Multi-Principal Agency and the Compliance with Professional Guidelines in Health Systems: Economic and Regulatory Perspectives

Amid the trend of rising health expenditure in developed economies, changing the healthcare delivery models is an important point of action for service regulators to contain this trend. Such a change is mostly induced by either financial incentives or regulatory tools issued by the regulators and targeting service providers and patients. This creates a tripartite interaction between service regulators, professionals, and patients that manifests a multi-principal agent relationship, in which professionals are agents to two principals: regulators and patients. This thesis is concerned with such a multi-principal agent relationship in healthcare and attempts to investigate the determinants of the (non-)compliance to regulatory tools in light of this tripartite relationship. In addition, the thesis provides insights into the different institutional, economic, and regulatory settings, which govern the multi-principal agent relationship in healthcare in different countries. Furthermore, the thesis provides and empirically tests a conceptual framework of the possible determinants of (non-)compliance by physicians to regulatory tools issued by the regulator. The main findings of the thesis are first, in a multi-principal agent setting, the utilization of financial incentives to align the objectives of professionals and the regulator is important but not the only solution. This finding is based on the heterogeneity in the financial incentives provided to professionals in different health markets, which does not provide a one-size-fits-all model of financial incentives to influence clinical decisions. Second, soft law tools as clinical practice guidelines (CPGs) are important tools to mitigate the problems of the multi-principal agent setting in health markets as they reduce information asymmetries while preserving the autonomy of professionals. Third, CPGs are complex and heterogeneous and so are the determinants of (non-)compliance to them. Fourth, CPGs work but under conditions. Factors such as intra-professional competition between service providers or practitioners might lead to non-compliance to CPGs – if CPGs are likely to reduce the professional’s utility. Finally, different degrees of soft law mandate have different effects on providers’ compliance. Generally, the stronger the mandate, the stronger the compliance, however, even with a strong mandate, drivers such as intra-professional competition and co-management of patients by different professionals affected the (non-)compliance.

Multi-organ support device for combined extracorporeal carbon dioxide removal and hemofiltration treatments with pump-free solution for ultrafiltration

The use of extracorporeal organ support (ECOS) devices is increasingly widespread, to temporarily sustain or replace the functions of impaired organs in critically ill patients. Among ECOS, respiratory functions are supplied by extracorporeal life support (ECLS) therapies like extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R), and renal replacement therapies (RRT) are used to support kidney functions. However, the leading cause of mortality in critically ill patients is multi-organ dysfunction syndrome (MODS), which requires a complex therapeutic strategy where extracorporeal treatments are often integrated to pharmacological approach. Recently, the concept of multi-organ support therapy (MOST) has been introduced, and several forms of isolated ECOS devices are sequentially connected to provide simultaneous support to different organ systems. The future of critical illness goes towards the development of extracorporeal devices offering multiple organ support therapies on demand by a single hardware platform, where treatment lines can be used alternately or in conjunction. The aim of this industrial PhD project is to design and validate a device for multi-organ support, developing an auxiliary line for renal replacement therapy (hemofiltration) to be integrated on a platform for ECCO2R. The intended purpose of the ancillary line, which can be connected on demand, is to remove excess fluids by ultrafiltration and achieve volume control by the infusion of a replacement solution, as patients undergoing respiratory support are particularly prone to develop fluid overload. Furthermore, an ultrafiltration regulation system shall be developed using a powered and software-modulated pinch-valve on the effluent line of the hemofilter, proposed as an alternative to the state-of-the-art solution with peristaltic pump.

