Le rôle de l’évaluation économique dans la pratique des médecins de famille = The role of economic evaluation in the practice of family physicians

L’évaluation économique en santé consiste en l’analyse comparative d’alternatives de services en regard à la fois de leurs coûts et de leurs conséquences. Elle est un outil d’aide à la décision. La grande majorité des décisions concernant l’allocation des ressources sont prises en clinique; particulièrement au niveau des soins primaires. Puisque chaque décision est associée à un coût d’opportunité, la non-prise en compte des considérations économiques dans les pratiques des médecins de famille peut avoir un impact important sur l’efficience du système de santé. Il existe peu de connaissances quant à l’influence des évaluations économiques sur la pratique clinique. L’objet de la thèse est de comprendre le rôle de l’évaluation économique dans la pratique des médecins de famille. Ses contributions font l’objet de quatre articles originaux (philosophique, théorique, méthodologique et empirique). L’article philosophique suggère l’importance des questions de complexité et de réflexivité en évaluation économique. La complexité est la perspective philosophique, (approche générale épistémologique) qui sous-tend la thèse. Cette vision du monde met l’attention sur l’explication et la compréhension et sur les relations et les interactions (causalité interactive). Cet accent sur le contexte et le processus de production des données souligne l’importance de la réflexivité dans le processus de recherche. L’article théorique développe une conception nouvelle et différente du problème de recherche. L’originalité de la thèse réside également dans son approche qui s’appuie sur la perspective de la théorie sociologique de Pierre Bourdieu; une approche théorique cohérente avec la complexité. Opposé aux modèles individualistes de l’action rationnelle, Bourdieu préconise une approche sociologique qui s’inscrit dans la recherche d’une compréhension plus complète et plus complexe des phénomènes sociaux en mettant en lumière les influences souvent implicites qui viennent chaque jour exercer des pressions sur les individus et leurs pratiques. L’article méthodologique présente le protocole d’une étude qualitative de cas multiples avec niveaux d’analyse imbriqués : les médecins de famille (niveau micro-individuel) et le champ de la médecine familiale (niveau macro-structurel). Huit études de cas furent réalisées avec le médecin de famille comme unité principale d’analyse. Pour le niveau micro, la collecte des informations fut réalisée à l’aide d’entrevues de type histoire de vie, de documents et d’observation. Pour le niveau macro, la collecte des informations fut réalisée à l’aide de documents, et d’entrevues de type semi-structuré auprès de huit informateurs clés, de neuf organisations médicales. L’induction analytique fut utilisée. L’article empirique présente l’ensemble des résultats empiriques de la thèse. Les résultats montrent une intégration croissante de concepts en économie dans le discours officiel des organisations de médecine familiale. Cependant, au niveau de la pratique, l'économisation de ce discours ne semble pas être une représentation fidèle de la réalité puisque la très grande majorité des participants n'incarnent pas ce discours. Les contributions incluent une compréhension approfondie des processus sociaux qui influencent les schèmes de perception, de pensée, d’appréciation et d’action des médecins de famille quant au rôle de l’évaluation économique dans la pratique clinique et la volonté des médecins de famille à contribuer à une allocation efficiente, équitable et légitime des ressources.

Mid-term Evaluation of the 2009-14 European Parliament: Legislative activity and decision-making dynamics. CEPS Special Report, 23 July 2012

This special report analyses legislative activity in the European Union and coalition formation in the European Parliament (EP) during the first half of the 7th legislative term, 2009-14. Co-decision is now the ordinary legislative procedure, not by name only: it was deployed on 90% of new proposals in 2010 and 86% in 2011, which suggests that the EP is now more influential than ever. There are differences in the degree of empowerment across committees, however. This report looks at the legislative workload of selected committees as an indicator of change in their influence, identifying which of them won and which lost out in terms of the quantity and type of legislation they tackle.

