Estudo sobre o panorama da energia elétrica no Brasil e tendências futuras

Pós-graduação em Engenharia Elétrica - FEB

Análise das internações por condições sensíveis à Atenção Primária em hospital de referência regional, SP/Brasil

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

A produção técnico-científica de James Precott Joule: uma leitura a partir da epistemologia de Ludwig Fleck

This paper aims an epistemologically analysis of the attempt of James Prescott Joule to replace the steam engine by the electric one. In this historical analysis, we use the epistemological categories: style of thinking, collective thinking, intercollective circulation of ideas and practices,Joule and other technicians in Machester received in that time financial incentives from governments and industry to replace the steam engine by the electric one, since it was in Manchester a culture of the technique of the accuracy and precision in which Joule was immersed, which allowed us to initially identify the styles of techniques thinking and experimental efficiency. However, Joule could not replace the steam engine by the electric; and the awareness of the problems faced by him, in the attempt to make such a substitution, led him to seek, through an intercollective circulation of ideas and practices, such as the studies of Faraday and Jacobi, a change of direction in his researches. According to our analysis, what happened was a change of style from a technical to a scientific thinking. In this sense, Joule began to investigate issues of a scientific nature, as the Joule’s effect and the mechanical equivalent of heat, which contributed significantly to the establishment of the principle of conservation of energy. We present here the contributions of this epistemological analysis to the discussion of questions of the nature of science in the basic education and for the training of physics teachers.

Hurdles at work: perceptions of hospital food handlers

Abstract Background Food handlers have a very important role in preventing food contamination during its preparation and distribution. This responsibility is even greater in hospitals, since a large number of patients have low immunity and consequently food contamination by pathogenic bacteria could be particularly harmful. Therefore, a good working environment and periodic training should be provided to food handlers by upper management. Methods This study is qualitative research by means of focus group and thematic content analysis methodologies to examine, in detail, the statements by food handlers working in the milk and specific-diet kitchens in a hospital to understand the problems they face in the workplace. Results We found that food handlers are aware of the role they play in restoring patients' health; they consider it important to offer a good-quality diet. However, according to their perceptions, a number of difficulties prevent them from reaching this aim. These include: upper management not prioritizing human and material resources to the dietetic services when making resource allocation decisions; a perception that upper management considers their work to be of lesser importance; delayed overtime payments; lack of periodic training; managers lacking administrative skills; insufficient dietitian staff assistants, leading to overwork, at the same time as there is an excess of dietitians; unhealthy environmental working conditions – high temperature, high humidity, loud and constant noise level, poor ventilation; lack of food, and kitchen utensils and equipment; and relationship conflicts with chief dieticians and co-workers. Conclusion From these findings, improvement in staff motivation could be achieved by considering non-financial incentives, such as improvement in working conditions and showing appreciation and respect through supervision, training and performance appraisal. Management action, such as investments in intermediary management so that managers have the capacity to provide supportive supervision, as well as better use of performance appraisal and access to training, may help overcome the identified problems.

A rede básica para o metrô de São Paulo e a priorização do automóvel

De que adiantam planos e projetos para determinadas políticas públicas se as decisões do Executivo nem sempre os consideram? Este trabalho busca demonstrar que os planos e os projetos para o setor de transporte têm sofrido com a priorização dos modais individuais. Desde as políticas de incentivos às indústrias automobilísticas até isenções fiscais. A existência de planos e projetos para o metrô de São Paulo e seu conseqüente abandono por longos períodos apontam para a supremacia do automóvel sobre o coletivo, principalmente no período de 1968 até 1983. Todo o planejamento, inclusive nos períodos de supremacia dos planos e projetos para o território urbano, cai por terra se estes instrumentos não vão ao encontro dos interesses político-econômicos do momento.

Essays in the Economics of Ageing

In the first paper, I assess if financial incentives may be used as an effective device to induce workers to postpone retirement by evaluating the Italian so called “super bonus” reform. The bonus consisted in economic incentives given for a limited period to private sector workers who had reached the requirements for seniority pension. Crucially for this study, public workers were not entitled to the bonus. Using data from the Bank of Italy Survey on Household Income andWealth, and exploiting the DID-Probit strategy proposed by Blundell et al. (JEEA, 2004), I assess the effect of the bonus on the decision to postpone retirement, by comparing private and public workers before and after the reform. Results suggest a reduction of 12ppt in the proportion of private workers who decided to retire among those qualifying for retirement. Results also suggest, not trivially, that most of the effect of the reform is driven by low-income workers. Finally, I propose an estimate of the extensive margin elasticity of Italian older workers. The second study estimates a structural reduced form of the “option value” model developed by Stock and Wise (1990) using Italian data from the Survey of Health, Ageing and Retirement in Europe (SHARE).Exploiting exogenous changes in social security wealth (SSW) results show a significant effect in the expected direction of SSW and of marginal incentives to retire. Results are robust even after controlling for individual heterogeneity and its correlation with financial incentives. Using detailed information on individuals, the results also highlights the importance of individual and job characteristics, which have been very little explored by this literature, as determinants of retirement. This suggests the potential of “tagging” in the design of social security incentives in order to reduce choice distortions and improve the overall efficiency of the system.