Tumor burden as assessed by 18 F FDG PET scan as predictive biomarker for immune checkpoint blockers in advanced NSCLC - a multi centric study

Introduction Only a proportion of patients with advanced NSCLC benefit from Immune checkpoint blockers (ICBs). No biomarker is validated to choose between ICBs monotherapy or in combination with chemotherapy (Chemo-ICB) when PD-L1 expression is above 50%. The aim of the present study is to validate the biomarker validity of total Metabolic Tumor Volume (tMTV) as assessed by 2-deoxy-2-[18F]fluoro-d-glucose positron emission tomography ([18F]FDG-PET) Material and methods This is a multicentric retrospective study. Patients with advanced NSCLC treated with ICBs, chemotherapy plus ICBs and chemotherapy were enrolled in 12 institutions from 4 countries. Inclusion criteria was a positive PET scan performed within 42 days from treatment start. TMTV was analyzed at each center based on a 42% SUVmax threshold. High tMTV was defined ad tMTV>median Results 493 patients were included, 163 treated with ICBs alone, 236 with chemo-ICBs and 94 with CT. No correlation was found between PD-L1 expression and tMTV. Median PFS for patients with high tMTV (100.1 cm3) was 3.26 months (95% CI 1.94–6.38) vs 14.70 (95% CI 11.51–22.59) for those with low tMTV (p=0.0005). Similarly median OS for pts with high tMTV was 11.4 months (95% CI 8.42 – 19.1) vs 33.1 months for those with low tMTV (95% CI 22.59 – NA), p .00067. In chemo-ICBs treated patients no correlation was found for OS (p = 0.11) and a borderline correlation was found for PFS (p=0.059). Patients with high tMTV and PD-L1 ≥ 50% had a better PFS when treated with combination of chemotherapy and ICBs respect to ICBs alone, with 3.26 months (95% CI 1.94 – 5.79) for ICBs vs 11.94 (95% CI 5.75 – NA) for Chemo ICBs (p = 0.043). Conclusion tMTV is predictive of ICBs benefit, not to CT benefit. tMTV can help to select the best upfront strategy in patients with high tMTV.

Multi-scale analysis of active landslides using two-pass differential interferometry

Landslides are common features of the landscape of the north-central Apennine mountain range and cause frequent damage to human facilities and infrastructure. Most of these landslides move periodically with moderate velocities and, only after particular rainfall events, some accelerate abruptly. Synthetic aperture radar interferometry (InSAR) provides a particularly convenient method for studying deforming slopes. We use standard two-pass interferometry, taking advantage of the short revisit time of the Sentinel-1 satellites. In this paper we present the results of the InSAR analysis developed on several study areas in central and Northern Italian Apennines. The aims of the work described within the articles contained in this paper, concern: i) the potential of the standard two-pass interferometric technique for the recognition of active landslides; ii) the exploration of the potential related to the displacement time series resulting from a two-pass multiple time-scale InSAR analysis; iii) the evaluation of the possibility of making comparisons with climate forcing for cognitive and risk assessment purposes. Our analysis successfully identified more than 400 InSAR deformation signals (IDS) in the different study areas corresponding to active slope movements. The comparison between IDSs and thematic maps allowed us to identify the main characteristics of the slopes most prone to landslides. The analysis of displacement time series derived from monthly interferometric stacks or single 6-day interferograms allowed the establishment of landslide activity thresholds. This information, combined with the displacement time series, allowed the relationship between ground deformation and climate forcing to be successfully investigated. The InSAR data also gave access to the possibility of validating geographical warning systems and comparing the activity state of landslides with triggering probability thresholds.

Multi-functional electrocatalysts for CO2 reduction reaction: towards the modulation of selectivity

The electrocatalytic reduction of CO2 (CO2RR) is a captivating strategy for the conversion of CO2 into fuels, to realize a carbon neutral circular economy. In the recent years, research has focused on the development of new materials and technology capable of capturing and converting CO2 into useful products. The main problem of CO2RR is given by its poor selectivity, which can lead to the formation of numerous reaction products, to the detriment of efficiencies. For this reason, the design of new electrocatalysts that selectively and efficiently reduce CO2 is a fundamental step for the future exploitation of this technology. Here we present a new class of electrocatalysts, designed with a modular approach, namely, deriving from the combination of different building blocks in a single nanostructure. With this approach it is possible to obtain materials with an innovative design and new functionalities, where the interconnections between the various components are essential to obtain a highly selective and efficient reduction of CO2, thus opening up new possibilities in the design of optimized electrocatalytic materials. By combining the unique physic-chemical properties of carbon nanostructures (CNS) with nanocrystalline metal oxides (MO), we were able to modulate the selectivity of CO2RR, with the production of formic acid and syngas at low overpotentials. The CNS have not only the task of stabilizing the MO nanoparticles, but the creation of an optimal interface between two nanostructures is able to improve the catalytic activity of the active phase of the material. While the presence of oxygen atoms in the MO creates defects that accelerate the reaction kinetics and stabilize certain reaction intermediates, selecting the reaction pathway. Finally, a part was dedicated to the study of the experimental parameters influencing the CO2RR, with the aim of improving the experimental setup in order to obtain commercial catalytic performances.