Dynamic simulation for closed loops in heating systems with decision-making support

Nowadays utilising the proper HVAC system is essential both in extreme weather conditions and dense buildings design. Hydraulic loops are the most common parts in all air conditioning systems. This article aims to investigate the performance of different hydraulic loop arrangements in variable flow systems. Technical, economic and environmental assessments have been considered in this process. A dynamic system simulation is generated to evaluate the system performance and an economic evaluation is conducted by whole life cost assessment. Moreover, environmental impacts have been studied by considering the whole life energy consumption, CO2 emission, the embodied energy and embodied CO2 of the system components. Finally, decision-making in choosing the most suitable hydraulic system among five well-known alternatives has been proposed.

Decision making for HVAC&R system selection for a typical office building in the UK

Demands for thermal comfort, better indoor air quality together with lower environmental impacts have had ascending trends in the last decade. In many circumstances, these demands could not be fully covered through the soft approach of bioclimatic design like optimisation of the building orientation and internal layout. This is mostly because of the dense urban environment and building internal energy loads. In such cases, heating, ventilation, air-conditioning and refrigeration (HVAC&R) systems make a key role to fulfill the requirements of indoor environment. Therefore, it is required to select the most proper HVAC&R system. In this study, a robust decision making approach for HVAC&R system selection is proposed. Technical performance, economic aspect and environmental impacts of 36 permutations of primary and secondary systems are taken into account to choose the most proper HVAC&R system for a case study office building. The building is a representative for the dominant form of office buildings in the UK. Dynamic performance evaluation of HVAC&R alternatives using TRNSYS package together with life cycle energy cost analysis provides a reliable basis for decision making. Six scenarios broadly cover the decision makers' attitudes on HVAC&R system selection which are analysed through Analytical Hierarchy Process (AHP). One of the significant outcomes reveals that, despite both the higher energy demand and more investment requirements associated with compound heating, cooling and power system (CCHP); this system is one of the top ranked alternatives due to the lower energy cost and C02 emissions. The sensitivity analysis reveals that in all six scenarios, the first five top ranked alternatives are not changed. Finally, the proposed approach and the results could be used by researchers and designers especially in the early stages of a design process in which all involved bodies face the lack of time, information and tools for evaluation of a variety of systems.

The Effect Of Conformity On Economic Decision Making

Inspired by research in the field of behavioral economics as well as social psychology, this study aimed to explore if conformity plays a role in the occurrence of herd behavior in the financial market. Participants received one of nine different versions of a survey either online or on paper. They answered questions related to riskiness when making decisions, dependency on others when making decisions, and investment preferences among other questions. In experimental conditions, participants were told the majority of investors, either sixty percent or eighty percent, invested in a certain stock or won a game. It was predicted that individuals would conform to the group behavior in both experimental conditions with the highest level of conformity in the high pressure to conform condition. Results of experiments revealed that when the overwhelming majority of other investors behaved a certain way (80%), participants were more likely to behave that same way. Results of the third experiment supported previous research stating that emotion affects economic decision-making and facilitates herd behavior.

Epidemiological, social, diagnostic and economic evaluation of population screening for genital chlamydial infection