Behavioral Economics and Physician Behavior

This study seeks to answer whether the availability heuristic leads physicians to utilize more medical care than is economically efficient. Do rare, salient events alter physicians' perceptions about the probability of patient harm? Do these events lead physicians to overutilize certain medical procedures? This study uses Pennsylvania inpatient hospital admissions data from 2009 aggregated at the physician level to investigate these questions. The data come from the 2009 Pennsylvania Health Care Cost Containment Council (PHC4). The study is divided into two parts. In Part I, we examine whether bad outcomes during childbirth (defined as maternal mortality, an obstetric fistula or a uterine rupture) lead physicians to utilize more cesarean sections on future patients. In Part II, we examine whether bad outcomes associated with appendicitis (defined as patient death, a perforated or ruptured appendix or sepsis) lead physicians to perform more negative appendectomies (appendectomies performed when the patient did not have appendicitis) on future patients. Overall the study does not find evidence to support the claim that the availability heuristic leads physicians to overutilize medical care on future patients. However, the study does find evidence that variations in health care utilization are strongly correlated with individual physician practice patterns. The results of the study also imply that physicians' financial incentives may be a source of variation in health care utilization.

A New Symbiosis: Municipalities, Private Contractors and Non-Governmental Organisations for the Provision of Local Public Services"

This project considered the second stage of transforming local administration and public service management to reflect democratic forms of government. In Hungary in the second half of the 1990s more and more public functions delegated to local governments have been handed over to the private or civil sectors. This has led to a relative decrease of municipal functions but not of local governments' responsibilities, requiring them to change their orientation and approach to their work so as to be effective in their new roles of managing these processes rather than traditional bureaucratic administration. Horvath analysed the Anglo-Saxon, French and German models of self-government, identifying the differing aspects emphasised in increasing the private sector's role in the provision of public services, and the influence that this process has on the system of public administration. He then highlighted linkages between actors and local governments in Hungary, concluding that the next necessary step is to develop institutional mechanisms, financial incentives and managerial practices to utilise the full potential of this process. Equally important is the need for conscious avoidance of restrictive barriers and unintended consequences, and for local governments to confront the social conflicts that have emerged in parallel with privatisation. A further aspect considered was a widening of the role of functional governance at local level in the field of human services. A number of different special purpose bodies have been set up in Hungary, but the results of their work are unclear and Horvath feels that this institutionalisation of symbiosis is not the right path in Hungary today. He believes that the change from local government to local governance will require the formulation of specific public policy, the relevance of which can be proven by processes supported with actions.

The rate of outpatient cataract surgery in ten European countries: an analysis using data from the SHARE survey

BACKGROUND: The aim of this study was to determine the rates of outpatient cataract surgery (ROCS) in ten European countries and to find country-specific health indicators explaining the differences. METHODS: Using data from the Survey of Health, Ageing and Retirement in Europe (SHARE), 251 eligible respondents were identified for which cataract surgery was the last surgical procedure. The ROCS of ten countries were compared using logistic regression. The influence of the public expenditure on health as per cent of the total expenditure on health, of the number of acute care beds per 1,000 population, and of the number of practicing physicians per 1,000 population, was studied by multiple logistic regression. Additional information was obtained from country-specific opinion leaders in the field of cataract surgery. RESULTS: The ROCS differed significantly between the ten analysed European countries where Denmark had the highest (100%) and Austria the lowest (0%) rate of day care surgery. A decrease in the density of acute care beds (p < 0.0000001) and in the density of practicing physicians (p < 0.05) and an increase in the public expenditure on health as per cent of the total health expenditure (p < 0.01) lead to an increase in the ROCS. According to the opinion leaders, regulations and financial incentives also have a strong influence on the ROCS. CONCLUSIONS: The outpatient rate of cataract surgery in the ten European countries was mainly influenced by the acute-care beds density, but also by the density of practicing physicians, and by the public expenditure on health.

