Health care supply, payment system and medical practice : evidence from obstetric practice

ABSTRACTA significant share of deliveries are performed by Cesarian section (C-section) in Europe and in many developed and developing countries. The aims of this thesis are to highlight the non medical, especially economic and financial, incentives that explain the use of C-section, as well as the medical consequences of C-section on women's health, in regard with other factors of ob¬stetrical care quality such as hospital concentration. Those diagnoses enable us to exhibit ways of improvement of obstetrical care quality in France. Our analysis focus on two countries, France and Switzerland. In the first part of the thesis, we show the influence of two non medical factors on the C-section use, namely the hospital payment system on the one hand and the obstetricians behaviour, especially their demand for leisure, on the other hand. With French data on the year 2003, we show firstly that the fee-for-service payment system of private for profit hospitals induces a higher probability of using C-section. Obstetricians play also a preeminent role in the decision to use a C-section, as the probability of a C-section rises with the number of obstetricians. We then focus on a French reform introduced in 2004, to investigate the impact of Prospective Payment System on obstetric practise. We show that the rise of C-section rate between 2003 and 2006 is mainly caused by changes in hospitals and patients features. Obstetricians practises do not vary a lot for patients with the same risk code. In the mean time however, the number of women coded with a high risk rises. This can be caused by improvements in the quality of coding, obstetricians chosing codes that match better the real health state of their patients. Yet, it can also show that obstetricians change their coding practises to justify the use of certain practises, such as C-section, with no regard to the health state of patients. Financial factors are not the only non medical fac¬tors that can influence the resort to C-section. Using Shelton Brown ΠΙ identification strategy, we focus on the potential impact of obstetricians leisure preference on the use of C-section. We use the distributions of days and hours of delivering and the types of C-section - planned or emergency C-sections - to show that the obstetricians demand for leisure has a significant impact on the resort to C-section, but only in emergency situations. The second part of the thesis deals with some ways to improve obstetric care quality. We use on the one hand swiss and french data to study the impact of C-section on the patients' probability of having an obstetric complication and on the other hand the influence of hospital concentration on the quality of obstetric care. We find the same results as former medical studies about the risks entailed by C-section on obstetric complications.These results prove women ought to be better informed of the medical consequences of C-section and that the slowing of C-section use should be a priority of public health policy. We finally focus on another way to improve obstetric care quality, that is hospital lmarket concentration. We investigate the impact of hospital concentration by integrating the Herfindahl-Hirschman index in our model, on health care quality, measured by the HCUP indicator. We find that hospital concentration has a negative impact on obstetric care quality, which undermines today's policy of hospital closings in France.JEL classification: 112; 118Keywords: Hospital; C-section; Payment System; Counterfactual Estimation; Quality of Care.RÉSUMÉUne part importante des accouchements sont réalisés par césarienne en Europe et dans de nom¬breux pays développés ou en développement. Les objectifs de cette thèse sont de mettre en évidence les déterminants non médicaux, notamment économiques et financiers, expliquant le développe¬ment de cette pratique, ainsi que ses conséquences sur la santé des femmes