Applying machine learning: a multi-role perspective

Machine (and deep) learning technologies are more and more present in several fields. It is undeniable that many aspects of our society are empowered by such technologies: web searches, content filtering on social networks, recommendations on e-commerce websites, mobile applications, etc., in addition to academic research. Moreover, mobile devices and internet sites, e.g., social networks, support the collection and sharing of information in real time. The pervasive deployment of the aforementioned technological instruments, both hardware and software, has led to the production of huge amounts of data. Such data has become more and more unmanageable, posing challenges to conventional computing platforms, and paving the way to the development and widespread use of the machine and deep learning. Nevertheless, machine learning is not only a technology. Given a task, machine learning is a way of proceeding (a way of thinking), and as such can be approached from different perspectives (points of view). This, in particular, will be the focus of this research. The entire work concentrates on machine learning, starting from different sources of data, e.g., signals and images, applied to different domains, e.g., Sport Science and Social History, and analyzed from different perspectives: from a non-data scientist point of view through tools and platforms; setting a problem stage from scratch; implementing an effective application for classification tasks; improving user interface experience through Data Visualization and eXtended Reality. In essence, not only in a quantitative task, not only in a scientific environment, and not only from a data-scientist perspective, machine (and deep) learning can do the difference.

User scheduling for low earth orbit multi-user multiple-input-multiple-output non-terrestrial network systems

In rural and isolated areas without cellular coverage, Satellite Communication (SatCom) is the best candidate to complement terrestrial coverage. However, the main challenge for future generations of wireless networks will be to meet the growing demand for new services while dealing with the scarcity of frequency spectrum. As a result, it is critical to investigate more efficient methods of utilizing the limited bandwidth; and resource sharing is likely the only choice. The research community’s focus has recently shifted towards the interference management and exploitation paradigm to meet the increasing data traffic demands. In the Downlink (DL) and Feedspace (FS), LEO satellites with an on-board antenna array can offer service to numerous User Terminals (UTs) (VSAT or Handhelds) on-ground in FFR schemes by using cutting-edge digital beamforming techniques. Considering this setup, the adoption of an effective user scheduling approach is a critical aspect given the unusually high density of User terminals on the ground as compared to the on-board available satellite antennas. In this context, one possibility is that of exploiting clustering algorithms for scheduling in LEO MU-MIMO systems in which several users within the same group are simultaneously served by the satellite via Space Division Multiplexing (SDM), and then these different user groups are served in different time slots via Time Division Multiplexing (TDM). This thesis addresses this problem by defining a user scheduling problem as an optimization problem and discusses several algorithms to solve it. In particular, focusing on the FS and user service link (i.e., DL) of a single MB-LEO satellite operating below 6 GHz, the user scheduling problem in the Frequency Division Duplex (FDD) mode is addressed. The proposed State-of-the-Art scheduling approaches are based on graph theory. The proposed solution offers high performance in terms of per-user capacity, Sum-rate capacity, SINR, and Spectral Efficiency.

