Economic analysis in health care regulation : three essays

ABSTRACT - It is the purpose of the present thesis to emphasize, through a series of examples, the need and value of appropriate pre-analysis of the impact of health care regulation. Specifically, the thesis presents three papers on the theme of regulation in different aspects of health care provision and financing. The first two consist of economic analyses of the impact of health care regulation and the third comprises the creation of an instrument for supporting economic analysis of health care regulation, namely in the field of evaluation of health care programs. The first paper develops a model of health plan competition and pricing in order to understand the dynamics of health plan entry and exit in the presence of switching costs and alternative health premium payment systems. We build an explicit model of death spirals, in which profitmaximizing competing health plans find it optimal to adopt a pattern of increasing relative prices culminating in health plan exit. We find the steady-state numerical solution for the price sequence and the plan’s optimal length of life through simulation and do some comparative statics. This allows us to show that using risk adjusted premiums and imposing price floors are effective at reducing death spirals and switching costs, while having employees pay a fixed share of the premium enhances death spirals and increases switching costs. Price regulation of pharmaceuticals is one of the cost control measures adopted by the Portuguese government, as in many European countries. When such regulation decreases the products’ real price over time, it may create an incentive for product turnover. Using panel data for the period of 1997 through 2003 on drug packages sold in Portuguese pharmacies, the second paper addresses the question of whether price control policies create an incentive for product withdrawal. Our work builds the product survival literature by accounting for unobservable product characteristics and heterogeneity among consumers when constructing quality, price control and competition indexes. These indexes are then used as covariates in a Cox proportional hazard model. We find that, indeed, price control measures increase the probability of exit, and that such effect is not verified in OTC market where no such price regulation measures exist. We also find quality to have a significant positive impact on product survival. In the third paper, we develop a microsimulation discrete events model (MSDEM) for costeffectiveness analysis of Human Immunodeficiency Virus treatment, simulating individual paths from antiretroviral therapy (ART) initiation to death. Four driving forces determine the course of events: CD4+ cell count, viral load resistance and adherence. A novel feature of the model with respect to the previous MSDEMs is that distributions of time to event depend on individuals’ characteristics and past history. Time to event was modeled using parametric survival analysis. Events modeled include: viral suppression, regimen switch due virological failure, regimen switch due to other reasons, resistance development, hospitalization, AIDS events, and death. Disease progression is structured according to therapy lines and the model is parameterized with cohort Portuguese observational data. An application of the model is presented comparing the cost-effectiveness ART initiation with two nucleoside analogue reverse transcriptase inhibitors (NRTI) plus one non-nucleoside reverse transcriptase inhibitor(NNRTI) to two NRTI plus boosted protease inhibitor (PI/r) in HIV- 1 infected individuals. We find 2NRTI+NNRTI to be a dominant strategy. Results predicted by the model reproduce those of the data used for parameterization and are in line with those published in the literature.

Old cellulose for new multifunctional networks

Dissertação para obtenção do Grau de Doutor em Ciência e Engenharia de Materiais

Safe reuse of treated urban wastewater in Praia, Cape Verde: a case study

Dissertação para a obtenção do Grau de Mestre em Engenharia e Gestão da Água

Analysis of urban land use and land cover changes: a case of study in Bahir Dar, Ethiopia

Dissertation submitted in partial fulfillment of the requirements for the Degree of Master of Science in Geospatial Technologies

Influence of Lean and Green on supply chain performance: an interpretive structural modelling model

This work aims to identify and rank a set of Lean and Green practices and supply chain performance measures on which managers should focus to achieve competitiveness and improve the performance of automotive supply chains. The identification of the contextual relationships among the suggested practices and measures, was performed through literature review. Their ranking was done by interviews with professionals from the automotive industry and academics with wide knowledge on the subject. The methodology of interpretive structural modelling (ISM) is a useful methodology to identify inter relationships among Lean and Green practices and supply chain performance measures and to support the evaluation of automotive supply chain performance. Using the ISM methodology, the variables under study were clustered according to their driving power and dependence power. The ISM methodology was proposed to be used in this work. The model intends to provide a better understanding of the variables that have more influence (driving variables), the others and those which are most influenced (dependent variables) by others. The information provided by this model is strategic for managers who can use it to identify which variables they should focus on in order to have competitive supply chains.