après Γ accouchement, en lien avec d'autres facteurs comme la concentration locale des structures hospitalières. Les résul¬tats exposés dans cette thèse éclairent les perspectives et voies d'amélioration de la qualité des soins en obstétriques.Notre analyse se concentre sur deux pays : la France et la Suisse. Dans la première partie de la thèse, nous mettons en évidence l'influence de deux déterminants non médicaux sur l'emploi de la césarienne : le système de paiement des hôpitaux d'une part, et le comportement des médecins obstétriciens d'autre part. En étudiant des données françaises de 2003, nous montrons d'abord que le financement à l'acte des établissements privés engendre une hausse de la proba¬bilité de pratiquer une césarienne. Le rôle de l'obstrétricien paraît également déterminant dans la décision d'opérer une césarienne, la probabilité d'employer cette technique augmentant avec le nombre d'obstétriciens. Nous nous intéressons ensuite à l'impact de la mise en place en 2004 du système de paiement prospectif sur l'évolution des pratiques obstétricales entre 2003 et 2006 en France. La hausse du taux de recours à la césarienne entre 2004 et 2006 peut ainsi être principa¬lement imputée aux évolutions des caractéristiques des hôpitaux et des patients, les pratiques des obstétriciens, pour un même codage de la situation du patient, variant peu. Dans le même temps cependant, les pratiques de codage des patients parles obstétriciens évoluent fortement, les femmes étant de plus en plus nombreuses à porter des codes correspondant à des situations à risques. Cette évolution peut indiquer que la qualité du codage en 2006 s'est améliorée par rapport à 2004, le codage correspondant de plus en plus à la situation réelle des patientes. H peut aussi indiquer que les pratiques de codage évoluent pour justifier un recours accru à la césarienne, sans lien avec l'état réel des patientes. Les facteurs financiers ne sont pas les seuls facteurs non médicaux à pouvoir expliquer le recours à la césarienne : nous nous intéressons, en suivant la stratégie d'identifica¬tion de Shelton Brown m, à l'impact potentiel de la demande de loisir des médecins obstétriciens sur la pratique de la césarienne. En utilisant la distribution des jours et heures d'accouchement, et en distinguant les césariennes planifiées de celles effectuées en urgence, nous constatons que la demande de loisir des obstétriciens influence significativement le recours à la césarienne, mais uni¬quement pour les interventions d'urgence. La deuxième partie de la thèse est consacrée à l'étude de la qualité des soins en obstétriques. Nous utilisons des données suisses et françaises pour analyser d'une part l'impact de la césarienne sur la survenue de complications obstétricales et d'autre part l'impact de la concentration des soins sur la qualité des soins en obstétrique. Nons confirmons les résultats antérieurs de la littérature médicale sur la dangerosité de la césarienne comme facteur de complications obstétricales. Ces conclusions montrent que les femmes ont besoin d'être informées des conséquences de la césarienne sur leur santé et que le ralentissement de l'augmentation de la pratique de la césarienne devrait être un objectif de la politique publique de santé. Nous nous in¬téressons à un autre facteur d'amélioration des soins en obstrétique, l'organisation des hôpitaux et particulièrement leur concentration. Nous estimons ainsi l'effet de la concentration sur la qualité des soins obstétriques en intégrant l'indice de Herfindahl-Hirschman dans notre modèle, la qualité des soins étant mesurée à l'aide de l'indicateur HCUP. Nous constatons que la concentration des naissances a un impact négatif sur la qualité des soins en obstétrique, résultat qui va dans le sens contraire des politiques de fermeture d'hôpitaux menées actuellement en France. JEL classification : 112 ; 118Mots-clés : Hôpital ; Césarienne ; Système de paiement ; Contrefactuels ; Qualité des soins, sur la qualité des soins en obstétrique.

