Lien entre durée de séjour et réadmissions en chirurgie et en obstétrique: étude de deux procédures à partir des données du PMSI = Using administrative data to assess the impact of length of stay on readmissions: study of two procedures in surgery and obstetrics

Position du problème: La mise en place de la tarification à l'activité pour les hôpitaux de court séjour pourrait entraîner une diminution des durées de séjour pour raisons financières. L'impact potentiel de ce phénomène sur la qualité des soins n'est pas connu. Les réadmissions identifiées à l'aide des données administratives hospitalières sont, pour certaines situations cliniques, des indicateurs de qualité des soins valides. Méthode: Étude rétrospective du lien entre la durée de séjour et la survenue de réadmissions imprévues liées au séjour initial, pour les cholécystectomies simples et les accouchements par voie basse sans complication, à partir des données du programme de médicalisation des systèmes d'information de l'Assistance publique-Hôpitaux de Paris des années 2002 à 2005. Résultats: Pour les deux procédures, la probabilité de réadmission suit une courbe en " J ". Après ajustement sur l'âge, le sexe, les comorbidités associées, l'hôpital et l'année d'admission, la probabilité de réadmission est plus élevée pour les durées de séjour les plus courtes : pour les cholécystectomies, odds ratio : 6,03 [IC95 % : 2,67-13,59] pour les hospitalisations d'un jour versus trois jours ; pour les accouchements, odds ratio : 1,74 [IC95 % : 1,05-2,91] pour les hospitalisations de deux jours versus trois jours. Conclusion: Pour deux pathologies communes, les durées de séjour les plus courtes sont associées à des probabilités de réadmission plus élevées. L'utilisation routinière des données du programme de médicalisation des systèmes d'information peut permettre d'assurer le suivi de la relation entre la réduction de la durée de séjour et les réadmissions. The prospective payment system for the French short-stay hospitals creates a financial incentive to reduce length of stay. The potential impact of the resulting decrease in length of stay on the quality of healthcare is unknown. Readmission rates are valid outcome indicators for some clinical procedures. Methods: Retrospective study of the association between length of stay and unplanned readmissions related to the initial stay, for two procedures: cholecystectomy and vaginal delivery. Data: Administrative diagnosis-related groups database of "Assistance publique-Hopitaux de Paris", a large teaching hospital, for years 2002 to 2005. Results: The risk of readmission according to length of stay, taking age, sex, comorbidity, hospital and year of admission into account, followed a J-shaped curve for both procedures. The probability of readmission was higher for very short stays, with odds ratios and 95% confidence intervals of 6.03 [2.67-13.59] for cholecystectomies (1- versus 3-night stays), and of 1.74 [1.05-2.91] for vaginal deliveries (2- versus 3-night stays). Conclusion: For both procedures, the shortest lengths of stay are associated with a higher readmission probability. Suitable indicators derived from administrative databases would enable monitoring of the association between length of stay and readmissions.

Bureaucracy and the flypaper effect : Evidence from intercommunal fiscal equalisation in the canton of Vaud

Unlike classical theoretical expectations, our empirical study shows that financial transfers to decentralised governments increase local public expenditures much more than would be triggered by an equivalent rise in local income. This empirical evidence of the presence of a flypaper effect is achieved using panel data from 375 municipalities located in the Swiss canton of Vaud covering the period 1994 to 2005. During that time there was a major change in the financial equalisation scheme. Furthermore, our study confirms the analysis of the public choice theory: the effect depends partly on the degree of complexity of the municipal bureaucracy. These results show that local bureaucratic behaviour may impede the effectiveness of a financial equalisation scheme that aims to reduce disparities in local tax.

Incentives and promotion in wage hierarchies

Most of the large firms organization schemes consist in hierarchical structures of tiers with different wage levels. Traditionally the existence of this kind of organizations has been associated to the separation of productive and managerial or supervision tasks and to differences in the skills of the workers. However, many firms now employ workers with similar skills, and then the hierarchical structure can be related to an incentive scheme to ensure that workers supply effort. The model we present investigates how firm owners should determine the optimal wage distribution in order to maximize profits.