OBJECTIVES: To investigate epidemiological, social, diagnostic and economic aspects of chlamydia screening in non-genitourinary medicine settings. METHODS: Linked studies around a cross-sectional population-based survey of adult men and women invited to collect urine and (for women) vulvovaginal swab specimens at home and mail these to a laboratory for testing for Chlamydia trachomatis. Specimens were used in laboratory evaluations of an amplified enzyme immunoassay (PCE EIA) and two nucleic acid amplification tests [Cobas polymerase chain reaction (PCR), Becton Dickinson strand displacement amplification (SDA)]. Chlamydia-positive cases and two negative controls completed a risk factor questionnaire. Chlamydia-positive cases were invited into a randomised controlled trial of partner notification strategies. Samples of individuals testing negative completed psychological questionnaires before and after screening. In-depth interviews were conducted at all stages of screening. Chlamydia transmission and cost-effectiveness of screening were investigated in a transmission dynamic model. SETTING AND PARTICIPANTS: General population in the Bristol and Birmingham areas of England. In total, 19,773 women and men aged 16-39 years were randomly selected from 27 general practice lists. RESULTS: Screening invitations reached 73% (14,382/19,773). Uptake (4731 participants), weighted for sampling, was 39.5% (95% CI 37.7, 40.8%) in women and 29.5% (95% CI 28.0, 31.0%) in men aged 16-39 years. Chlamydia prevalence (219 positive results) in 16-24 year olds was 6.2% (95% CI 4.9, 7.8%) in women and 5.3% (95% CI 4.4, 6.3%) in men. The case-control study did not identify any additional factors that would help target screening. Screening did not adversely affect anxiety, depression or self-esteem. Participants welcomed the convenience and privacy of home-sampling. The relative sensitivity of PCR on male urine specimens was 100% (95% CI 89.1, 100%). The combined relative sensitivities of PCR and SDA using female urine and vulvovaginal swabs were 91.8% (86.1, 95.7, 134/146) and 97.3% (93.1, 99.2%, 142/146). A total of 140 people (74% of eligible) participated in the randomised trial. Compared with referral to a genitourinary medicine clinic, partner notification by practice nurses resulted in 12.4% (95% CI -3.7, 28.6%) more patients with at least one partner treated and 22.0% (95% CI 6.1, 37.8%) more patients with all partners treated. The health service and patients costs (2005 prices) of home-based postal chlamydia screening were 21.47 pounds (95% CI 19.91 pounds, 25.99) per screening invitation and 28.56 pounds (95% CI 22.10 pounds, 30.43) per accepted offer. Preliminary modelling found an incremental cost-effectiveness ratio (2003 prices) comparing screening men and women annually to no screening in the base case of 27,000 pounds/major outcome averted at 8 years. If estimated screening uptake and pelvic inflammatory disease incidence were increased, the cost-effectiveness ratio fell to 3700 pounds/major outcome averted. CONCLUSIONS: Proactive screening for chlamydia in women and men using home-collected specimens was feasible and acceptable. Chlamydia prevalence rates in men and women in the general population are similar. Nucleic acid amplification tests can be used on first-catch urine specimens and vulvovaginal swabs. The administrative costs of proactive screening were similar to those for opportunistic screening. Using empirical estimates of screening uptake and incidence of complications, screening was not cost-effective.

Financial decision making about found oil and gas in Ghana : real options vs. traditional methods

This research is a study of the use of capital budgeting methods for investment decisions. It uses both the traditional methods and the newly introduced approach called the real options analysis to make a decision. The research elucidates how capital budgeting can be done when analysts encounter projects with high uncertainty and are capital intensive, for example oil and gas production. It then uses the oil and gas find in Ghana as a case study to support its argument. For a clear understanding a thorough literature review was done, which highlights the advantages and disadvantages of both methods. The revenue that the project will generate and the costs of production were obtained from the predictions by analysts from GNPC and compared to others experts’ opinion. It then applied both the traditional and real option valuation on the oil and gas find in Ghana to determine the project’s feasibility. Although, there are some short falls in real option analysis that are presented in this research, it is still helpful in valuing projects that are capital intensive with high volatility due to the strategic flexibility management possess in their decision making. It also suggests that traditional methods of evaluation should still be maintained and be used to value projects that have no options or those with options yet the options do not have significant impact on the project. The research points out the economic ripples the production of oil and gas will have on Ghana’s economy should the project be undertaken. These ripples include economic growth, massive job creation and reduction of the balance of trade deficit for the country. The long run effect is an eventually improvement of life of the citizens. It is also belief that the production of gas specifically can be used to generate electricity in Ghana which would enable the country to have a more stable and reliable power source necessary to attract more foreign direct investment.

Assessment of low-flow, low-gradient, severe aortic stenosis: an invasive evaluation is required for decision making.

Low-flow, low-gradient severe aortic stenosis (AS) is characterised by a small aortic valve area (AVA) and low mean gradient (MG) secondary to a low cardiac output and may occur in patients with either a preserved or reduced left ventricular ejection fraction (LVEF). Symptomatic patients presenting with low-flow, low-gradient severe AS have a dismal prognosis independent of baseline LVEF if managed conservatively and should therefore undergo aortic valve replacement if feasible. Transthoracic echocardiography (TTE) is the first-line investigation for the assessment of AS haemodynamic severity. However, when confronted with guideline-discordant AVA (small) and MG (low) values, there are several reasons other than severe AS combined with a low cardiac output which may lead to such a situation, including erroneous measurements, small body size, inherent inconsistencies in the guidelines' criteria, prolonged ejection time and aortic pseudostenosis. The distinction between these various entities poses a diagnostic challenge. However, it is important to make a distinction because each has very different implications in terms of risk stratification and therapeutic management. In such instances, cardiac catheterisation forms an integral part of the work-up of these patients in order to confirm or refute the echocardiographic findings to guide management decisions appropriately.