Digital microfluidic devices: the role of the dielectric layer

Digital microfluidics (DMF) is a field which has emerged in the last decade as a re-liable and versatile tool for sensing applications based on liquid reactions. DMF allows the discrete displacement of droplets, over an array of electrodes, by the application of voltage, and also the dispensing from a reservoir, mixing, merging and splitting fluidic operations. The main drawback of these devices is due to the need of high driving volt-ages for droplet operations. In this work, alternative dielectric layers combinations were studied aiming the reduction of these driving voltages. DMF chips were designed, pro-duced and optimized according to the theory of electrowetting-on-dielectric, adopting different combinations of parylene-C and tantalum pentoxide (Ta2O5) as dielectric ma-terials, and Teflon as hydrophobic layer. With both devices’ configurations, i.e., Parylene as single dielectric, and multilayer chips combining Parylene and Ta2O5, it was possible to perform all the fluidic opera-tions in the microliter down to hundreds of nanoliters range. Multilayer chips presented significant reduction on driving voltages for droplet op-erations in silicone oil filler medium: from 70 V (parylene only) down to 30 V (parylene/Ta2O5) for dispensing; and from 50 V (parylene only) down to 15 V (parylene/Ta2O5) for movement. Peroxidase colorimetric reactions were successfully performed as proof-of-concept, using multilayer configuration devices.

Fatores de risco auto reportados associados aos acidentes rodoviários : um estudo sobre os condutores portugueses de veículos ligeiros

RESUMO - Objetivos: Anualmente morrem cerca de 1,3 milhões de pessoas, a nível mundial, devido aos acidentes de viação. Também mais de 20 milhões de pessoas sofrem ferimentos ligeiros ou graves devido aos acidentes de viação que resultam em incapacidade temporária ou permanente. Desta forma, consideram-se os acidentes de viação, um grave problema de saúde pública, com custos elevados para as sociedades afetando a saúde das populações e economias de cada país. Este estudo pretendeu descrever e caracterizar os condutores de veículos ligeiros, residentes em Portugal Continental, abrangendo características sociodemográficas, experiência de condução e questões relativas a atitudes, opiniões e comportamentos. Por outro lado procurou-se analisar a associação entre as opiniões, atitudes e comportamentos, auto reportados e a ocorrência de um acidente de viação nos últimos três anos a fim de construir um modelo final preditivo do risco de sofrer um acidente de viação. Método: Foi realizado um estudo observacional analítico transversal baseado num questionário traduzido para a língua portuguesa e com origem no projeto europeu SARTRE 4. A população-alvo foram todos os condutores de veículos ligeiros possuidores de uma licença de condução e residentes em Portugal Continental, baseado numa amostra de igual dimensão à definida no estudo europeu SARTRE 4 (600 condutores de veículos ligeiros). Das 52 perguntas existentes, selecionaram-se pela análise de componentes principais (ACP) variáveis potencialmente independentes e complementares para as componentes opiniões, atitudes e comportamentos. Para além das medidas descritivas usuais, recorreu-se à regressão logística binária para analisar associações e obter um modelo que permitisse estimar a probabilidade de sofrer um acidente rodoviário em função das variáveis selecionadas referentes às opiniões, atitudes e comportamentos auto reportados. Resultados: Dos 612 condutores inquiridos, 62,7% (383) responderam não ter sofrido nenhum acidente de viação nos últimos três anos enquanto 37,3% (228) respondeu ter estado envolvido em pelo menos um acidente de viação com danos materiais ou feridos, no mesmo período. De uma forma geral, o típico condutor que referiu ter sofrido um acidente nos últimos três anos é homem com mais de 65 anos de idade, com o 1º ensino básico, viúvo e sem filhos, não empregado e reside numa área urbana. Os condutores residentes numa área suburbana apresentaram um risco 5,368 mais elevado de sofrer um acidente de viação em relação aos condutores que habitam numa zona rural (IC 95%: 2,344-12,297; p<0,001). Os condutores que foram apenas submetidos uma vez a um controlo de álcool, nos últimos três anos, durante o exercício da condução apresentaram um risco 3,009 superior de sofrer um acidente de viação em relação aos condutores que nunca foram fiscalizados pela polícia (IC 95%: 1,949-4,647, p<0,001). Os condutores que referiram muito frequentemente parar para dormir quando se sentem cansados a conduzir têm uma probabilidade inferior de 81% de sofrer um acidente de viação em relação aos condutores que nunca o fazem (IC 95%: 0,058-0,620; p=0,006). Os condutores que quando cansados raramente bebem um café/bebida energética têm um risco de 4,829 superior de sofrer um acidente de viação do que os condutores que sempre o referiram fazer (IC 95%:1,807-12,903; p=0,002). Conclusões: Os resultados obtidos em relação aos fatores comportamentais vão ao encontro da maioria dos fatores de risco associados aos acidentes de viação referidos na literatura. Ainda assim, foram identificadas novas associações entre o risco de sofrer um acidente e as opiniões e as atitudes auto reportadas que através de estudos de maiores dimensões populacionais poderão vir a ser mais exploradas. Este trabalho vem reforçar a necessidade urgente de novas estratégias de intervenção, principalmente na componente comportamental, direcionadas aos grupos de risco, mantendo as existentes.