VOLUME YIELDS OF SMALLHOLDER Eucalyptus grandis W. HILL EX MAIDEN STANDS IN EASTERN PARAGUAY

Smallholders in eastern Paraguay plant small stands of Eucalyptus grandis W. Hill ex Maiden intended for sale on the local market. Smallholders have been encouraged to plant E. grandis by local forestry extension agents who offer both forestry education and incentive programs. Smallholders who practice recommended forestry techniques geared towards growing large diameter trees of good form are financially rewarded by the local markets which desire saw log quality trees. The question was posed, are smallholders engaging in recommended silvicultural practices and producing reasonable volume yields? It was hypothesized that smallholders, having received forestry education and having financial incentives from the local market, would engage in silvicultural practices resulting in trees of good form and volume yields that were reasonable for the local climate and soil characteristics. Yield volume results from this study support this hypothesis. Mean volume yield was estimated at 70 cubic meters per hectare at age four and 225 cubic meters per hectare at age eight. These volume yields compare favorably to volume yields from other studies of E. grandis grown in similar climates, with similar stocking levels and site qualities.

Agricultural land use and biodiversity in the Alps - How cultural tradition and socioeconomically motivated changes are shaping grassland biodiversity in the Swiss Alps

Alpine grasslands are ecosystems with a great diversity of plant species. However, little is known about other levels of biodiversity, such as landscape diversity, diversity of biological interactions of plants with herbivores or fungal pathogens, and genetic diversity. We therefore explored natural and anthropogenic determinants of grassland biodiversity at several levels of biological integration, from the genetic to the landscape level in the Swiss Alps. Differences between cultural traditions (Romanic, Germanic, and Walser) turned out to still affect land use diversity and thus landscape diversity. Increasing land use diversity, in turn, increased plant species diversity per village. However, recent land use changes have reduced this diversity. Within grassland parcels, plant species diversity was higher on unfertilized mown grasslands than on fertilized or grazed ones. Most individual plants were affected by herbivores and fungal leaf pathogens, reflecting that parcels harbored a great diversity of herbivores and pathogens. However, as plant damage by herbivores and pathogens was not severe, conserving these biological interactions among plants is hardly compromising agricultural goals. A common-garden experiment revealed genetic differentiation of the important fodder grass Poa alpina between mown and grazed sites, suggesting adaptation. Per-village genetic diversity of Poa alpina was greater in villages with higher land use diversity, analogous to the higher plant species diversity there. Overall, landscape diversity and biodiversity within grassland parcels are currently declining. As this contradicts the intention of Swiss law and international agreements, financial incentives need to be re-allocated and should focus on promoting high biodiversity at the local and the landscape level. At the same time, this will benefit landscape attractiveness for tourists and help preserve a precious cultural heritage in the Swiss Alps.

Delaying mowing and leaving uncut refuges boosts orthopterans in extensively managed meadows: Evidence drawn from field-scale experimentation

Semi-natural grasslands are widely recognized for their high ecological value. They often count among the most species-rich habitats, especially in traditional cultural landscapes. Maintaining and/or restoring them is a top priority, but nevertheless represents a real conservation challenge, especially regarding their invertebrate assemblages. The main goal of this study was to experimentally investigate the influence of four different mowing regimes on orthopteran communities and populations: (1) control meadow (C-meadow): mowing regime according to the Swiss regulations for extensively managed meadows declared as ecological compensation areas, i.e. first cut not before 15 June; (2) first cut not before 15 July (delayed treatment, D-meadow); (3) first cut not before 15 June and second cut not earlier than 8 weeks from the first cut (8W-meadow); (4) refuges left uncut on 10–20% of the meadow area (R-meadow). Data were collected two years after the introduction of these mowing treatments. Orthopteran densities from spring to early summer were five times higher in D-meadows, compared to C-meadows. In R-meadows, densities were, on average, twice as high as in C-meadows, while mean species richness was 23% higher in R-meadows than in C-meadows. Provided that farmers were given the appropriate financial incentives, the D- and R-meadow regimes could be relatively easy to implement within agri-environment schemes. Such meadows could deliver substantial benefits for functional biodiversity, including sustenance to many secondary consumers dependent on field invertebrates as staple food.

Cost-effectiveness analysis of paclitaxel-coated balloons for endovascular therapy of femoropopliteal arterial obstructions.

PURPOSE To explore the cost-effectiveness of using drug-eluting balloon (DEB) angioplasty for the treatment of femoropopliteal arterial lesions, which has been shown to significantly lower the rates of target lesion revascularization (TLR) compared with standard balloon angioplasty (BA). METHODS A simplified decision-analytic model based on TLR rates reported in the literature was applied to baseline and follow-up costs associated with in-hospital patient treatment during 1 year of follow-up. Costs were expressed in Swiss Francs (sFr) and calculated per 100 patients treated. Budgets were analyzed in the context of current SwissDRG reimbursement figures and calculated from two different perspectives: a general budget on total treatment costs (third-party healthcare payer) as well as a budget focusing on the physician/facility provider perspective. RESULTS After 1 year, use of DEB was associated with substantially lower total inpatient treatment costs when compared with BA (sFr 861,916 vs. sFr 951,877) despite the need for a greater investment at baseline related to higher prices for DEBs. In the absence of dedicated reimbursement incentives, however, use of DEB was shown to be the financially less favorable treatment approach from the physician/facility provider perspective (12-month total earnings: sFr 179,238 vs. sFr 333,678). CONCLUSION Use of DEBs may be cost-effective through prevention of TLR at 1 year of follow-up. The introduction of dedicated financial incentives aimed at improving DEB reimbursements may help lower total healthcare costs.

