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.

Novel tools for conservation genetics in marine fish: population structure and evolution of the European hake (Merluccius merluccius) inferred by SNP variation and applications to traceability

The research presented in my PhD thesis is part of a wider European project, FishPopTrace, focused on traceability of fish populations and products. My work was aimed at developing and analyzing novel genetic tools for a widely distributed marine fish species, the European hake (Merluccius merluccius), in order to investigate population genetic structure and explore potential applications to traceability scenarios. A total of 395 SNPs (Single Nucleotide Polymorphisms) were discovered from a massive collection of Expressed Sequence Tags, obtained by high-throughput sequencing, and validated on 19 geographic samples from Atlantic and Mediterranean. Genome-scan approaches were applied to identify polymorphisms on genes potentially under divergent selection (outlier SNPs), showing higher genetic differentiation among populations respect to the average observed across loci. Comparative analysis on population structure were carried out on putative neutral and outlier loci at wide (Atlantic and Mediterranean samples) and regional (samples within each basin) spatial scales, to disentangle the effects of demographic and adaptive evolutionary forces on European hake populations genetic structure. Results demonstrated the potential of outlier loci to unveil fine scale genetic structure, possibly identifying locally adapted populations, despite the weak signal showed from putative neutral SNPs. The application of outlier SNPs within the framework of fishery resources management was also explored. A minimum panel of SNP markers showing maximum discriminatory power was selected and applied to a traceability scenario aiming at identifying the basin (and hence the stock) of origin, Atlantic or Mediterranean, of individual fish. This case study illustrates how molecular analytical technologies have operational potential in real-world contexts, and more specifically, potential to support fisheries control and enforcement and fish and fish product traceability.

The role of collective action in the provision of agri-environmental public goods: theoretical development through case studies in Italy

The thesis aims at analysing the role of collective action as a viable alternative to the traditional forms of intervention in agriculture in order to encourage the provision of agri-environmental public goods. Which are the main benefits of collective action, in terms of effectiveness and efficiency, compared to traditional market or public intervention policies? What are the drivers that encourage farmers to participate into collective action? To what extent it is possible to incorporate collective aspects into policies aimed at providing agri-environmental public goods? With the objective of addressing these research questions, the thesis is articulated in two levels: a theoretical analysis on the role of collective action in the provision of public goods and a specific investigation of two local initiative,s were an approach collective management of agro-environmental resources was successfully implemented. The first case study concerns a project named “Custodians of the Territory”, developed by the local agency in Tuscany “Comunità Montana Media Valle del Serchio”, which settled for an agreement with local farmers for a collective provision of environmental services related to the hydro-geological management of the district. The second case study is related to the territorial agri-environmental agreement experimented in Valdaso (Marche), where local farmers have adopted integrated pest management practices collectively with the aim of reducing the environmental impact of their farming practices. The analysis of these initiatives, carried out through participatory methods (Rapid Rural Appraisal), allowed developing a theoretical discussion on the role of innovative tools (such as co-production and co-management) in the provision of agri-environmental public goods. The case studies also provided some recommendations on the government intervention and policies needed to promote successful collective action for the provision of agri-environmental public goods.

Tetti verdi: Analisi sperimentale e Modellazione numerica

I tetti verdi rappresentano, sempre più frequentemente, una tecnologia idonea alla mitigazione alle problematiche connesse all’ urbanizzazione, tuttavia la conoscenza delle prestazioni dei GR estensivi in clima sub-Mediterraneo è ancora limitata. La presente ricerca è supportata da 15 mesi di analisi sperimentali su due GR situati presso la Scuola di Ingegneria di Bologna. Inizialmente vengono comparate, tra loro e rispetto a una superficie di riferimento (RR), le prestazioni idrologiche ed energetiche dei due GR, caratterizzati da vegetazione a Sedum (SR) e a erbe native perenni (NR). Entrambi riducono i volumi defluiti e le temperature superficiali. Il NR si dimostra migliore del SR sia in campo idrologico che termico, la fisiologia della vegetazione del NR determina l'apertura diurna degli stomi e conseguentemente una maggiore evapotraspirazione (ET). Successivamente si sono studiate la variazioni giornaliere di umidità nel substrato del SR riscontrando che la loro ampiezza è influenzata dalla temperatura, dall’umidità iniziale e dalla fase vegetativa. Queste sono state simulate mediante un modello idrologico basato sull'equazione di bilancio idrico e su due modelli convenzionali per la stima della ET potenziale combinati con una funzione di estrazione dell’ umidità dal suolo. Sono stati proposti dei coefficienti di correzione, ottenuti per calibrazione, per considerare le differenze tra la coltura di riferimento e le colture nei GR durante le fasi di crescita. Infine, con l’ausilio di un modello implementato in SWMM 5.1. 007 utilizzando il modulo Low Impact Development (LID) durante simulazioni in continuo (12 mesi) si sono valutate le prestazioni in termini di ritenzione dei plot SR e RR. Il modello, calibrato e validato, mostra di essere in grado di riprodurre in modo soddisfacente i volumi defluiti dai due plot. Il modello, a seguito di una dettagliata calibrazione, potrebbe supportare Ingegneri e Amministrazioni nella valutazioni dei vantaggi derivanti dall'utilizzo dei GR.