Clinical impact of next-generation sequencing multi-gene panel highlighting the landscape of germline alterations in ovarian cancer patients

BRCA1 and BRCA2 are the most frequently mutated genes in ovarian cancer (OC), crucial both for the identification of cancer predisposition and therapeutic choices. However, germline variants in other genes could be involved in OC susceptibility. We characterized OC patients to detect mutations in genes other than BRCA1/2 that could be associated with a high risk to develop OC, and that could permit patients to enter the most appropriate treatment and surveillance program. Next-Generation Sequencing analysis with a 94-gene panel was performed on germline DNA of 219 OC patients. We identified 34 pathogenic/likely-pathogenic variants in BRCA1/2 and 38 in other 21 genes. Patients with pathogenic/likely-pathogenic variants in non-BRCA1/2 genes developed mainly OC alone compared to the other groups that developed also breast cancer or other tumors (p=0.001). Clinical correlation analysis showed that low-risk patients were significantly associated with platinum sensitivity (p<0.001). Regarding PARP inhibitors (PARPi) response, patients with pathogenic mutations in non-BRCA1/2 genes had significantly worse PFS and OS. Moreover, a statistically significant worse PFS was found for every increase of one thousand platelets before PARPi treatment. To conclude, knowledge about molecular alterations in genes beyond BRCA1/2 in OC could allow for more personalized diagnostic, predictive, prognostic, and therapeutic strategies for OC patients.

Development of machine learning methods for multi-modal biomarkers detection and integration

In medicine, innovation depends on a better knowledge of the human body mechanism, which represents a complex system of multi-scale constituents. Unraveling the complexity underneath diseases proves to be challenging. A deep understanding of the inner workings comes with dealing with many heterogeneous information. Exploring the molecular status and the organization of genes, proteins, metabolites provides insights on what is driving a disease, from aggressiveness to curability. Molecular constituents, however, are only the building blocks of the human body and cannot currently tell the whole story of diseases. This is why nowadays attention is growing towards the contemporary exploitation of multi-scale information. Holistic methods are then drawing interest to address the problem of integrating heterogeneous data. The heterogeneity may derive from the diversity across data types and from the diversity within diseases. Here, four studies conducted data integration using customly designed workflows that implement novel methods and views to tackle the heterogeneous characterization of diseases. The first study devoted to determine shared gene regulatory signatures for onco-hematology and it showed partial co-regulation across blood-related diseases. The second study focused on Acute Myeloid Leukemia and refined the unsupervised integration of genomic alterations, which turned out to better resemble clinical practice. In the third study, network integration for artherosclerosis demonstrated, as a proof of concept, the impact of network intelligibility when it comes to model heterogeneous data, which showed to accelerate the identification of new potential pharmaceutical targets. Lastly, the fourth study introduced a new method to integrate multiple data types in a unique latent heterogeneous-representation that facilitated the selection of important data types to predict the tumour stage of invasive ductal carcinoma. The results of these four studies laid the groundwork to ease the detection of new biomarkers ultimately beneficial to medical practice and to the ever-growing field of Personalized Medicine.

Exact and heuristic algorithms for the integrated planning of multi-energy systems

The aim of this thesis is to present exact and heuristic algorithms for the integrated planning of multi-energy systems. The idea is to disaggregate the energy system, starting first with its core the Central Energy System, and then to proceed towards the Decentral part. Therefore, a mathematical model for the generation expansion operations to optimize the performance of a Central Energy System system is first proposed. To ensure that the proposed generation operations are compatible with the network, some extensions of the existing network are considered as well. All these decisions are evaluated both from an economic viewpoint and from an environmental perspective, as specific constraints related to greenhouse gases emissions are imposed in the formulation. Then, the thesis presents an optimization model for solar organic Rankine cycle in the context of transactive energy trading. In this study, the impact that this technology can have on the peer-to-peer trading application in renewable based community microgrids is inspected. Here the consumer becomes a prosumer and engages actively in virtual trading with other prosumers at the distribution system level. Moreover, there is an investigation of how different technological parameters of the solar Organic Rankine Cycle may affect the final solution. Finally, the thesis introduces a tactical optimization model for the maintenance operations’ scheduling phase of a Combined Heat and Power plant. Specifically, two types of cleaning operations are considered, i.e., online cleaning and offline cleaning. Furthermore, a piecewise linear representation of the electric efficiency variation curve is included. Given the challenge of solving the tactical management model, a heuristic algorithm is proposed. The heuristic works by solving the daily operational production scheduling problem, based on the final consumer’s demand and on the electricity prices. The aggregate information from the operational problem is used to derive maintenance decisions at a tactical level.