Self-initiation expatriation: A focus on Italian and Portuguese students

The purpose of this work project is to analyze the phenomenon of self-initiated expatriation (SIE) through its link to the Protean Career and Career Capital theories, focusing in particular on Italian and Portuguese students attending a Master in the business area. The main research questions are to understand the reasons driving the intention to expatriate, after the conclusion of the academic path, using three main categories (Adventure Motivation, Work Characteristic Motivation and instrumental Motivation) and the intention to repatriate. A sample of Italian and Portuguese students was obtained. Italians show a higher intention to expatriate relative to Portuguese; nevertheless, no other significant differences were found among the two populations, because of the similar cultural background and economic situation. Additionally, several heterogeneities were observed considering other clusters defined by Gender, Teaching Language of the Master and Past International Experiences, across the two nationalities. Furthermore, possible future researches and practical implications were discussed.

The role of income inequality on fiscal multipliers

A Work Project, presented as part of the requirements for the Award of a Masters Double Degree in Economics from the Nova School of Business and Economics and University of Maastricht

Process virtualization theory (PVT) and institutional theory (INT) to explain SAAS adoption

Software as a service (SaaS) is a service model in which the applications are accessible from various client devices through internet. Several studies report possible factors driving the adoption of SaaS but none have considered the perception of the SaaS features and the pressures existing in the organization’s environment. We propose an integrated research model that combines the process virtualization theory (PVT) and the institutional theory (INT). PVT seeks to explain whether SaaS processes are suitable for migration into virtual environments via an information technology-based mechanism. INT seeks to explain the effects of the institutionalized environment on the structure and actions of the organization. The research makes three contributions. First, it addresses a gap in the SaaS adoption literature by studying the internal perception of the technical features of SaaS and external coercive, normative, and mimetic pressures faced by an organization. Second, it empirically tests many of the propositions of PVT and INT in the SaaS context, thereby helping to determine how the theory operates in practice. Third, the integration of PVT and INT contributes to the information system (IS) discipline, deepening the applicability and strengths of these theories.