Incentives and promotion in wage hierarchies

Most of the large firms organization schemes consist in hierarchical structures of tiers with different wage levels. Traditionally the existence of this kind of organizations has been associated to the separation of productive and managerial or supervision tasks and to differences in the skills of the workers. However, many firms now employ workers with similar skills, and then the hierarchical structure can be related to an incentive scheme to ensure that workers supply effort. The model we present investigates how firm owners should determine the optimal wage distribution in order to maximize profits.

Regulation of Electricity Transmission and Distribution in Russia

The regulation of electricity transmission and distribution business is an essential issue for any electricity market; it is widely introduced in developed electricity markets of Great Britain, Scandinavian countries and United States of America and other. Those markets which were liberalized recently also need well planned regulation model to be chosen and implemented. In open electricity markets the sectors of electricity distribution and transmission remain monopolies, so called "natural monopolies", as introducing the competition into these sectors in most cases appears to be inefficient. Thatis why regulation becomes very important as its main tasks are: to set reasonable tariffs for customers, to ensure non-discriminating process of electricity transmission and distribution, at the same time to provide distribution companies with incentives to operate efficiently and the owners of the companies with reasonable profits as well; the problem of power quality should be solved at the same time. It should be mentioned also, that there is no incentive scheme which will be suitable for any conditions, that is why it is essential to study differentregulation models in order to form the best one for concrete situation. The aim of this Master's Thesis is to give an overview over theregulation of electricity transmission and distribution in Russia. First, the general information about theory of regulation of natural monopolies will be described; the situation in Russian network business and the importance of regulation process for it will be discussed next. Then there is a detailed description ofexisting regulatory system and the process of tariff calculation with an example. And finally, in the work there is a brief analysis of problems of present scheme of regulation, an attempt to predict the following development of regulationin Russia and the perspectives and risks connected to regulation which could face the companies that try to enter Russian electricity market (such as FORTUM OY).

Myyntiprosessin kehittäminen logistiikkapalveluyrityksessä

Tämä diplomityö on toteutettu HUB logistics Oy:lle ja se keskittyy yrityksen myyntiprosessin kehittämiseen. Tutkimuksen tavoitteena on selvittää millaisilla myynnin johtamisen keinoilla ja myyntiprosessin vaiheilla voidaan tehokkaasti toteuttaa yrityksen myyntiä. Tutkimus keskittyy myynnin suunnitteluun, tavoit- teiden asettamiseen ja niiden mittaamiseen sekä seurantaan. Tutkimuksessa huomioidaan myyntiorganisaation rakenne sekä myyntiprosessin eri vaiheet. Näiden näkökulmien lisäksi tärkeänä teemana on myös lean-ajattelun hyödyn- täminen myyntiprosessin kehittämisessä. Kohdeyrityksestä on kerätty tietoa toteuttamalla haastatteluita myyntiorganisaatiossa mukana oleville henkilöille. Tutkimuksen tuloksena saatiin, että myyntiprosessin toiminnalla ja tehokkuu- della on merkittävä rooli koko yrityksen toiminnan kannalta. Myynnin käytän- nön tekeminen on sidottu vahvasti yrityksen strategisiin tavoitteisiin ja niiden tulokset vaikuttavat tavoitteiden onnistumiseen. Myyntiprosessi on raskas ja vaatii usein paljon resursseja. Resurssien tehokkaalla käytöllä ja prosessin vai- heita parantamalla voidaan saavuttaa mittavia säästöjä. Toisaalta vähintään yhtä tärkeää on ymmärtää myyntiprosessin sisältämät hukat. Niiden poistamisella ja keskittymisellä asiakkaalle luotavaan arvoon saadaan jatkuvan kehittämisen kautta yhä sujuvampi ja tehokkaampi myyntiprosessi yrityksen käyttöön.