Risk Factors for Sternal Wound Infection After Open Heart Operations Vary According to Type of Operation

BACKGROUND This study evaluated whether risk factors for sternal wound infections vary with the type of surgical procedure in cardiac operations. METHODS This was a university hospital surveillance study of 3,249 consecutive patients (28% women) from 2006 to 2010 (median age, 69 years [interquartile range, 60 to 76]; median additive European System for Cardiac Operative Risk Evaluation score, 5 [interquartile range, 3 to 8]) after (1) isolated coronary artery bypass grafting (CABG), (2) isolated valve repair or replacement, or (3) combined valve procedures and CABG. All other operations were excluded. Univariate and multivariate binary logistic regression were conducted to identify independent predictors for development of sternal wound infections. RESULTS We detected 122 sternal wound infections (3.8%) in 3,249 patients: 74 of 1,857 patients (4.0%) after CABG, 19 of 799 (2.4%) after valve operations, and 29 of 593 (4.9%) after combined procedures. In CABG patients, bilateral internal thoracic artery harvest, procedural duration exceeding 300 minutes, diabetes, obesity, chronic obstructive pulmonary disease, and female sex (model 1) were independent predictors for sternal wound infection. A second model (model 2), using the European System for Cardiac Operative Risk Evaluation, revealed bilateral internal thoracic artery harvest, diabetes, obesity, and the second and third quartiles of the European System for Cardiac Operative Risk Evaluation were independent predictors. In valve patients, model 1 showed only revision for bleeding as an independent predictor for sternal infection, and model 2 yielded both revision for bleeding and diabetes. For combined valve and CABG operations, both regression models demonstrated revision for bleeding and duration of operation exceeding 300 minutes were independent predictors for sternal infection. CONCLUSIONS Risk factors for sternal wound infections after cardiac operations vary with the type of surgical procedure. In patients undergoing valve operations or combined operations, procedure-related risk factors (revision for bleeding, duration of operation) independently predict infection. In patients undergoing CABG, not only procedure-related risk factors but also bilateral internal thoracic artery harvest and patient characteristics (diabetes, chronic obstructive pulmonary disease, obesity, female sex) are predictive of sternal wound infection. Preventive interventions may be justified according to the type of operation.

Economic evaluation of latent tuberculosis infection screening among health care workers in Houston

Since interferon-gamma release assays (IGRAs) were introduced in the 2000's, tuberculin skin testing (TST) and IGRAs have been used in various latent tuberculosis infection (LTBI) screening settings. IGRAs are laboratory-based tests and are considered not to be affected by previous Bacille de Calmette et Guérin (BCG) vaccination; however, they are more costly when compared directly with TST, which does not require specimen processing in a laboratory. This study aimed to examine TST and two types of IGRAs, QuantiFERON-TB Gold in Tube (QFT-GIT) and T-SPOT. TB (TSPOT), from an economic viewpoint. Firstly, a systematic literature review was conducted to identify cost related analyses of LTBI screening. Secondly, specific cost information detailing each test's items and labor was collected from an LTBI screening program of health care workers in Houston, and the cost of each test was computed. Thirdly, using the computed cost estimate of each test, cost-effectiveness analyses were conducted to compare TST and IGRAs.^ A literature search showed that a limited number of studies have been conducted, but the IGRA's economic advantages were common among studies. Cost analyses showed that IGRAs were much more costly than TST. The results were consistent with previous studies. In cost-effectiveness analyses, where test cost and consequential TB-related cost were considered, IGRAs showed variable advantages over TST depending on the targeted population. When only non BCG-vaccinated people were considered, TST was the least costly option among the three tests. On the other hand, when only BCG-vaccinated people were considered, IGRAs were less costly options. These results were mostly consistent even with varying assumption parameters.^ IGRAs can be more costly than TST, but their economic disadvantages are alleviated when the target population was BCG-vaccinated. Based on current knowledge, IGRAs may be recommended in a population where the BCG history is mixed. Additional studies are needed to better understand IGRA's reliability among low-incidence and low-risk populations in which background TB prevalence is low.^