Collective actions for environmental monitoring and conservation: citizen science, informal environmental education, and participatory approach

This PhD was driven by an interest for inclusive and participatory approaches. The methodology that bridges science and society is known as 'citizen science' and is experiencing a huge upsurge worldwide, in the scientific and humanities fields. In this thesis, I have focused on three topics: i) assessing the reliability of data collected by volunteers; ii) evaluating the impact of environmental education activities in tourist facilities; and iii) monitoring marine biodiversity through citizen science. In addition to these topics, during my research stay abroad, I developed a questionnaire to investigate people's perceptions of natural areas to promote the implementation of co-management. The results showed that volunteers are not only able to collect sufficiently reliable data, but that during their participation in this type of project, they can also increase their knowledge of marine biology and ecology and their awareness of the impact of human behaviour on the environment. The short-term analysis has shown that volunteers are able to retain what they have learned. In the long term, knowledge is usually forgotten, but awareness is retained. Increased awareness could lead to a change in behaviour and in this case a more environmentally friendly attitude. This aspect could be of interest for the development of environmental education projects in tourism facilities to reduce the impact of tourism on the environment while adding a valuable service to the tourism offer. We also found that nature experiences in childhood are important to connect to nature in adulthood. The results also suggest that membership or volunteering in an environmental education association could be a predictor of people's interest in more participatory approaches to nature management. In most cases, the COVID -19 pandemic had not changed participants' perceptions of the natural environment.

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.

Model predictive control in thermal management of multiprocessor systems-on-chip

MultiProcessor Systems-on-Chip (MPSoC) are the core of nowadays and next generation computing platforms. Their relevance in the global market continuously increase, occupying an important role both in everydaylife products (e.g. smartphones, tablets, laptops, cars) and in strategical market sectors as aviation, defense, robotics, medicine. Despite of the incredible performance improvements in the recent years processors manufacturers have had to deal with issues, commonly called “Walls”, that have hindered the processors development. After the famous “Power Wall”, that limited the maximum frequency of a single core and marked the birth of the modern multiprocessors system-on-chip, the “Thermal Wall” and the “Utilization Wall” are the actual key limiter for performance improvements. The former concerns the damaging effects of the high temperature on the chip caused by the large power densities dissipation, whereas the second refers to the impossibility of fully exploiting the computing power of the processor due to the limitations on power and temperature budgets. In this thesis we faced these challenges by developing efficient and reliable solutions able to maximize performance while limiting the maximum temperature below a fixed critical threshold and saving energy. This has been possible by exploiting the Model Predictive Controller (MPC) paradigm that solves an optimization problem subject to constraints in order to find the optimal control decisions for the future interval. A fully-distributedMPC-based thermal controller with a far lower complexity respect to a centralized one has been developed. The control feasibility and interesting properties for the simplification of the control design has been proved by studying a partial differential equation thermal model. Finally, the controller has been efficiently included in more complex control schemes able to minimize energy consumption and deal with mixed-criticalities tasks

Development and Validation of a Model-Based Combustion Controller for Water Injection Management

This manuscript reports the overall development of a Ph.D. research project during the “Mechanics and advanced engineering sciences” course at the Department of Industrial Engineering of the University of Bologna. The project is focused on the development of a combustion control system for an innovative Spark Ignited engine layout. In details, the controller is oriented to manage a prototypal engine equipped with a Port Water Injection system. The water injection technology allows an increment of combustion efficiency due to the knock mitigation effect that permits to keep the combustion phasing closer to the optimal position with respect to the traditional layout. At the beginning of the project, the effects and the possible benefits achievable by water injection have been investigated by a focused experimental campaign. Then the data obtained by combustion analysis have been processed to design a control-oriented combustion model. The model identifies the correlation between Spark Advance, combustion phasing and injected water mass, and two different strategies are presented, both based on an analytic and semi-empirical approach and therefore compatible with a real-time application. The model has been implemented in a combustion controller that manages water injection to reach the best achievable combustion efficiency while keeping knock levels under a pre-established threshold. Three different versions of the algorithm are described in detail. This controller has been designed and pre-calibrated in a software-in-the-loop environment and later an experimental validation has been performed with a rapid control prototyping approach to highlight the performance of the system on real set-up. To further make the strategy implementable on an onboard application, an estimation algorithm of combustion phasing, necessary for the controller, has been developed during the last phase of the PhD Course, based on accelerometric signals.