Customer relationship management at Siemens Healthcare – a diagnosis and proposal for strategy and market segmentation

Towards a holistic perspective of CRM, this project aims to diagnose and propose a strategy and market segmentation for Siemens Healthcare. The main underlying principle is to apply a full customer-centric outlook taking own business properties into consideration while preserving Siemens Healthcare’s culture and vision. Mainly focused on market segmentation, this project goes beyond established boundaries by employing an unbiased perspective of CRM while challenging current strategy, goals, processes, tools, initiatives and KPIs. In order to promote a sustainable business excellence strategy, this project aspires to streamline CRM strategic importance and driving the company one step forward.

Factors that determine the level of care children and adolescents experiencing mental disorders receive

RESUMO: Resumo Uma prestação de serviços de saúde mental para crianças e adolescentes (CAMHS) oportuna, eficaz e baseada na evidência pode evitar incapacidade a longo prazo. No entanto, estes serviços são criticamente sub-financiados em todo o mundo. É um imperativo garantir que este precioso recurso não seja desperdiçado. Os governos e outras partes interessadas relevantes na área da saúde mental precisam de conhecer o estado de saúde mental da população, quais os recursos disponíveis e como melhor utilizar os recursos disponíveis para orientar uma política e decisões efectivas sobre os níveis de serviços. Objetivo: O objetivo deste artigo é explorar o papel da acuidade, gravidade e complexidade na determinação dos cuidados em saúde mental especializados recebidos por crianças e adolescentes que sofrem perturbações mentais. Métodos: Este estudo é exploratório envolvendo uma revisão sistemática da literatura. Foi realizada uma pesquisa com palavras-chave utilizando bases de dados PsychINFO, EMBASE, PubMed e MEDLINE. A literatura cinzenta também foi investigada com um enfoque nas abordagens sistémicas, organizacionais e políticas para a organização e comissionamento de CAMHS. Foram selecionados apenas documentos escritos em Inglês. Três países, Bélgica, Reino Unido e Estados Unidos, todos eles com modelos muito diferentes de organização de CAMHS, foram revistos para investigar de que forma os conceitos de acuidade, gravidade e complexidade foram utilizados na sua concepção de serviços para determinar o nível da assistência prestada. Resultados: Nem a Bélgica, nem o modelo norte-americano de CAMHS organização de serviço parecem estar alinhados com os principais conceitos na determinação do nível de prestação de serviços. O sistema de serviços do Reino Unido de CAMHS está mais estreitamente alinhado com esses conceitos e tem uma alocação de recursos mais equilibrada entre o hospital e a comunidade. O seu ponto fraco está na falta de flexibilidade entre os níveis de serviço e na falta de apoio para com o sector dos cuidados de saúde primários. Conclusões: A variabilidade na alocação de recursos a diferentes níveis especializados de CAMHS (em regime de internamento, ambulatório, e na comunidade) e o modelo diferente de estrutura de serviços entre os países estudados indica uma inconsistência na forma como as crianças e adolescentes que apresentam aos CAMHS são referenciados para os cuidados que recebem. Isto põe em questão se as crianças e adolescentes com perturbações mentais estão a receber o nível e tipo de cuidados concordantes com as suas necessidades. A concepção e o comissionamento de sistemas de CAMHS levam-nos à discussão de uma série de princípios fundamentais que devem ser considerados. O sistema perfeito no entanto, ainda está para ser encontrado. -------------------------------- ABSTRACT: Provision of timely, effective, evidence based mental health services to children and adolescents can prevent long term impairment, but they are critically underfunded across the globe. There is an imperative to ensure this precious resource is not wasted. Governments and other relevant mental health stakeholders need to know the mental health status of the population, what resources are available and how best to use the resources available to guide effective policy and decisions about service levels. Aim: The aim of this paper is to explore the role of acuity, severity and complexity in determining the specialist mental health care that children and adolescents experiencing mental disorders receive. Methods: This study is exploratory involving a systematic scan of the literature. A key word search was conducted using databases PSYCHINFO, EMBASE, PUBMED and MEDLINE. Grey literature was also searched to focus on systemic, organisational and policy approaches to the organisation and commissioning of CAMHS. Only documents written in English were selected. Three countries Belgium, UK and the US all with very different models of service organisation for CAMHS were reviewed to investigate how well the concepts of acuity, severity and complexity were used to determine the level of care delivered in their service design. Findings: Neither the Belgium nor the US model of CAMHS service organisation appear to align with the key concepts driving intensity of level of service provision. The UK CAMHS service system most closely aligns with the concepts. It has a more balanced resource allocation between hospital and community. Its downfall is in its lack of flexibility between service levels and its lack of support for the primary care sector. Conclusions: The variability in resource allocation to different service levels (inpatient, outpatient, community) within specialist CAMHS and the differing model of service structure across countries indicates an inconsistency in how children and adolescents presenting to CAMHS are allocated to the care they receive. This puts into question whether children and adolescent with mental disorders are receiving a level and type of care commensurate with their needs. In commissioning and designing CAMHS systems a number of key principles that should be considered are discussed. The perfect system however, is yet to be found.