MOIRA-PLUS use in decision making on the long-term management of contaminated freshwater bodies and catchments

In the mid-long-term after a nuclear accident, the contamination of drinking water sources, fish and other aquatic foodstuffs, irrigation supplies and people?s exposure during recreational activities may create considerable public concern, even though dose assessment may in certain situations indicate lesser importance than for other sources, as clearly experienced in the aftermath of past accidents. In such circumstances there are a number of available countermeasure options, ranging from specific chemical treatment of lakes to bans on fish ingestion or on the use of water for crop irrigation. The potential actions can be broadly grouped into four main categories, chemical, biological, physical and social. In some cases a combination of actions may be the optimal strategy and a decision support system (DSS) like MOIRA-PLUS can be of great help to optimise a decision. A further option is of course not to take any remedial actions, although this may also have significant socio-economic repercussions which should be adequately evaluated. MOIRA-PLUS is designed to allow for a reliable assessment of the long-term evolution of the radiological situation and of feasible alternative rehabilitation strategies, including an objective evaluation of their social, economic and ecological impacts in a rational and comprehensive manner. MOIRA-PLUS also features a decision analysis methodology, making use of multi-attribute analysis, which can take into account the preferences and needs of different types of stakeholders. The main functions and elements of the system are described summarily. Also the conclusions from end-user?s experiences with the system are discussed, including exercises involving the organizations responsible for emergency management and the affected services, as well as different local and regional stakeholders. MOIRAPLUS has proven to be a mature system, user friendly and relatively easy to set up. It can help to better decisionmaking by enabling a realistic evaluation of the complete impacts of possible recovery strategies. Also, the interaction with stakeholders has allowed identifying improvements of the system that have been recently implemented.

Systematic Approach for the selection of monitoring technologies in CO2 geological storage projects. Application of multicriteria decision making

Geologic storage of carbon dioxide (CO2) has been proposed as a viable means for reducing anthropogenic CO2 emissions. Once injection begins, a program for measurement, monitoring, and verification (MMV) of CO2 distribution is required in order to: a) research key features, effects and processes needed for risk assessment; b) manage the injection process; c) delineate and identify leakage risk and surface escape; d) provide early warnings of failure near the reservoir; and f) verify storage for accounting and crediting. The selection of the methodology of monitoring (characterization of site and control and verification in the post-injection phase) is influenced by economic and technological variables. Multiple Criteria Decision Making (MCDM) refers to a methodology developed for making decisions in the presence of multiple criteria. MCDM as a discipline has only a relatively short history of 40 years, and it has been closely related to advancements on computer technology. Evaluation methods and multicriteria decisions include the selection of a set of feasible alternatives, the simultaneous optimization of several objective functions, and a decision-making process and evaluation procedures that must be rational and consistent. The application of a mathematical model of decision-making will help to find the best solution, establishing the mechanisms to facilitate the management of information generated by number of disciplines of knowledge. Those problems in which decision alternatives are finite are called Discrete Multicriteria Decision problems. Such problems are most common in reality and this case scenario will be applied in solving the problem of site selection for storing CO2. Discrete MCDM is used to assess and decide on issues that by nature or design support a finite number of alternative solutions. Recently, Multicriteria Decision Analysis has been applied to hierarchy policy incentives for CCS, to assess the role of CCS, and to select potential areas which could be suitable to store. For those reasons, MCDM have been considered in the monitoring phase of CO2 storage, in order to select suitable technologies which could be techno-economical viable. In this paper, we identify techniques of gas measurements in subsurface which are currently applying in the phase of characterization (pre-injection); MCDM will help decision-makers to hierarchy the most suitable technique which fit the purpose to monitor the specific physic-chemical parameter.

Participatory modelling to support decision making in water management under uncertainty: Two comparative case studies in the Guadiana river basin, Spain.

