Quantifying the Economics of Medical Malpractice - A View from a Civil Law Perspective

Life is full of uncertainties. Legal rules should have a clear intention, motivation and purpose in order to diminish daily uncertainties. However, practice shows that their consequences are complex and hard to predict. For instance, tort law has the general objectives of deterring future negligent behavior and compensating the victims of someone else's negligence. Achieving these goals are particularly difficult in medical malpractice cases. To start with, when patients search for medical care they are typically sick in the first place. In case harm materializes during the treatment, it might be very hard to assess if it was due to substandard medical care or to the patient's poor health conditions. Moreover, the practice of medicine has a positive externality on the society, meaning that the design of legal rules is crucial: for instance, it should not result in physicians avoiding practicing their activity just because they are afraid of being sued even when they acted according to the standard level of care. The empirical literature on medical malpractice has been developing substantially in the past two decades, with the American case being the most studied one. Evidence from civil law tradition countries is more difficult to find. The aim of this thesis is to contribute to the empirical literature on medical malpractice, using two civil law countries as a case-study: Spain and Italy. The goal of this thesis is to investigate, in the first place, some of the consequences of having two separate sub-systems (administrative and civil) coexisting within the same legal system, which is common in civil law tradition countries with a public national health system (such as Spain, France and Portugal). When this holds, different procedures might apply depending on the type of hospital where the injury took place (essentially whether it is a public hospital or a private hospital). Therefore, a patient injured in a public hospital should file a claim in administrative courts while a patient suffering an identical medical accident should file a claim in civil courts. A natural question that the reader might pose is why should both administrative and civil courts decide medical malpractice cases? Moreover, can this specialization of courts influence how judges decide medical malpractice cases? In the past few years, there was a general concern with patient safety, which is currently on the agenda of several national governments. Some initiatives have been taken at the international level, with the aim of preventing harm to patients during treatment and care. A negligently injured patient might present a claim against the health care provider with the aim of being compensated for the economic loss and for pain and suffering. In several European countries, health care is mainly provided by a public national health system, which means that if a patient harmed in a public hospital succeeds in a claim against the hospital, public expenditures increase because the State takes part in the litigation process. This poses a problem in a context of increasing national health expenditures and public debt. In Italy, with the aim of increasing patient safety, some regions implemented a monitoring system on medical malpractice claims. However, if properly implemented, this reform shall also allow for a reduction in medical malpractice insurance costs. This thesis is organized as follows. Chapter 1 provides a review of the empirical literature on medical malpractice, where studies on outcomes and merit of claims, costs and defensive medicine are presented. Chapter 2 presents an empirical analysis of medical malpractice claims arriving to the Spanish Supreme Court. The focus is on reversal rates for civil and administrative decisions. Administrative decisions appealed by the plaintiff have the highest reversal rates. The results show a bias in lower administrative courts, which tend to focus on the State side. We provide a detailed explanation for these results, which can rely on the organization of administrative judges career. Chapter 3 assesses predictors of compensation in medical malpractice cases appealed to the Spanish Supreme Court and investigates the amount of damages attributed to patients. The results show horizontal equity between administrative and civil decisions (controlling for observable case characteristics) and vertical inequity (patients suffering more severe injuries tend to receive higher payouts). In order to execute these analyses, a database of medical malpractice decisions appealed to the Administrative and Civil Chambers of the Spanish Supreme Court from 2006 until 2009 (designated by the Spanish Supreme Court Medical Malpractice Dataset (SSCMMD)) has been created. A description of how the SSCMMD was built and of the Spanish legal system is presented as well. Chapter 4 includes an empirical investigation of the effect of a monitoring system for medical malpractice claims on insurance premiums. In Italy, some regions adopted this policy in different years, while others did not. The study uses data on insurance premiums from Italian public hospitals for the years 2001-2008. This is a significant difference as most of the studies use the insurance company as unit of analysis. Although insurance premiums have risen from 2001 to 2008, the increase was lower for regions adopting a monitoring system for medical claims. Possible implications of this system are also provided. Finally, Chapter 5 discusses the main findings, describes possible future research and concludes.

