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.

L'impatto della geometria urbana per applicazioni del telerilevamento in ambito energetico: l'influenza dello sky view factor.

Comprensione delle formulazioni analitiche e dei metodi tradizionali per il calcolo puntuale dello Sky View Factor (SVF), un parametro adimensionale in grado di esprimere con un singolo valore l’influenza dei fattori morfologici sulla porzione di volta celeste visibile da un punto. Valutazione delle performance dei software di mappatura dello SVF in area urbana al variare di tipologia e qualità del dato di input e dei parametri utilizzati. Al fine di studiare degli aspetti algoritmici dei modelli esistenti, è stato sviluppato uno script in linguaggio MATLAB per apportare miglioramenti alle tecniche esaminate.

SCADA Lite View

Progettazione UML (diagrammi classi, casi d'uso, sequenze), programmazione Java per dispositivi Android

Novel two photon absorbers: evaluation of photophysical properties in view of biomedical applications

This thesis was focused on the investigation of the linear optical properties of novel two photon absorbers for biomedical applications. Substituted imidazole and imidazopyridine derivatives, and organic dendrimers were studied as potential fluorophores for two photon bioimaging. The results obtained showed superior luminescence properties for sulphonamido imidazole derivatives compared to other substituted imidazoles. Imidazo[1,2-a]pyridines exhibited an important dependence on the substitution pattern of their luminescence properties. Substitution at imidazole ring led to a higher fluorescence yield than the substitution at the pyridine one. Bis-imidazo[1,2-a]pyridines of Donor-Acceptor-Donor type were examined. Bis-imidazo[1,2-a]pyridines dimerized at C3 position had better luminescence properties than those dimerized at C5, displaying high emission yields and important 2PA cross sections. Phosphazene-based dendrimers with fluorene branches and cationic charges on the periphery were also examined. Due to aggregation phenomena in polar solvents, the dendrimers registered a significant loss of luminescence with respect to fluorene chromophore model. An improved design of more rigid chromophores yields enhanced luminescence properties which, connected to large 2PA cross-sections, make this compounds valuable as fluorophores in bioimaging. The photophysical study of several ketocoumarine initiators, designed for the fabrication of small dimension prostheses by two photon polymerization (2PP) was carried out. The compounds showed low emission yields, indicative of a high population of the triplet excited state, which is the active state in producing the reactive species. Their efficiency in 2PP was proved by fabrication of microstructures and their biocompatibility was tested in the collaborator’s laboratory. In the frame of the 2PA photorelease of drugs, three fluorene-based dyads have been investigated. They were designed to release the gamma-aminobutyric acid via two photon induced electron transfer. The experimental data in polar solvents showed a fast electron transfer followed by an almost equally fast back electron transfer process, which indicate a poor optimization of the system.

Anthropology in the twenty-first century : a view of, and from, Germany

The article explores the developments in German-language anthropology in the past decades, focussing on the period after the 1970s. It argues that the recent history of German-language Ethnologie (social and cultural anthropology) is one of catching-up modernization. German-speaking anthropologists are increasingly involved in, and contribute to, broader theoretical debates, publish in English and in international journals, and are actively engaged in international academic networks. The paper discusses how and under what conditions of knowledge production these transformations have taken place. It analyses the changing institutional environment in which German anthropologists have worked and work today, as well as the theoretical impulses from within and outside the discipline that have given rise to the contemporary orientation of German-language anthropology as an anthropology of the 'present'. Finally, and beyond the focus on Germany, the article offers some ideas on the future of anthropology as a symmetrical social science, characterized by a continued strong reliance on field work and a high level of 'worldliness', a basic attitude of systematically shifting perspectives, the critical reflection of the social and political embeddedness of knowledge production, and an engagement with social theory across disciplinary boundaries.

A multi-regional view on aging societies accounting for the existence of non-tradable goods

This thesis assesses the question, whether accounting for non-tradable goods sectors in a calibrated Auerbach-Kotlikoff multi-regional overlapping-generations-model significantly affects this model’s results when simulating the economic impact of demographic change. Non-tradable goods constitute a major part of up to 80 percent of GDP of modern economies. At the same time, multi-regional overlapping-generations-models presented by literature on demographic change so far ignored their existence and counterfactually assumed perfect tradability between model regions. Moreover, this thesis introduces the assumption of an increasing preference share for non-tradable goods of old generations. This fact-based as-sumption is also not part of models in relevant literature. rnThese obvious simplifications of common models vis-à-vis reality notwithstanding, this thesis concludes that differences in results between a model featuring non-tradable goods and a common model with perfect tradability are very small. In other words, the common simplifi-cation of ignoring non-tradable goods is unlikely to lead to significant distortions in model results. rnIn order to ensure that differences in results between the ‘new’ model, featuring both non-tradable and tradable goods, and the common model solely reflect deviations due to the more realistic structure of the ‘new’ model, both models are calibrated to match exactly the same benchmark data and thus do not show deviations in their respective baseline steady states.rnA variation analysis performed in this thesis suggests that differences between the common model and a model with non-tradable goods can theoretically be large, but only if the bench-mark tradable goods sector is assumed to be unrealistically small.rnFinally, this thesis analyzes potential real exchange rate effects of demographic change, which could occur due to regional price differences of non-tradable goods. However, results show that shifts in real exchange rate based on these price differences are negligible.rn

High-energy view of radio galaxies: prospects for the new generation of Cherenkov telescopes