A participatory modelling process has been conducted in two areas of the Guadiana river (the upper and the middle sub-basins), in Spain, with the aim of providing support for decision making in the water management field. The area has a semi-arid climate where irrigated agriculture plays a key role in the economic development of the region and accounts for around 90% of water use. Following the guidelines of the European Water Framework Directive, we promote stakeholder involvement in water management with the aim to achieve an improved understanding of the water system and to encourage the exchange of knowledge and views between stakeholders in order to help building a shared vision of the system. At the same time, the resulting models, which integrate the different sectors and views, provide some insight of the impacts that different management options and possible future scenarios could have. The methodology is based on a Bayesian network combined with an economic model and, in the middle Guadiana sub-basin, with a crop model. The resulting integrated modelling framework is used to simulate possible water policy, market and climate scenarios to find out the impacts of those scenarios on farm income and on the environment. At the end of the modelling process, an evaluation questionnaire was filled by participants in both sub-basins. Results show that this type of processes are found very helpful by stakeholders to improve the system understanding, to understand each others views and to reduce conflict when it exists. In addition, they found the model an extremely useful tool to support management. The graphical interface, the quantitative output and the explicit representation of uncertainty helped stakeholders to better understand the implications of the scenario tested. Finally, the combination of different types of models was also found very useful, as it allowed exploring in detail specific aspects of the water management problems.

Del plan a la realidad: gobernanza y toma de decisiones en los procesos de regeneración urbana. El caso de Boston = From plan to reality: governance and decision-making in urban regeneration processes in Boston