Essays On CEO Compensation: New Evidence On The Managerial-Power Vs. Optimal Contracting Debate

This dissertation analyzes the effect of market analysts’ expectations of share prices (price targets) on executive compensation. It examines how well the estimated effects of price targets on compensation fit with two competing views on determining executive compensation: the arm’s length bargaining model, which assumes that a board seeks to maximize shareholders’ interests, and the managerial power model, which assumes that a board seeks to maximize managers’ compensation (Bebchuk et al. 2005). The first chapter documents the pattern of CEO pay from fiscal year 1996 to 2010. The second chapter analyzes the Institutional Broker Estimate System Detail History Price Target data file, which that reports analysts’ price targets for firms. I show that the number of price target announcements is positively associated with company share price’s volatility, that price targets are predictive of changes in the value of stocks, and that when analysts announce positive (negative) expectations of future stock price, share prices change in the same direction in the short run. The third chapter analyzes the effect of price targets on executive compensation. I find that analysts' price targets alter the composition of executive pay between cash-based compensation and stock-based compensation. When analysts forecast a rise (fall) in the share price for a firm, the compensation package tilts toward stock-based (cash-based) compensation. The substitution effect is stronger in companies that have weaker corporate governance. The fourth chapter explores the effect of the introduction of the Sarbanes-Oxley Act (SOX) in 2002 and its reinforcement in 2006 on the options granting process. I show that the introduction of SOX and its reinforcement eliminated the practice of backdating options but increased “spring-loading” of option grants around price targets announcements. Overall, the dissertation shows that price targets provide insights into the determinants of executive pay in favor of the managerial power model.

Physiologie eines erlernten Körpermodells in Drosophila melanogaster

In der vorliegenden Dissertation wird ein Körpergrößengedächtnis untersucht. Es wird dargestellt, wie diese Information über die Reichweite der Fliege beim Lückenklettern unter kotrollierten Umweltbedingungen erworben und prozessiert wird. Zusätzlich wird geklärt, welche biochemischen Signale benötigt werden, um daraus ein lang anhalten-des Gedächtnis zu formen. Adulte Fliegen sind in der Lage, ihre Körperreichweite zu lernen. Naive Fliegen, die in der Dunkelheit gehalten wurden, versuchen erfolglos, zu breite Lücken zu überqueren, während visuell erfahrene Fliegen die Kletterversuche an ihre Körpergröße anpassen. Erfahrene kleine Fliegen scheinen Kenntnis ihres Nachteils zu haben. Sie kehren an Lückenbreiten um, welche ihre größeren Artgenos-sen durchaus noch versuchen. Die Taufliegen lernen die größenabhängige Reichweite über die visuelle Rückmeldung während des Laufens (aus Parallaxenbewegung). Da-bei reichen 15 min in strukturierter, heller Umgebung aus. Es gibt keinen festgelegten Beginn der sensiblen Phase. Nach 2 h ist das Gedächtnis jedoch konsolidiert und kann durch Stress nicht mehr zerstört oder durch sensorische Eingänge verändert werden. Dunkel aufgezogene Fliegen wurden ausgewählten Streifenmustern mit spezifischen Raumfrequenzen ausgesetzt. Nur die Insekten, welche mit einem als „optimal“ klassi-fizierten Muster visuell stimuliert wurden, sind in der Lage, die Körperreichweite einzu-schätzen, indem die durchschnittliche Schrittlänge in Verbindung mit der visuellen Wahrnehmung gebracht wird. Überraschenderweise ist es sogar mittels partieller Kompensation der Parallaxen möglich, naive Fliegen so zu trainieren, dass sie sich wie kleinere Exemplare verhalten. Da die Experimente ein Erlernen der Körperreich-weite vermuten lassen, wurden lernmutante Stämme beim Lückenüberwinden getes-tet. Sowohl die Ergebnisse von rut1- und dnc1-Mutanten, als auch das defizitäre Klet-tern von oc1-Fliegen ließ eine Beteiligung der cAMP-abhängigen Lernkaskade in der Protocerebralbrücke (PB) vermuten. Rettungsexperimente der rut1- und dnc1-Hinter-gründe kartierten das Gedächtnis in unterschiedliche Neuronengruppen der PB, wel-che auch für die visuelle Ausrichtung des Kletterns benötigt werden. Erstaunlicher-weise haben laterale lokale PB-Neurone und PFN-Neurone (Projektion von der PB über den fächerförmigen Körper zu den Noduli) verschiedene Erfordernisse für cAMP-Signale. Zusammenfassend weisen die Ergebnisse darauf hin, dass hohe Mengen an cAMP/PKA-Signalen in den latero-lateralen Elementen der PB benötigt werden, wäh-rend kolumnäre PFN-Neurone geringe oder keine Mengen an cAMP/PKA erfordern. Das Körperreichweitengedächtnis ist vermutlich das am längsten andauernde Ge-dächtnis in Drosophila. Wenn es erst einmal konsolidiert ist hält es länger als drei Wo-chen.rnAußerdem kann die Fruchtliege Drosophila melanogaster trainiert werden, die kom-plexe motorische Aufgabe des Lückenkletterns zu optimieren. Die trainierten Fliegen werden erfolgreicher und schneller beim Überqueren von Lücken, welche größer sind als sie selbst. Dabei existiert eine Kurzeitkomponente (STM), die 40 min nach dem ersten Training anhält. Nach weiteren vier Trainingsdurchläufen im Abstand von 20 min wird ein Langzeitgedächtnis (LTM) zum Folgetag geformt. Analysen mit Mutati-onslinien wiesen eine Beteiligung der cAMP-abhängigen Lernkaskade an dieser Ge-dächtnisform auf. Rettungsexperimente des rut2080-Hintergrunds kartierten sowohl das STM, als auch das LTM in PFN-Neuronen. Das STM kann aber ebenso in den alpha- und beta- Loben der Pilzkörper gerettet werden.rnLetztendlich sind wildtypische Fliegen sogar in der Lage, sich an einen Verlust eines Mittelbeintarsuses und dem einhergehenden Fehlen des Adhäsionsorgans am Tarsusende anzupassen. Das Klettern wird zwar sofort schlechter, erholt sich aber bis zum Folgetag wieder auf ein normales Niveau. Dieser neue Zustand erfordert ein Ge-dächtnis für die physischen Möglichkeiten, die nur durch plastische Veränderungen im Nervensystem des Insekts erreicht werden können.

