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.

Demokratie, good governance und Entwicklung: Eine quantitative Analyse für 191 Staaten im Zeitraum 1996 bis 2005

Das Jahr 1989 markiert nicht nur den Beginn entscheidender geopolitischer Veränderungen, sondern gleichzeitig den Ursprung eines bedeutsamen Wandels in der internationalen Entwicklungszusammenarbeit. Mit der viel beachteten Studie ‚Sub-Saharan Africa – From Crisis to Sustainable Growth’ initiierte die Weltbank eine Debatte über die Relevanz institutioneller Faktoren für wirtschaftliche Entwicklung, die in den folgenden Jahren unter dem Titel ‚Good Governance’ erhebliche Bedeutung erlangte. Nahezu alle zentralen Akteure begannen, entsprechende Aspekte in ihrer praktischen Arbeit zu berücksichtigen, und entwickelten eigene Konzepte zu dieser Thematik. Wenn auch mit der Konzentration auf Institutionen als Entwicklungsdeterminanten eine grundlegende Gemeinsamkeit der Ansätze festzustellen ist, unterscheiden sie sich jedoch erheblich im Hinblick auf die Einbeziehung politischer Faktoren, so dass von einem einheitlichen Verständnis von ‚Good Governance’ nicht gesprochen werden kann. Während die meisten bilateralen Akteure sowie DAC und UNDP Demokratie und Menschenrechte explizit als zentrale Bestandteile betrachten, identifiziert die Weltbank einen Kern von Good Governance, der unabhängig von der Herrschaftsform, also sowohl in Demokratien wie auch in Autokratien, verwirklicht werden kann. Die Implikationen dieser Feststellung sind weit reichend. Zunächst erlaubt erst diese Sichtweise der Bank überhaupt, entsprechende Aspekte aufzugreifen, da ihr eine Berücksichtigung politischer Faktoren durch ihre Statuten verboten ist. Bedeutsamer ist allerdings, dass die Behauptung der Trennbarkeit von Good Governance und der Form politischer Herrschaft die Möglichkeit eröffnet, Entwicklung zu erreichen ohne eine demokratische Ordnung zu etablieren, da folglich autokratische Systeme in gleicher Weise wie Demokratien in der Lage sind, die institutionellen Voraussetzungen zu verwirklichen, welche als zentrale Determinanten für wirtschaftlichen Fortschritt identifiziert wurden. Damit entfällt nicht nur ein bedeutsamer Rechtfertigungsgrund für demokratische Herrschaft als solche, sondern rekurrierend auf bestimmte, dieser zu attestierende, entwicklungshemmende Charakteristika können Autokratien nun möglicherweise als überlegene Herrschaftsform verstanden werden, da sie durch jene nicht gekennzeichnet sind. Die Schlussfolgerungen der Weltbank unterstützen somit auch die vor allem im Zusammenhang mit der Erfolgsgeschichte der ostasiatischen Tigerstaaten vertretene Idee der Entwicklungsdiktatur, die heute mit dem Aufstieg der Volksrepublik China eine Renaissance erlebt. Der wirtschaftliche Erfolg dieser Staaten ist danach auf die überlegene Handlungsfähigkeit autokratischer Systeme zurückzuführen, während Demokratien aufgrund der Verantwortlichkeitsbeziehungen zwischen Regierenden und Regierten nicht in der Lage sind, die notwendigen Entscheidungen zu treffen und durchzusetzen. Die dargestellte Sichtweise der Weltbank ist allerdings von verschiedenen Autoren in Zweifel gezogen worden, die auch für ein im Wesentlichen auf technische Elemente beschränktes Good Governance-Konzept einen Zusammenhang mit der Form politischer Herrschaft erkennen. So wird beispielsweise vertreten, das Konzept der Bank bewege sich ausdrücklich nicht in einem systemneutralen Vakuum, sondern propagiere zumindest implizit die Etablierung demokratischer Regierungsformen. Im Übrigen steht die aus den Annahmen der Weltbank neuerlich abgeleitete Idee der Entwicklungsdiktatur in einem erheblichen Widerspruch zu der von multilateralen wie bilateralen Akteuren verstärkt verfolgten Förderung demokratischer Herrschaft als Mittel für wirtschaftliche Entwicklung sowie der fortschreitenden Verbreitung der Demokratie. Besteht nun doch ein Einfluss der Herrschaftsform auf die Verwirklichung von Good Governance als zentraler Entwicklungsdeterminante und kann zudem davon ausgegangen werden, dass Demokratien diesbezüglich Vorteile besitzen, dann ist eine Entwicklungsdiktatur keine denkbare Möglichkeit, sondern im Gegenteil demokratische Herrschaft der gebotene Weg zu wirtschaftlichem Wachstum bzw. einer Verbesserung der Lebensverhältnisse. Aufgrund der mit den Schlussfolgerungen der Weltbank verbundenen bedeutsamen Implikationen und der bisher weitestgehend fehlenden ausführlichen Thematisierung dieses Gegenstands in der Literatur ist eine detaillierte theoretische Betrachtung der Zusammenhänge zwischen den zentralen Elementen von Good Governance und demokratischer Herrschaft notwendig. Darüber hinaus sollen die angesprochenen Beziehungen auch einer empirischen Analyse unterzogen werden. Gegenstand dieser Arbeit ist deshalb die Fragestellung, ob Good Governance eine von demokratischer Herrschaft theoretisch und empirisch unabhängige Entwicklungsstrategie darstellt.