Utilization of steelmaking waste materials for production of calcium carbonate (CaCO3)

The steel industry produces, besides steel, also solid mineral by-products or slags, while it emits large quantities of carbon dioxide (CO2). Slags consist of various silicates and oxides which are formed in chemical reactions between the iron ore and the fluxing agents during the high temperature processing at the steel plant. Currently, these materials are recycled in the ironmaking processes, used as aggregates in construction, or landfilled as waste. The utilization rate of the steel slags can be increased by selectively extracting components from the mineral matrix. As an example, aqueous solutions of ammonium salts such as ammonium acetate, chloride and nitrate extract calcium quite selectively already at ambient temperature and pressure conditions. After the residual solids have been separated from the solution, calcium carbonate can be precipitated by feeding a CO2 flow through the solution. Precipitated calcium carbonate (PCC) is used in different applications as a filler material. Its largest consumer is the papermaking industry, which utilizes PCC because it enhances the optical properties of paper at a relatively low cost. Traditionally, PCC is manufactured from limestone, which is first calcined to calcium oxide, then slaked with water to calcium hydroxide and finally carbonated to PCC. This process emits large amounts of CO2, mainly because of the energy-intensive calcination step. This thesis presents research work on the scale-up of the above-mentioned ammonium salt based calcium extraction and carbonation method, named Slag2PCC. Extending the scope of the earlier studies, it is now shown that the parameters which mainly affect the calcium utilization efficiency are the solid-to-liquid ratio of steel slag and the ammonium salt solvent solution during extraction, the mean diameter of the slag particles, and the slag composition, especially the fractions of total calcium, silicon, vanadium and iron as well as the fraction of free calcium oxide. Regarding extraction kinetics, slag particle size, solid-to-liquid ratio and molar concentration of the solvent solution have the largest effect on the reaction rate. Solvent solution concentrations above 1 mol/L NH4Cl cause leaching of other elements besides calcium. Some of these such as iron and manganese result in solution coloring, which can be disadvantageous for the quality of the PCC product. Based on chemical composition analysis of the produced PCC samples, however, the product quality is mainly similar as in commercial products. Increasing the novelty of the work, other important parameters related to assessment of the PCC quality, such as particle size distribution and crystal morphology are studied as well. As in traditional PCC precipitation process, the ratio of calcium and carbonate ions controls the particle shape; a higher value for [Ca2+]/[CO32-] prefers precipitation of calcite polymorph, while vaterite forms when carbon species are present in excess. The third main polymorph, aragonite, is only formed at elevated temperatures, above 40-50 °C. In general, longer precipitation times cause transformation of vaterite to calcite or aragonite, but also result in particle agglomeration. The chemical equilibrium of ammonium and calcium ions and dissolved ammonia controlling the solution pH affects the particle sizes, too. Initial pH of 12-13 during the carbonation favors nonagglomerated particles with a diameter of 1 μm and smaller, while pH values of 9-10 generate more agglomerates of 10-20 μm. As a part of the research work, these findings are implemented in demonstrationscale experimental process setups. For the first time, the Slag2PCC technology is tested in scale of ~70 liters instead of laboratory scale only. Additionally, design of a setup of several hundreds of liters is discussed. For these purposes various process units such as inclined settlers and filters for solids separation, pumps and stirrers for material transfer and mixing as well as gas feeding equipment are dimensioned and developed. Overall emissions reduction of the current industrial processes and good product quality as the main targets, based on the performed partial life cycle assessment (LCA), it is most beneficial to utilize low concentration ammonium salt solutions for the Slag2PCC process. In this manner the post-treatment of the products does not require extensive use of washing and drying equipment, otherwise increasing the CO2 emissions of the process. The low solvent concentration Slag2PCC process causes negative CO2 emissions; thus, it can be seen as a carbon capture and utilization (CCU) method, which actually reduces the anthropogenic CO2 emissions compared to the alternative of not using the technology. Even if the amount of steel slag is too small for any substantial mitigation of global warming, the process can have both financial and environmental significance for individual steel manufacturers as a means to reduce the amounts of emitted CO2 and landfilled steel slag. Alternatively, it is possible to introduce the carbon dioxide directly into the mixture of steel slag and ammonium salt solution. The process would generate a 60-75% pure calcium carbonate mixture, the remaining 25-40% consisting of the residual steel slag. This calcium-rich material could be re-used in ironmaking as a fluxing agent instead of natural limestone. Even though this process option would require less process equipment compared to the Slag2PCC process, it still needs further studies regarding the practical usefulness of the products. Nevertheless, compared to several other CO2 emission reduction methods studied around the world, the within this thesis developed and studied processes have the advantage of existing markets for the produced materials, thus giving also a financial incentive for applying the technology in practice.