Disseny d'un adaptador d'IPs per a NoCs tolerants a falles

L’aparició d’un nou paradigma per al disseny de sistemes multiprocessador, les NoC; requereixen una manera d’adaptar els IP cores ja existents i permetre la seva connexió en xarxa. Aquest projecte presenta un disseny d’una interfície que aconsegueix adaptar un IP core existent, el LEON3; del protocol del bus AMBA al protocol de la xarxa. D’aquesta manera i basant-nos en idees d’interfícies discutides en l’estat de l’art, aconseguim desacoblar el processador del disseny i topologia de la xarxa.

Medidas de controle

The control measures preconized by Ministério da Saúde/Fundaçao Nacional de Saúde for 1990/1991, started to have a new focus when significant advances were evidenced in the two last decades and after internal meetings with participation of the cientific community interested in accompanting the actions directed to the control of schistosomiasis in our country. Since then, the priority started to be the suppressing of the occurence of advanced clinical forms, having as an objective, the detection and treatment of all carrier of Schistosoma mansoni. Beyond the control measures, factors that may interfere in the application of those measures were also boarded, the diverse phasis of field operations, the work methodology and results obtained in the first semester of 1991.

Novel approaches in anti-arenaviral drug development.

Hemorrhagic fevers caused by arenaviruses are among the most devastating emerging human diseases. Considering the number of individuals affected, the current lack of a licensed vaccine, and the limited therapeutic options, arenaviruses are arguably among the most neglected tropical pathogens and the development of efficacious anti-arenaviral drugs is of high priority. Over the past years significant efforts have been undertaken to identify novel potent inhibitors of arenavirus infection. High throughput screening of small molecule libraries employing pseudotype platforms led to the discovery of several potent and broadly active inhibitors of arenavirus cell entry that are effective against the major hemorrhagic arenaviruses. Mechanistic studies revealed that these novel entry inhibitors block arenavirus membrane fusion and provided novel insights into the unusual mechanism of this process. The success of these approaches highlights the power of small molecule screens in antiviral drug discovery and establishes arenavirus membrane fusion as a robust drug target. These broad screenings have been complemented by strategies targeting cellular factors involved in productive arenavirus infection. Approaches targeting the cellular protease implicated in maturation of the fusion-active viral envelope glycoprotein identified the proteolytic processing of the arenavirus glycoprotein precursor as a novel and promising target for anti-arenaviral strategies.

Barn owls do not interrupt their siblings

Animals communicate with conspecifics to resolve conflicts over how resources are shared. Since signals reflect individuals' resource-holding potential and motivation to compete, it is crucial that opponents efficiently transmit and receive information to adjust investment optimally in competitive interactions. Acoustic communication is particularly flexible as it can be quickly modulated according to background noise and audience. Diverse mechanisms have evolved to minimize acoustic signal interference, one being the avoidance of signal overlap by adjusting the timing of call production to alternate calls with those of competitors. However, the occurrence and function of overlap avoidance in the resolution of competition among relatives have barely been studied. Using young barn owl siblings, Tyto alba, which vocally negotiate over who will have priority access to food provided by parents, we investigated the extent to which nestlings avoid calling simultaneously and the function of this behaviour. We found that nestlings overlapped both their live siblings' calls and experimentally broadcast calls at least five times less often than expected at random. Furthermore, a focal nestling engaged more intensely in vocal negotiation when competing with nestmates that called simultaneously compared to those that did not overlap their respective calls. This suggests that barn owl nestlings avoid calling simultaneously, as overlapped calls are less efficient at deterring siblings from competing. Overlap avoidance reduces signal interference and, as a consequence, would improve the efficiency of communication among kin.

Dynamical modeling and analysis of large cellular regulatory networks.

The dynamical analysis of large biological regulatory networks requires the development of scalable methods for mathematical modeling. Following the approach initially introduced by Thomas, we formalize the interactions between the components of a network in terms of discrete variables, functions, and parameters. Model simulations result in directed graphs, called state transition graphs. We are particularly interested in reachability properties and asymptotic behaviors, which correspond to terminal strongly connected components (or "attractors") in the state transition graph. A well-known problem is the exponential increase of the size of state transition graphs with the number of network components, in particular when using the biologically realistic asynchronous updating assumption. To address this problem, we have developed several complementary methods enabling the analysis of the behavior of large and complex logical models: (i) the definition of transition priority classes to simplify the dynamics; (ii) a model reduction method preserving essential dynamical properties, (iii) a novel algorithm to compact state transition graphs and directly generate compressed representations, emphasizing relevant transient and asymptotic dynamical properties. The power of an approach combining these different methods is demonstrated by applying them to a recent multilevel logical model for the network controlling CD4+ T helper cell response to antigen presentation and to a dozen cytokines. This model accounts for the differentiation of canonical Th1 and Th2 lymphocytes, as well as of inflammatory Th17 and regulatory T cells, along with many hybrid subtypes. All these methods have been implemented into the software GINsim, which enables the definition, the analysis, and the simulation of logical regulatory graphs.

Control of schistosomiasis transmission

Despite the success of control programmes, schistosomiasis is still a serious public health problem in the world. More than 70 countries where 200 million individuals are evaluated to be infected of a total 600 million at risk. Though there have been important local success in the control of transmission, globally the infection has increased. Economic constrains in developing countries, environmental changes associated with migration and water resources development have been blocking the progress. The main objective of schistosomiasis control is to achieve reduction of disease due to schistosomiasis. We discussed the control measures like: health education, diagnosis and chemotherapy, safe water supplies, sanitation and snail control. We emphasized the need to give priority to school-age children and the importance of integrating the measures of control into locally available systems of health care. The control of schistosomiasis is directly related to the capacity of the preventive health services of an endemic country. The strategy of control requires long-term commitment from the international to the local level.