Low coronary perfusion pressure is associated with endocardial fibrosis in a rat model of volume overload cardiac hypertrophy

Left ventricular hypertrophy following volume overload is regarded as an example of cardiac remodeling without increased fibrosis accumulation. However, infarction is associated with increased fibrosis within the noninfarcted, hypertrophied myocardium, particularly in the subendocardial regions. It is conceivable to suppose that, as also occurs postinfarction, low coronary driving pressure may also interfere with accumulation of myocardial fibrosis following aortocaval fistula. PURPOSE: To investigate the role of acute hemodynamic changes in subsequent deposition of cardiac fibrosis in response to aortocaval fistula. METHOD: Aortocaval fistula were created in 4 groups of Wistar rats that were followed over 4 and 8 weeks: aortocaval fistula 4 and aortocaval fistula 8 (10 rats each) and their respective controls (sham-operated controls - Sh), Sh4 and Sh8 (8 rats each). Hemodynamic measurements were performed 1 week after surgery. Hypertrophy and fibrosis were quantified by myocyte diameter and collagen volume fraction at the end of follow up. RESULT: Compared with Sh4 and Sh8, pulse pressure, left ventricular end-diastolic pressure, and +dP/dt were higher in aortocaval fistula 4 and aortocaval fistula 8, but -dP/dt was similar. Coronary driving pressure (mm Hg), used as an estimate of perfusion pressure, was lower in aortocaval fistula 8 (52.6 ± 4.1) than in Sh8 (100.8 ± 1.3), but comparable between aortocaval fistula 4 (50.0 ± 8.9) and Sh4 (84.8 ± 2.3). Myocyte diameter was greater in aortocaval fistula 8, whereas interstitial and subendocardial fibrosis were greater in aortocaval fistula 4 and aortocaval fistula 8. Coronary driving pressure correlated inversely and independently with subendocardial fibrosis (r² = .86, P <.001), whereas left ventricular systolic pressure (r² = 0.73, P = .004) and end-diastolic pressure (r² = 0.55, P = 012) correlated positively and independently with interstitial fibrosis. CONCLUSION: Coronary driving pressure falls and ventricular pressures increase early after aortocaval fistula and are associated with subsequent myocardial fibrosis deposition.

O gosto como fator motivacional nos primeiros anos de estudo de violino

Relatório de estágio de mestrado em Ensino de Música

Dynamic range prediction for an electric vehicle

Electric Vehicles (EVs) have limited energy storage capacity and the maximum autonomy range is strongly dependent of the driver's behaviour. Due to the fact of that batteries cannot be recharged quickly during a journey, it is essential that a precise range prediction is available to the driver of the EV. With this information, it is possible to check if the desirable destination is achievable without a stop to charge the batteries, or even, if to reach the destination it is necessary to perform an optimized driving (e.g., cutting the air-conditioning, among others EV parameters). The outcome of this research work is the development of an Electric Vehicle Assistant (EVA). This is an application for mobile devices that will help users to take efficient decisions about route planning, charging management and energy efficiency. Therefore, it will contribute to foster EVs adoption as a new paradigm in the transportation sector.