Autonomic and Electrophysiological Correlates of Cognitive Control in Aging

This thesis tested a model of neurovisceral integration (Thayer & Lane, 2001) wherein parasympathetic autonomic regulation is considered to play a central role in cognitive control. We asked whether respiratory sinus arrhythmia (RSA), a parasympathetic index, and cardiac workload (rate pressure product, RPP) would influence cognition and whether this would change with age. Cognitive control was measured behaviourally and electrophysiologically through the error-related negativity (ERN) and error positivity (Pe). The ERN and Pe are thought to be generated by the anterior cingulate cortex (ACC), a region involved in regulating cognitive and autonomic control and susceptible to age-related change. In Study 1, older and younger adults completed a working memory Go/NoGo task. Although RSA did not relate to performance, higher pre-task RPP was associated with poorer NoGo performance among older adults. Relations between ERN/Pe and accuracy were indirect and more evident in younger adults. Thus, Study 1 supported the link between cognition and autonomic activity, specifically, cardiac workload in older adults. In Study 2, we included younger adults and manipulated a Stroop task to clarify conditions under which associations between RSA and performance will likely emerge. We varied task parameters to allow for proactive versus reactive strategies, and motivation was increased via financial incentive. Pre-task RSA predicted accuracy when response contingencies required maintenance of a specific item in memory. Thus, RSA was most relevant when performance required proactive control, a metabolically costly strategy that would presumably be more reliant on autonomic flexibility. In Study 3, we included older adults and examined RSA and proactive control in an additive factors framework. We maintained the incentive and measured fitness. Higher pre-task RSA among older adults was associated with greater accuracy when proactive control was needed most. Conversely, performance of young women was consistently associated with fitness. Relations between ERN/Pe and accuracy were modest; however, isolating ACC activity via independent component analysis allowed for more associations with accuracy to emerge in younger adults. Thus, performance in both groups appeared to be differentially dependent on RSA and ACC activation. Altogether, these data are consistent with a neurovisceral integration model in the context of cognitive control.

Intention-based economic theories of reciprocity

In recent years, several experiments have shown individuals exhibit authentic reciprocal behaviour in anonymous one-shot interactions. As reciprocity has been shown to be relevant in several economic fields, there have also been several attempts to model reciprocal bahaviour. I review the intention-based models of reciprocity and present an example of teacher management in the public sector in which the government offers an incentive scheme to implement a program. The incentive scheme has a prisoner´s dilemma structure. In both simultaneous and sequential games, equilibrium results may differ from those predicted by standard theory.

Making the least active pay: a simulation of rewards and penalties under Demand Side Participation programs

The orthodox approach for incentivising Demand Side Participation (DSP) programs is that utility losses from capital, installation and planning costs should be recovered under financial incentive mechanisms which aim to ensure that utilities have the right incentives to implement DSP activities. The recent national smart metering roll-out in the UK implies that this approach needs to be reassessed since utilities will recover the capital costs associated with DSP technology through bills. This paper introduces a reward and penalty mechanism focusing on residential users. DSP planning costs are recovered through payments from those consumers who do not react to peak signals. Those consumers who do react are rewarded by paying lower bills. Because real-time incentives to residential consumers tend to fail due to the negligible amounts associated with net gains (and losses) or individual users, in the proposed mechanism the regulator determines benchmarks which are matched against responses to signals and caps the level of rewards/penalties to avoid market distortions. The paper presents an overview of existing financial incentive mechanisms for DSP; introduces the reward/penalty mechanism aimed at fostering DSP under the hypothesis of smart metering roll-out; considers the costs faced by utilities for DSP programs; assesses linear rate effects and value changes; introduces compensatory weights for those consumers who have physical or financial impediments; and shows findings based on simulation runs on three discrete levels of elasticity.