En las últimas tres décadas, las dinámicas de restructuración económica a nivel global han redefinido radicalmente el papel de las ciudades. La transición del keynesianismo al neoliberalismo ha provocado un cambio en las políticas urbanas de los gobiernos municipales, que han abandonado progresivamente las tareas de regulación y redistribución para centrarse en la promoción del crecimiento económico y la competitividad. En este contexto, muchas voces críticas han señalado que la regeneración urbana se ha convertido en un vehículo de extracción de valor de la ciudad y está provocando la expulsión de los ciudadanos más vulnerables. Sin embargo, la regeneración de áreas consolidadas supone también una oportunidad de mejora de las condiciones de vida de la población residente, y es una política necesaria para controlar la expansión de la ciudad y reducir las necesidades de desplazamiento, promoviendo así ciudades más sostenibles. Partiendo de la hipótesis de que la gobernanza de los procesos de regeneración urbana es clave en el resultado final de las operaciones y determina el modelo de ciudad resultante, el objetivo de esta investigación es verificar si la regeneración urbana es necesariamente un mecanismo de extracción de valor o si puede mejorar la calidad de vida en las ciudades a través de la participación de los ciudadanos. Para ello, propone un marco de análisis del proceso de toma de decisiones en los planes de regeneración urbana y su impacto en los resultados de los planes, tomando como caso de estudio la ciudad de Boston, que desde los años 1990 trata de convertirse en una “ciudad de los barrios”, fomentando la participación ciudadana al tiempo que se posiciona en la escena económica global. El análisis se centra en dos operaciones de regeneración iniciadas a finales de los años 1990. Por un lado, el caso de Jackson Square nos permite comprender el papel de la sociedad civil y el tercer sector en la regeneración de los barrios más desfavorecidos, en un claro ejemplo de urbanismo “desde abajo” (bottom-up planning). Por otro, la reconversión del frente marítimo de South Boston para la construcción del Distrito de Innovación nos acerca a las grandes operaciones de regeneración urbana con fines de estímulo económico, tradicionalmente vinculadas a los centros financieros (downtown) y dirigidas por las élites gubernamentales y económicas (la growth machine) a través de procesos más tecnocráticos (top-down planning). La metodología utilizada consiste en el análisis cualitativo de los procesos de toma de decisiones y la relación entre los agentes implicados, así como de la evaluación de la implementación de dichas decisiones y su influencia en el modelo urbano resultante. El análisis de los casos permite afirmar que la gobernanza de los procesos de regeneración urbana influye decisivamente en el resultado final de las intervenciones; sin embargo, la participación de la comunidad local en la toma de decisiones no es suficiente para que el resultado de la regeneración urbana contrarreste los efectos de la neoliberalización, especialmente si se limita a la fase de planeamiento y no se extiende a la fase de ejecución, y si no está apoyada por una movilización política de mayor alcance que asegure una acción pública redistributiva. Asimismo, puede afirmarse que los procesos de regeneración urbana suponen una redefinición del modelo de ciudad, dado que la elección de los espacios de intervención tiene consecuencias sobre el equilibrio territorial de la ciudad. Los resultados de esta investigación tienen implicaciones para la disciplina del planeamiento urbano. Por una parte, se confirma la vigencia del paradigma del “urbanismo negociado”, si bien bajo discursos de liderazgo público y sin apelación al protagonismo del sector privado. Por otra parte, la planificación colaborativa en un contexto de “responsabilización” de las organizaciones comunitarias puede desactivar la potencia política de la participación ciudadana y servir como “amortiguador” hacia el gobierno local. Asimismo, la sustitución del planeamiento general como instrumento de definición de la ciudad futura por una planificación oportunista basada en la actuación en áreas estratégicas que tiren del resto de la ciudad, no permite definir un modelo coherente y consensuado de la ciudad que se desea colectivamente, ni permite utilizar el planeamiento como mecanismo de redistribución. ABSTRACT In the past three decades, the dynamics of global economic restructuring have radically redefined the role of cities. The transition from keynesianism to neoliberalism has caused a shift in local governments’ urban policies, which have progressively abandoned the tasks of regulation and redistribution to focus on promoting economic growth and competitiveness. In this context, many critics have pointed out that urban regeneration has become a vehicle for extracting value from the city and is causing the expulsion of the most vulnerable citizens. However, regeneration of consolidated areas is also an opportunity to improve the living conditions of the resident population, and is a necessary policy to control the expansion of the city and reduce the need for transportation, thus promoting more sustainable cities. Assuming that the governance of urban regeneration processes is key to the final outcome of the plans and determines the resulting city model, the goal of this research is to verify whether urban regeneration is necessarily a value extraction mechanism or if it can improve the quality of life in cities through citizens’ participation. It proposes a framework for analysis of decision-making in urban regeneration processes and their impact on the results of the plans, taking as a case study the city of Boston, which since the 1990s is trying to become a "city of neighborhoods", encouraging citizen participation, while seeking to position itself in the global economic scene. The analysis focuses on two redevelopment plans initiated in the late 1990s. The Jackson Square case allows us to understand the role of civil society and the third sector in the regeneration of disadvantaged neighborhoods, in a clear example of bottom-up planning. On the contrary, the conversion of the South Boston waterfront to build the Innovation District takes us to the big redevelopment efforts with economic stimulus’ goals, traditionally linked to downtowns and led by government and economic elites (the local “growth machine”) through more technocratic processes (top-down planning). The research is based on a qualitative analysis of the processes of decision making and the relationship between those involved, as well as the evaluation of the implementation of those decisions and their influence on the resulting urban model. The analysis suggests that the governance of urban regeneration processes decisively influences the outcome of interventions; however, community engagement in the decision-making process is not enough for the result of the urban regeneration to counteract the effects of neoliberalization, especially if it is limited to the planning phase and does not extend to the implementation of the projects, and if it is not supported by a broader political mobilization to ensure a redistributive public action. Moreover, urban regeneration processes redefine the urban model, since the choice of intervention areas has important consequences for the territorial balance of the city. The results of this study have implications for the discipline of urban planning. On the one hand, it confirms the validity of the "negotiated planning" paradigm, albeit under public leadership discourse and without a direct appeal to the leadership role of the private sector. On the other hand, collaborative planning in a context of "responsibilization" of community based organizations can deactivate the political power of citizen participation and serve as a "buffer" towards the local government. Furthermore, the replacement of comprehensive planning, as a tool for defining the city's future, by an opportunistic planning based on intervention in strategic areas that are supposed to induce change in the rest of the city, does not allow a coherent and consensual urban model that is collectively desired, nor it allows to use planning as a redistribution mechanism.