Deviation from Murray's law is associated with a higher degree of calcification in coronary bifurcations

Murray's law describes the optimal branching anatomy of vascular bifurcations. If Murray's law is obeyed, shear stress is constant over the bifurcation. Associations between Murray's law and intravascular ultrasound (IVUS) assessed plaque composition near coronary bifurcations have not been investigated previously.

Testing strategies and follow-up for coeliac disease in a general internal medicine outpatient department from 2000 to 2005

PRINCIPLES: Coeliac disease (gluten sensitive enteropathy) is a genetically determined disorder with an incidence in the general population that is comparable to type 2 diabetes mellitus. Awareness of this fact and of the often atypical and oligosymptomatic manifestations is only now gaining ground in the medical profession. A high index of suspicion is important in order to minimise diagnostic and therapeutic delay. METHODS: Testing patterns and follow-up for coeliac disease in our institution have been analysed retrospectively for the past five years. The current literature was reviewed with respect to recommendations for clinical practice. RESULTS: A total of 271 patients were tested for coeliac disease over a period of five years. Only in 24 patients were positive results found; after further work-up, the final number of cases with certain or presumed coeliac disease was four. Followup was often difficult, many patients being lost after a single visit. CONCLUSIONS: This study showed that the number of tests ordered in our institution, more often for abdominal than atypical symptoms, has started to increase in the past two years. It also showed that screening tests have found their place in general clinical practice, while the final choice of tests needs to be determined in accordance with available guidelines and local resources. Upper endoscopy with small bowel biopsy remains the gold standard for diagnosis, but its place in follow-up is less certain. Coeliac disease is a disorder for which there is a definite treatment (gluten free diet); if it is left untreated diminished quality of life and potentially serious complications may ensue. Further education of the medical profession regarding coeliac disease, its incidence, presentation and treatment, is clearly indicated..

Echocardiographic screening of purebred cats: an overview from 2002 to 2005

During the last 3 years, a total of 144 cats underwent echocardiographic screening at two investigational clinics before being admitted for breeding. The number of cats presented for that purpose has constantly increased. 8.3% of cats were diagnosed as having hypertrophic cardiomyopathy and 6.9% were diagnosed as suspicious. Male cats were more affected than females (9.4% vs 7.7%). In 4.2 of all presented cats, a congenital cardiac malformation was recognised, most often tricuspid valve dysplasia.

Prevalence of heart disease in symptomatic cats: an overview from 1998 to 2005

A total of 408 cats with various cardiovascular problems has been presented to two investigational clinics during the last 8 years. The number of yearly examinations has steadily increased during this period. Definitive cardiovascular disease was diagnosed in 287 cats, whereby hypertrophic cardiomyopathy (HCM) was the most common diagnosis with 67.6%. Congenital cardiovascular malformations were found in 11.8% of the cases. Ventricular septal defect (VSD) was the most frequent anomaly, in contrast to previously published studies. The ECG was found to be relatively non-specific and insensitive for the diagnosis of heart disease: Its usefulness lies in the recognition and diagnosis of cardiac arrhythmias. The radiographically recognized changes were also non-specific for certain heart diseases. Radiographs of the thorax are especially useful in the evaluation of cardiomegaly, and secondary signs of congestion.

Antarctic Volcanic Flux Ratios from Law Dome Ice Cores

Explosive volcanic eruptions can inject large quantities of sulphur dioxide into the stratosphere. The aerosols that result from oxidation of the sulphur dioxide can produce significant cooling of the troposphere by reflecting or absorbing solar radiation. It is possible to obtain an estimate of the relative stratospheric sulphur aerosol concentration produced by different volcanoes by comparing sulphuric acid fluxes determined by analysis of polar ice cores. Here, we use a non-sea-salt sulphate time series derived from three well-dated Law Dome ice cores to investigate sulphuric acid flux ratios for major eruptions over the period AD 1301-1995. We use additional data from other cores to investigate systematic spatial variability in the ratios. Only for the Kuwae eruption (Law Dome ice date AD 1459.5) was the H2SO4 flux larger than that deposited by Tambora (Law Dome ice date AD 1816.7).

A 700-Year Record of Atmospheric Circulation Developed from the Law Dome Ice Core, East Antarctica

A 700-year, high-resolution, multivariate ice core record from Dome Summit South (DSS) (66degrees46'S, 112degrees48'E; 1370 m), Law Dome, is used to investigate sea level pressure (SLP) variability in the region of East Antarctica. Empirical orthogonal function (EOF) analysis reveals that the first EOF (LDEOF1) of the combined glaciochemical, oxygen isotope ratio, and accumulation rate record from DSS represents most of the variability in sea salt seen in the record. LDEOF1 is positively correlated (at least 95% confidence level) to instrumental June mean SLP across most of East Antarctica. Over the last 700 years, LDEOF1 levels at Law Dome were the highest during the nineteenth century, suggesting an increase in intensification of winter circulation during this period. The Law Dome DSS oxygen isotope ratio series also indicates that the nineteenth century had the coldest winters of any century in the record. In contrast, LDEOF1 levels were the lowest at Law Dome during the eighteenth century, suggesting a significant shift in the patterns and/or intensity of East Antarctic atmospheric circulation between the eighteenth and the nineteenth centuries. The LDEOF1 sea salt record is characterized by significant decadal-scale variability with a strong 25-year periodic structure.