.

  • 5. Monitoring of the effectiveness and improving the quality of care for HD patients: Adequacy of dialysis is evaluated through clinical assessment of general health, fluid status, and control of laboratory parameters, along with determination of dialysis dose [34]. Therefore, at least 90% of patients (three times a week) should have minimum Kt/V > 1.2 or URR > 65% (urea reduction ratio) [31, 34, 35]. Control of laboratory parameters is carried out on a monthly basis. Inadequate protein consumption, insufficient education about nutritional restrictions, defects of HD machines and cardiovascular diseases are the main identified causes of dialysis inadequacies among most of the patients.

Evaluation of fluid status was recommended to be predicted by determining clinical dry weight through monthly based clinical evaluation of fluid status, chest radiography, bioelectrical impedance assessment at regular intervals, lung ultrasound, etc. These tools may not be available in LMICs [29, 34, 36]. Barriers to use bio-impedance are insufficient validity, lack of awareness, insufficient knowledge, limited self-efficacy, lack of required infrastructure and contradictory regulations. Factors such as the device's attractiveness and users’ experiences of its benefits in practice were reported to facilitate its use [36]. In Iran, due to the lack of access to specialized equipment (bio-impedance analysis machine), the evaluation of fluid status is generally based on the once a month clinical evaluation (blood pressure measurement, respiratory status, and weighing before and after dialysis) and per annum echocardiography.

Several Studies recommended cognitive-behavioral strategies to promote adherence to the food/fluid diet based on the evaluation of biological and clinical indicators [14, 37]. The main reasons for the non-adherence of HD patients in Iran are inadequate social support in all dimensions and lack of a regular schedule for mental health screening.

A quality improvement program is required to endorse standard care provision to HD patients, including control of hypertension, fluid overload, infections, management of anemia, metabolic parameters, and full documenting of the physical findings [29]. These inadequacies in the INHS were addressed and reported by the approached nephrologists and nurses, but there is no targeted program and a standard protocol in the system to improve HD quality.

Transplantation for adults should be considered if risk factors such as: lack of social support, treatment nonadherence, severe mental illness, substance abuse with severe dependency with poor outcomes are identified [38]. The high cost of transplantation and the preparation of immunosuppressive medicines after transplantation are the main challenges for the patients in the country.

Limitations

This evidence-informed gap analysis has main methodological limitations. First, because of the heterogeneity of the included studies with regard to their stated aims, the research team preferred to give an augmented summary of findings. Second, despite efforts were made to identify all relevant publications possibility of selection bias should not be ruled out completely. Third, the one-sided analysis of the reported de facto conditions of healthcare delivery to HD patients by the recruited experts and recommended elements of practices in NASGH [16] has potential to cast shadow on real world circumstances and experiences of HD patients since opinions of the patients were not examined in this study. Last, based on the employed qualitative approach for the data analysis no attempt was made to examine quantitaitve differences between the devised CPC-HD’s elements and the current provided care components.

Despite the mentioned limitations, the findings could provide a promising evidence base to be used for transformation of the current care practices that are offered to HD patients in Iran. Planning a qualitative reseach in future to understand major challenges and barriers of revising the current care protocol for HD patients in Iran throuth the key policymakers’ point of views and most importantly exploring the sollutions that might be applicable to tackle the shortcomings in the INHS could have added value for correctional interventions.

Suggestions

Sound strategies and policies are needed in the country to respond unmet healthcare needs of the HD patients that reside in different geographical locations (rural/urban) and provinces as a part of social justice endeavor that is recommended by the WHO [39]. The discussed caveats in the Iranian hospitals’ HD wards are currently infuriating due to surge of healthcare professionals’ migration from the country [40, 41] that posed extra burden on the shoulders of the country’s healthcare policy makers. Healthcare professionals’ migration from LMICs is a global phenomenon [42] but needs to be especially addressed in Iran because of a consistent high inflation rate [43, 44] with considerable impact on their quality of life. With the current pattern of experienced health professionals’ depletion from the INHS worsening of the provided care quality to HDs is anticipated in near future. However, in short term the gap analysis outputs could be used to justify prioritization of measures that are applicable for improving HD patients care quality in Iran.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

ADL:

Activities of Daily Living

APC:

Annual Practicing Certificate

ASQCGF:

Australian Anglicare Southern Queensland Clinical and Care Governance Framework

AVF:

Arterio-Venous Fistula

AVG:

Arterio-Venous Graft

CKD:

Chronic Kidney Disease

CPC-HD:

Comprehensive Package of Care for HD patients

CPR:

CardioPulomonary Resaciation

CQI:

Care Quality Improvement

CRBSIs:

Catheter-Related Bloodstream Infections

CRRT:

Continuous Renal Replacement Therapy

CVC:

Central Venous Catheter

eGFR:

Estimated Glomerular Filtration Rate

EP:

Expert Panel

ESRD:

End Stage Renal Disease

GA:

Gap Analysis

HCP:

Health Care Provider

HCDs:

Healthcare Delivery Systems

HD:

HemoDialysis

HIV:

Human Immunodeficiency Virus

ISN:

International Society of Nephrology

IWO:

Iranian Welfare Organizations

LMICs:

Low Middle Income Countries

MoCLSW:

Ministry of Cooperatives, Labour, and Social Welfare

NASGH:

National Accreditation Standards and Guidelines for Hospitals

NGOs:

Non-Governmental Organizations

QOL:

Quality Of Life

RO:

Reverse Osmosis

RRT:

Renal Replacement Therapy

UICs:

Upper Income Countries

URR:

Urea Reduction Ratio

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Acknowledgements

We thank all those who supported us to complete the study.

Funding

The study was partially funded by the Tabriz University of Medical Sciences (grant number: 5-D-193090-1397-06-10).

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Authors and Affiliations

  1. Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran

    Leila Zhianfar

  2. Social Determinants of Health Research Center, Health Education & Promotion Department, Tabriz University of Medical Sciences, Tabriz, Iran

    Haidar Nadrian

  3. Health Education & Promotion Department, Faculty of Health, Tabriz University of Medical Sciences, Golgasht Ave., Tabriz, Iran

    Abdolreza Shaghaghi

Authors
  1. Leila Zhianfar
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  3. Abdolreza Shaghaghi
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Contributions

L.Zh searched the literature, selected studies and assessed quality, extracted data and drafted the manuscript; A.Sh selected studies and assessed quality, revised the draft and prepared Figs. 1 and 2; H.N assessed quality of studies and all authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Abdolreza Shaghaghi.

Ethics declarations

Ethics approval and consent to participate

This gap analysis process was implemented based on the collected data in one of the stages of a larger study that had been endorsed by the Iranian Registry of Clinical Trials (approval number: IRCT20171213037859N1) and institutional level Medical Ethics Board of Trustees (MEBoT) affiliated to the Tabriz University of Medical Sciences (approval number: IR.TBZMED.REC.1397.425). Since, no human subjects were enrolled in this phase of the study, it was sought exempt from obtaining re-application for ethical approval.

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The authors declare no competing interests.

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Zhianfar, L., Nadrian, H. & Shaghaghi, A. A benchmarking and evidence-informed gap analysis of the hemodialysis care provision in Iran. BMC Health Serv Res 24, 1608 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12913-024-12054-0

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BMC Health Services Research

ISSN: 1472-6963

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