Integración de políticas medio ambientales: Transformaciones institucionales en España

La Integración de la Políticas Ambientales (IPA) consiste en la incorporación de los objetivos ambientales en todos los estadios de elaboración e implementación de las políticas no ambientales (o sectoriales), con un reconocimiento específico de dicho objetivo como principio director de la programación y la puesta en práctica. Se complementa con la previsión de las consecuencias ambientales mediante una evaluación de conjunto de la política con objeto de minimizar las contradicciones entre las políticas ambientales y no ambientales dando prioridad a las primeras. La naturaleza transversal de la IPA no se ajusta a la forma tradicional de gobernanza jerárquica basada en la autoridad del Estado, la diferenciación sectorial, y los instrumentos típicos de dirección y control. Por ello, no es extraño que la IPA se encuentre a menudo asociada a los llamados "nuevos modos de gobernanza". Esta tesis propone analizar empíricamente el estado de la cuestión en España con respecto a la Integración de la política ambiental , tanto a nivel estatal como autonómico (Cataluña, País Vasco), yendo más allá de los compromisos políticos a favor de un mayor grado de integración de los factores ambientales en las demás políticas. En particular, los ámbitos de investigación seleccionados para esta finalidad son el de las políticas de mitigación de las causas y los efectos del cambio climático, y las políticas de desarrollo sostenible. En términos de ‘variable independiente’ La hipótesis que se quiere comprobar es que la acción llevada a cabo por la Unión Europea ha generado profundos cambios en las estructuras de las instituciones mencionadas y en los procesos de elaboración y implementación de determinadas políticas (energía y transporte) así como en las relaciones entre sectores de la administración pública y entre el sector público y el privado.

La correspondencia entre Robert Moray y Christiaan Huygens (1661-1669): encuentros y desencuentros en la promoción del conocimiento

Sir Robert Moray (1608/9-1673) fue un soldado, cortesano y "hombre de ciencia" escocés, que estuvo en el exilio durante el período de Oliver Cromwell. Poco después de su regreso a Inglaterra en 1660 y gracias en gran medida a su amistad con Carlos II, aparece vinculado al grupo que formará la Royal Society de Londres y será nombrado el primer presidente de la institución durante los primeros meses. Moray ha sido reconocido como una figura imprescindible para entender la consolidación de la Royal Society. Establece, además, una correspondencia muy importante con Christiaan Huygens, en donde aparecen tratados temas de gran relevancia en la década de 1660, tales como la determinación de la longitud en el mar mediante el uso del reloj de péndulo y la construcción y experimentación con la máquina neumática (emblema del proyecto experimental de Robert Boyle). En esta correspondencia aparecen reflejadas, así mismo, las tensiones sobre los problemas de prioridad en diferentes áreas de conocimiento. Una de estas agrias polémicas es la que enfrenta a James Gregory y a Huygens, que acabará con la relación epistolar entre Moray y el sabio holandés.

Laboratori Assistit per Ordinador mitjançant eines ofimàtiques convencionals

El projecte "Laboratori Asssit per Ordinador Mitjançant Eines Ofimàtiques Convencionals" ha estat realitzat en la facultat de Física de la Universitat de Barcelona durant els anys 2007 i 2008 (projecte biennal). El principal objectiu d’aquest projecte és demostrar la possibilitat d’utilitzar les eines informàtiques més habituals en la realització d’experiències de laboratori assistit per ordinador (LAO). En particular, es proposa la utilització del Excel © juntament amb les seves macros (Visual Basic para Aplicacions, VBA) en pràctiques de laboratori d’assignatures en l’àrea de Física Aplicada. Excel és un full de càlcul molt conegut i usat tant per professors com pels estudiants. En aquest treball mostrem exemples concrets que abasten les diferents tècniques de control i adquisició de dades: programació del port sèrie (RS- 232) i paral·lel, i interfase GPIB. La implementació d’aquestes tècniques es realitza mitjançant macros VBA de Excel. La resta de programació de l’aplicació LAO, la representació gràfica i el tractament de les dades, es realitza de forma molt simple a partir del maneig habitual d’un full de càlcul. La realització del projecte ha demostrat la conveniència d’aquesta metodologia. Actualment pràcticament la totalitat de les pràctiques LAO de les quals és responsable el Departament de Física Aplicada utilitzen la programació a través del full de càlcul. La resposta dels estudiants ha estat molt positiva. La combinació de les característiques d’aquesta eina juntament amb la programació VBA té un enorme potencial i representa, probablement, una forma senzilla d’introduir tant a l’alumne com al professor en el món de la programació.