Osteoporosis and bisphosphonates-related osteonecrosis of the jaw: Not just a sporadic coincidence - a multi-centre study

Bisphosphonates (BPs) are powerful drugs that inhibit bone metabolism. Adverse side effects are rare but potentially severe such as bisphosphonate-related osteonecrosis of the jaw (BRONJ). To date, research has primarily focused on the development and progression of BRONJ in cancer patients with bone metastasis, who have received high dosages of BPs intravenously. However, a potential dilemma may arise from a far larger cohort, namely the millions of osteoporosis patients on long-term oral BP therapy.

Determination of Pelvic Orientation from Ultrasound Images Using Patch-SSMs and a Hierarchical Speed of Sound Compensation Strategy

In the field of computer assisted orthopedic surgery (CAOS) the anterior pelvic plane (APP) is a common concept to determine the pelvic orientation by digitizing distinct pelvic landmarks. As percutaneous palpation is - especially for obese patients - known to be error-prone, B-mode ultrasound (US) imaging could provide an alternative means. Several concepts of using ultrasound imaging to determine the APP landmarks have been introduced. In this paper we present a novel technique, which uses local patch statistical shape models (SSMs) and a hierarchical speed of sound compensation strategy for an accurate determination of the APP. These patches are independently matched and instantiated with respect to associated point clouds derived from the acquired ultrasound images. Potential inaccuracies due to the assumption of a constant speed of sound are compensated by an extended reconstruction scheme. We validated our method with in-vitro studies using a plastic bone covered with a soft-tissue simulation phantom and with a preliminary cadaver trial.

Inactivation of the hypermethylated in cancer 1 tumour suppressor--not just a question of promoter hypermethylation?

The chromosomal region 17p13.3 is frequently deleted or epigenetically silenced in a variety of human cancers. It includes the hypermethylated in cancer 1 (HIC1) gene placed telomerically to the p53 tumour suppressor gene. HIC1 encodes a transcriptional repressor, and its targets identified to date are genes involved in proliferation, tumour growth and angiogenesis. In addition, HIC1 functionally cooperates with p53 to suppress cancer development. Frequent allelic loss at position 17p13.1 in human cancers often points to mutations of the tumour suppressor p53. However, in a variety of cancer types, allelic loss of the short arm of chromosome 17 may hit regions distal to p53 and, interestingly, without leading to p53 mutations. Furthermore, the neighbouring region 17p13.3 often shows loss of heterozygosity or DNA hypermethylation in various types of solid tumours and leukaemias. In line with this concept, Wales et al. described a new potential tumour suppressor in this region and named it hypermethylated in cancer 1 (HIC1). Further, it was shown that in the majority of cases hypermethylation of this chromosomal region leads to epigenetic inactivation of HIC1. A role for HIC1 in tumour development is further supported by a mouse model, since various spontaneous, age- and gender-specific malignant tumours occur in heterozygous Hic1+/- knockout mice. Furthermore, exogenously delivered HIC1 leads to a significant decrease in clonogenic survival in cancer cell lines. This review highlights the role of HIC1 inactivation in solid tumours and particularly in leukaemia development.