Clinically relevant quality measures for risk factor control in primary care: a retrospective cohort study

BACKGROUND Assessment of the proportion of patients with well controlled cardiovascular risk factors underestimates the proportion of patients receiving high quality of care. Evaluating whether physicians respond appropriately to poor risk factor control gives a different picture of quality of care. We assessed physician response to control cardiovascular risk factors, as well as markers of potential overtreatment in Switzerland, a country with universal healthcare coverage but without systematic quality monitoring, annual report cards on quality of care or financial incentives to improve quality. METHODS We performed a retrospective cohort study of 1002 randomly selected patients aged 50-80 years from four university primary care settings in Switzerland. For hypertension, dyslipidemia and diabetes mellitus, we first measured proportions in control, then assessed therapy modifications among those in poor control. "Appropriate clinical action" was defined as a therapy modification or return to control without therapy modification within 12 months among patients with baseline poor control. Potential overtreatment of these conditions was defined as intensive treatment among low-risk patients with optimal target values. RESULTS 20% of patients with hypertension, 41% with dyslipidemia and 36% with diabetes mellitus were in control at baseline. When appropriate clinical action in response to poor control was integrated into measuring quality of care, 52 to 55% had appropriate quality of care. Over 12 months, therapy of 61% of patients with baseline poor control was modified for hypertension, 33% for dyslipidemia, and 85% for diabetes mellitus. Increases in number of drug classes (28-51%) and in drug doses (10-61%) were the most common therapy modifications. Patients with target organ damage and higher baseline values were more likely to have appropriate clinical action. We found low rates of potential overtreatment with 2% for hypertension, 3% for diabetes mellitus and 3-6% for dyslipidemia. CONCLUSIONS In primary care, evaluating whether physicians respond appropriately to poor risk factor control, in addition to assessing proportions in control, provide a broader view of the quality of care than relying solely on measures of proportions in control. Such measures could be more clinically relevant and acceptable to physicians than simply reporting levels of control.

Biomarker-guided personalised emergency medicine for all - hope for another hype?

Polymorbid patients, diverse diagnostic and therapeutic options, more complex hospital structures, financial incentives, benchmarking, as well as perceptional and societal changes put pressure on medical doctors, specifically if medical errors surface. This is particularly true for the emergency department setting, where patients face delayed or erroneous initial diagnostic or therapeutic measures and costly hospital stays due to sub-optimal triage. A "biomarker" is any laboratory tool with the potential better to detect and characterise diseases, to simplify complex clinical algorithms and to improve clinical problem solving in routine care. They must be embedded in clinical algorithms to complement and not replace basic medical skills. Unselected ordering of laboratory tests and shortcomings in test performance and interpretation contribute to diagnostic errors. Test results may be ambiguous with false positive or false negative results and generate unnecessary harm and costs. Laboratory tests should only be ordered, if results have clinical consequences. In studies, we must move beyond the observational reporting and meta-analysing of diagnostic accuracies for biomarkers. Instead, specific cut-off ranges should be proposed and intervention studies conducted to prove outcome relevant impacts on patient care. The focus of this review is to exemplify the appropriate use of selected laboratory tests in the emergency setting for which randomised-controlled intervention studies have proven clinical benefit. Herein, we focus on initial patient triage and allocation of treatment opportunities in patients with cardiorespiratory diseases in the emergency department. The following five biomarkers will be discussed: proadrenomedullin for prognostic triage assessment and site-of-care decisions, cardiac troponin for acute myocardial infarction, natriuretic peptides for acute heart failure, D-dimers for venous thromboembolism, C-reactive protein as a marker of inflammation, and procalcitonin for antibiotic stewardship in infections of the respiratory tract and sepsis. For these markers we provide an overview on physiopathology, historical evolution of evidence, strengths and limitations for a rational implementation into clinical algorithms. We critically discuss results from key intervention trials that led to their use in clinical routine and potential future indications. The rational for the use of all these biomarkers, first, tackle diagnostic ambiguity and consecutive defensive medicine, second, delayed and sub-optimal therapeutic decisions, and third, prognostic uncertainty with misguided triage and site-of-care decisions all contributing to the waste of our limited health care resources. A multifaceted approach for a more targeted management of medical patients from emergency admission to discharge including biomarkers, will translate into better resource use, shorter length of hospital stay, reduced overall costs, improved patients satisfaction and outcomes in terms of mortality and re-hospitalisation. Hopefully, the concepts outlined in this review will help the reader to improve their diagnostic skills and become more parsimonious laboratory test requesters.