Assessing the state of Nephrops norvegicus and management measures in the Central Adriatic Sea

Nephrops norvegicus is a sedentary bottom-dwelling crustacean that represents one of the main commercial species exploited in the Adriatic Sea (Central Mediterranean). An evaluation of the status of this important resource is thus extremely important in order to manage it in a sustainable way. The evaluation of N. norvegicus is complicated by several issues, mainly: (i) the complex biology and behaviour of the species itself, (ii) the presence of subpopulations with different biological traits within the same stock unit. Relevant concentration of N.norvegicus occurs within the Pomo/Jabuka Pits area which is characterised by peculiar oceanographic and geophysical conditions. This area represented for a long time an important fishing ground shared by Italian and Croatian fleets and recently a Fishery Restricted Area (FRA) was established there. The aim of the present study is to perform for the first time an evaluation of the status of the N.norvegicus subpopulation inhabiting the Pomo/Jabuka Pits also accounting for the possible effects on it of the management measures. To achieve this, the principal fisheryindependent and fishery-dependent dataset available for the study area were firstly analysed and then treated. Data collected by the CNR-IRBIM of Ancona through both indirect (“UWTV”) and direct (trawling) methods were refined by means of a revision of the time series and related biases, and a modelling approach accounting for environmental and fishery effects, respectively. Commercial data for both Italy and Croatia were treated in order to obtain landings and length distributions for the Pomo area only; an historical reconstruction of data starting from 1970 was carried out for both countries. The obtained information was used as input for a Bayesian length-based stock assessment model developed through the CASAL software; the flexibility of this model is recommended for N.norvegicus and similar species allowing to deal with sex- and fleet-based integrated assessment method

Spatial based approach to fisheries management. An application to bottom trawling in the strait of Sicily

At the beginning of my thesis project, considering that some stocks are in overfishing status due to both high fishing effort and high level of juveniles in the catch, my main purpose was to understand how to contribute to improving the state of the fishery resources of the Mediterranean Sea. To mitigate the overfishing, the General Fisheries Commission for the Mediterranean (GFCM) adopted several Fishery Restricted Areas, which are geographically defined areas where some specific fishing activities are temporarily or permanently banned or restricted in order to reduce the exploitation patterns and conservation of specific stocks as well as of habitats and deep-sea ecosystems, including the Essential Fish Habitats (EFH) and the Vulnerable Marine Ecosystems (VME). Considering that GFCM established 3 Fisheries Restricted Areas (FRAs) in the Strait of Sicily (SoS) in 2016 aimed at protecting the nursery areas of the deep-water rose shrimp (DPS, Parapenaeus longirostris – Lucas, 1846) and the European hake (HKE, Merluccius merluccius – Linnaeus, 1758) to reduce the exploitation pattern of undersized species, in my thesis project I devoted myself to evaluate the effect of the FRAs on the status stock and the fishery performance using a spatial bio-economic model.

Evaluation and management of demersal stocks in the Adriatic: the case of common sole (Solea solea, L.) in the northern and central Adriatic Sea

This PhD thesis aimed to assess the status of common sole, one of the main commercial stocks in the Adriatic Sea, using a mix of conventional and innovative techniques to provide more reliable estimates of stock status compared to past advice. First, a meta-analysis was carried out using data-poor assessment model to analyze the whole catch assemblage of rapido fishery. The outcomes were used to estimate rebuilding time and forecast catches under different harvest control rule scenarios, with a reduction of 20% of fishing effort being suggested as a way to allow most of the species to recover to sustainable levels. Secondly, an ensemble of data-rich assessment models was developed to better incorporate uncertainty by using alternative hypotheses of main parameters. This was the first time an ensemble of models has been used in the Mediterranean to provide management advice. Consistent with data-poor analysis results, the ensemble outcomes indicated that the common sole stock was showing a recovering trend probably due to the effective management actions underway in the area rather than the moderate effort reduction according to the actual management plan. Moreover, back-calculation measurements were used to fit and compare monophasic and biphasic growth curves through the use of non-linear mixed effects models. The analyses revealed that the fitting of the biphasic curve was superior, confirming the theory that growth in size would decrease as a consequence of reproductive effort. A stock assessment simulation showed how the use of the monophasic pattern would result in a critical overestimation of biomass that could lead to a greater risk of overfishing. As a final step, a simulation-testing procedure was applied to determine the best performing reference points using stock-specific characteristic. The procedure could be routinely adopted to increase transparency in reference points calculation enhancing the credibility of scientific advice.