From commitment to non-commitment: allowing type dynamic in Laffont and Tirole's regulation model

This paper investigates the introduction of type dynamic in the La ont and Tirole's regulation model. The regulator and the rm are engaged in a two period relationship governed by short-term contracts, where, the regulator observes cost but cannot distinguish how much of the cost is due to e ort on cost reduction or e ciency of rm's technology, named type. There is asymmetric information about the rm's type. Our model is developed in a framework in which the regulator learns with rm's choice in the rst period and uses that information to design the best second period incentive scheme. The regulator is aware of the possibility of changes in types and takes that into account. We show how type dynamic builds a bridge between com- mitment and non-commitment situations. In particular, the possibility of changing types mitigates the \ratchet e ect". We show that for small degree of type dynamic the equilibrium shows separation and the welfare achived is close to his upper bound (given by the commitment allocation).

Avaliação longitudinal do impacto da saúde bucal na estratégia saúde da família em Natal

As a result of the financial incentive provided by the GM / MS 1.444, since 2000, Brazil has experienced a substantial increase in the number of oral health services at the Family Health Strategy. There is, however, evidence that these teams have produced qualitatively different experiences which do not translate necessarily into improved quality of life and health. Thus, evaluative research of great importance. This study aims to assess the impact of the Family Health Strategy in oral health in a longitudinal perspective natalense the years 2006 and 2009. This is an intervention study whose design is a community trial in parallel, nearly randomized. The sample consisted of census tracts covered by oral health teams in the Family Health and the Traditional Model (Basic Health Units and non-FHS Program of Community Health Agents and areas not covered.) The sample was determined by drawing ten census tracts to form the experimental group and ten other sectors for the control group by pairing intentional based on socio-economic and geographic. To check the net effect of the intervention was performed multivariate analysis by Poisson regression. As a result of cross-sectional analysis of year 2009, it was found that the effects of the ESF in Natal were satisfactory only for the variables of injuries and for other purposes without and with negative impact on stock coverage reclaimers. However, the longitudinal analysis revealed that the ESB / ESF improved their performance in dealing with grievances, access and coverage of the type of actions and this fact is independent of age, sex and social and economic conditions. In other employees' words are related to the presence of the Family Health Strategy in the region. However it does not say that both models under study (the Family Health Strategy Model and Traditional) are different in terms of performance and it is pertinent to reflect on the need for further development of evaluation studies that use other approaches able to clarify the dynamics of the process whose results can come to the knowledge of the actors responsible for leading the ESF and encourage them to incorporate the assessment in their routine

Best practices for the implantation of ISO 14001 norms: a study of change management in two industrial companies in the Midwest region of the state of São Paulo - Brazil

Among the difficulties found in the implementation of ISO 14001 systems, resistance to change can always be found. It is mainly a consequence of the hurry to change, loss of focus, concentration of decision making at the level of top management, arbitrary imposition of objectives and results, faulty communication, and the absence of motivational and financial incentive for change.Therefore, the main objective of this paper is to present best practices with respect to the management of organizational change due to the implementation of ISO 14001 norms in two industrial companies in the Midwest region of the State of São Paulo - Brazil. (C) 2008 Elsevier Ltd. All rights reserved.

Atenção odontológica no Programa de Saúde da Família de Campos dos Goytacazes

Durante décadas, a política de saúde bucal no Brasil foi centrada na prestação de assistência à doença, e ainda hoje grande parcela da população brasileira não tem acesso a cuidados odontológicos. Pela Portaria nº 1.444, de 28 de dezembro de 2000, o Ministério da Saúde estabelece incentivo financeiro para a reorganização da atenção à saúde bucal aos municípios. Insere-se, assim, a Odontologia no programa e, conseqüentemente, a possibilidade de ampliar e reorientar a atenção odontológica no Brasil. Dentro desse contexto, este estudo teve por objetivo avaliar a situação da equipe de saúde bucal inserida no Programa de Saúde da Família (PSF) do município de Campos dos Goytacazes - RJ, em 2002. Os resultados demonstraram algumas limitações na inclusão e funcionamento da Odontologia no PSF da cidade. A atenção odontológica deve ser inserida no PSF, atendendo aos princípios básicos do Plano de Reorganização das Ações de Saúde Bucal na Atenção Básica, proposto pelo Ministério da Saúde, e à consolidação do Sistema Único de Saúde.

Pension reform in Europe in the 90's and lessons for Latin America

Includes bibliography