New insights into vaginal environment during pregnancy: a multi-omics approach

The present thesis aims to provide a thorough comprehension of the vaginal ecosystem of pregnant women and enhance the knowledge of pregnancy pathophysiology. The first study emphasized the importance of limiting protein intake from animal sources, consuming carbohydrates, and avoiding starting pregnancy overweight to maintain a healthy vaginal environment characterized by lactobacilli and related metabolites. In the second paper, a reduction in bacterial diversity, an increase in Lactobacillus abundance, and a decrease in bacterial vaginosis-related genera were observed during pregnancy. Lactobacillus abundance correlated with higher levels of lactate, sarcosine, and amino acids, while bacterial vaginosis-related genera were associated with amines, formate, acetate, alcohols, and short-chain fatty acids. An association between intrapartum antibiotic prophylaxis for Group B Streptococcus and higher vaginal abundance of Prevotella was found. Moreover, women experiencing a first-trimester miscarriage displayed a higher abundance of Fusobacterium. The third study explored the presence of macrolides and tetracyclines resistance genes in the vaginal environment, highlighting that different vaginal microbiota types were associated with distinct resistance profiles. Lactobacilli-dominated ecosystems showed fewer or no resistance genes, while women with increased bacterial vaginosis-related genera were positive for resistance genes. The last two papers aimed to identify potential biomarkers of vaginal health or disease status. The fourth paper showed that positivity for Torquetenovirus decreased from the first to the third trimester, being more prevalent in women with higher vaginal leukocyte counts. Torquetenovirus-positive samples showed higher levels of cytokines, propionate, and cadaverine. Lactobacillus species decreased in Torquetenovirus-positive samples, while Sneathia and Shuttleworthia increased. The last work pointed out the association between clade 2 of Gardnerella vaginalis and bacterial vaginosis. Moreover, as the number of simultaneously detected G. vaginalis clades increased, bacterial vaginosis-associated bacteria also tended to increase. Additionally, sialidase gene levels negatively correlated with Lactobacillus and positively correlated with Gardnerella, Atopobium, Prevotella, Megasphaera, and Sneathia.

The interplay of multiplicity and effective energy for (multi) strange hadron production in pp collisions at the LHC

The enhanced production of strange hadrons in heavy-ion collisions relative to that in minimum-bias pp collisions is historically considered one of the first signatures of the formation of a deconfined quark-gluon plasma. At the LHC, the ALICE experiment observed that the ratio of strange to non-strange hadron yields increases with the charged-particle multiplicity at midrapidity, starting from pp collisions and evolving smoothly across interaction systems and energies, ultimately reaching Pb-Pb collisions. The understanding of the origin of this effect in small systems remains an open question. This thesis presents a comprehensive study of the production of $K^{0}_{S}$, $\Lambda$ ($\bar{\Lambda}$) and $\Xi^{-}$ ($\bar{\Xi}^{+}$) strange hadrons in pp collisions at $\sqrt{s}$ = 13 TeV collected in LHC Run 2 with ALICE. A novel approach is exploited, introducing, for the first time, the concept of effective energy in the study of strangeness production in hadronic collisions at the LHC. In this work, the ALICE Zero Degree Calorimeters are used to measure the energy carried by forward emitted baryons in pp collisions, which reduces the effective energy available for particle production with respect to the nominal centre-of-mass energy. The results presented in this thesis provide new insights into the interplay, for strangeness production, between the initial stages of the collision and the produced final hadronic state. Finally, the first Run 3 results on the production of $\Omega^{\pm}$ ($\bar{\Omega}^{+}$) multi-strange baryons are presented, measured in pp collisions at $\sqrt{s}$ = 13.6 TeV and 900 GeV, the highest and lowest collision energies reached so far at the LHC. This thesis also presents the development and validation of the ALICE Time-Of-Flight (TOF) data quality monitoring system for LHC Run 3. This work was fundamental to assess the performance of the TOF detector during the commissioning phase, in the Long Shutdown 2, and during the data taking period.