I Nuclei Galattici Attivi (AGN) sono sorgenti luminose e compatte alimentate dall'accrescimento di materia sul buco nero supermassiccio al centro di una galassia. Una frazione di AGN, detta "radio-loud", emette fortemente nel radio grazie a getti relativistici accelerati dal buco nero. I Misaligned AGN (MAGN) sono sorgenti radio-loud il cui getto non è allineato con la nostra linea di vista (radiogalassie e SSRQ). La grande maggioranza delle sorgenti extragalattiche osservate in banda gamma sono blazar, mentre, in particolare in banda TeV, abbiamo solo 4 MAGN osservati. Lo scopo di questa tesi è valutare l'impatto del Cherenkov Telescope Array (CTA), il nuovo strumento TeV, sugli studi di MAGN. Dopo aver studiato le proprietà dei 4 MAGN TeV usando dati MeV-GeV dal telescopio Fermi e dati TeV dalla letteratura, abbiamo assunto come candidati TeV i MAGN osservati da Fermi. Abbiamo quindi simulato 50 ore di osservazioni CTA per ogni sorgente e calcolato la loro significatività. Assumendo una estrapolazione diretta dello spettro Fermi, prevediamo la scoperta di 9 nuovi MAGN TeV con il CTA, tutte sorgenti locali di tipo FR I. Applicando un cutoff esponenziale a 100 GeV, come forma spettrale più realistica secondo i dati osservativi, prevediamo la scoperta di 2-3 nuovi MAGN TeV. Per quanto riguarda l'analisi spettrale con il CTA, secondo i nostri studi sarà possibile ottenere uno spettro per 5 nuove sorgenti con tempi osservativi dell'ordine di 250 ore. In entrambi i casi, i candidati migliori risultano essere sempre sorgenti locali (z<0.1) e con spettro Fermi piatto (Gamma<2.2). La migliore strategia osservativa per ottenere questi risultati non corrisponde con i piani attuali per il CTA che prevedono una survey non puntata, in quanto queste sorgenti sono deboli, e necessitano di lunghe osservazioni puntate per essere rilevate (almeno 50 ore per studi di flusso integrato e 250 per studi spettrali).

Supergeometry: a categorical point of view

In questa tesi viene studiato l'approccio funtoriale alla supergeometria. In particolare si usano le topologie di Grothendieck per studiare il concetto di rappresentabilità in questo contesto, in analogia a quanto fatto in geometria algebrica classica. Vengono poi introdotti i funtori di Weil-Berezin e lo Schwarz embedding, motivando i legami tra questi concetti e la rappresentabilità nel caso classico.

Radiation dose optimized lateral expansion of the field of view in synchrotron radiation X-ray tomographic microscopy

Volumetric data at micrometer level resolution can be acquired within a few minutes using synchrotron-radiation-based tomographic microscopy. The field of view along the rotation axis of the sample can easily be increased by stacking several tomograms, allowing the investigation of long and thin objects at high resolution. On the contrary, an extension of the field of view in the perpendicular direction is non-trivial. This paper presents an acquisition protocol which increases the field of view of the tomographic dataset perpendicular to its rotation axis. The acquisition protocol can be tuned as a function of the reconstruction quality and scanning time. Since the scanning time is proportional to the radiation dose imparted to the sample, this method can be used to increase the field of view of tomographic microscopy instruments while optimizing the radiation dose for radiation-sensitive samples and keeping the quality of the tomographic dataset on the required level. This approach, dubbed wide-field synchrotron radiation tomographic microscopy, can increase the lateral field of view up to five times. The method has been successfully applied for the three-dimensional imaging of entire rat lung acini with a diameter of 4.1 mm at a voxel size of 1.48 microm.

Xenobiotic metabolism: a view through the metabolometer

The combination of advanced ultraperformance liquid chromatography coupled with mass spectrometry, chemometrics, and genetically modified mice provide an attractive raft of technologies with which to examine the metabolism of xenobiotics. Here, a reexamination of the metabolism of the food mutagen PhIP (2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine), the suspect carcinogen areca alkaloids (arecoline, arecaidine, and arecoline 1-oxide), the hormone supplement melatonin, and the metabolism of the experimental cancer therapeutic agent aminoflavone is presented. In all cases, the metabolic maps of the xenobiotics were considerably enlarged, providing new insights into their toxicology. The inclusion of transgenic mice permitted unequivocal attribution of individual and often novel metabolic pathways to particular enzymes. Last, a future perspective for xenobiotic metabolomics is discussed and its impact on the metabolome is described. The studies reviewed here are not specific to the mouse and can be adapted to study xenobiotic metabolism in any animal species, including humans. The view through the metabolometer is unique and visualizes a metabolic space that contains both established and unknown metabolites of a xenobiotic, thereby enhancing knowledge of their modes of toxic action.

[Musculoskeletal puncture, injection and infiltration: swiss rheumatologists' point of view]

Arthrocentesis, injection and infiltration of joints and soft tissues belong to the basic procedures in rheumatology. The indications and the practical performance are based on experience and tradition. Nowadays, a crucial reappraisal and adaption of indications and technical aspects appear important in the light of new evidence and technical developments. The main indications for puncture remain the search of an infectious arthritis and reduction of intra-articular pressure due to effusion. Good indications for the injection of glucocorticoids are inflammation in sterile joints and activated osteoarthritis. The local infiltration with corticosteroids in mechanically induced enthesopathies at the lateral epicondyle of the humerus or at the plantar fascia have to be questioned in the light of recent publications which show that this common practice is associated with a poorer outcome than without injection.