Sistema integral d’anàlisi i avaluació d’un format general d’assignatura específic dels estudis de les arts

En el període 2006-2008, l'equip investigador de l'Observatori sobre la Didàctica de les Arts (ODAS) s'ha concentrat en la innovació i la investigació en el camp de la didàctica aplicada als estudis universitaris de les arts. Des del punt de vista propi de la investigació-acció, la finalitat ha estat la de plantejar i explorar una revisió integral de l'organització del treball a peu d'aula que fos extensible a d'altres assignatures i matèries. Així, prenent com a eix l'aprenentatge dels estudiants, les accions escomeses es fonamentaren en sis premisses: integració —de sessions de treball i activitats d'aprenentatge—, diversitat —d'escenaris, recursos i materials didàctics—, equilibri —entre coneixements i habilitats específiques i transversals—, modularitat —de les parts constitutives de la innovació proposada—, aplicabilitat —a d'altres assignatures i matèries— i progressió en la seva posada en marxa. I sobre aquestes bases, hom va establir cinc línies de treball: l'organització del treball a l'aula i del treball guiat de l'estudiant en diferents tipus de sessions, l'organització del treball autònom de l'alumne des dels pressupòsits d'una avaluació continuada, la incorporació de les TIC com autèntics recursos d'ensenyament-aprenentatge, la col·laboració amb d'altres unitats de la Universitat de Barcelona que tinguessin entre els seus objectius l'impuls de l'aprenentatge, i el seguiment del procés d'implantació de la iniciativa didàctica i l'anàlisi regular dels seus resultats. Pel que fa a aquest darrer punt, en aquest primer període, hom ha prioritzat l'estudi de les dades quantitatives i quasi-quantitatives derivades del judici dels alumnes que participaren en la nova proposta didàctica. En conseqüència, la investigació va acomplir una primera funció diagnòstica de la innovació docent duta a terme, i es va enquadrar en la categoria dels estudis descriptius transversals a través d'enquestes amb mostres probabilístiques.

Entorno gráfico de configuración para el soft-core OpenRISC

Aquest projecte consisteix en la realització d'un entorn gràfic que serveixi per generar SoCs basats en el processador soft-core OpenRISC. Aquest entorn permetrà afegir diferents components de manera dinàmica a un repositori d’IPs, mostrar i sel·leccionar qualsevol component disponible dins d’aquest repositori, amb la finalitat d’unir-los al bus del sistema i fer-los accessibles al processador OpenRISC. L’entorn també mostrarà en tot moment com va evolucionant el nostre SoC, guardarà cadascún dels projectes que es realitzen amb aquest entorn i finalment permetrà generar el SoC dissenyat.

Pseudomarkets with priorities in large random assignment economies

I study large random assignment economies with a continuum of agents and a finite number of object types. I consider the existence of weak priorities discriminating among agents with respect to their rights concerning the final assignment. The respect for priorities ex ante (ex-ante stability) usually precludes ex-ante envy-freeness. Therefore I define a new concept of fairness, called no unjustified lower chances: priorities with respect to one object type cannot justify different achievable chances regarding another object type. This concept, which applies to the assignment mechanism rather than to the assignment itself, implies ex-ante envy-freeness among agents of the same priority type. I propose a variation of Hylland and Zeckhauser' (1979) pseudomarket that meets ex-ante stability, no unjustified lower chances and ex-ante efficiency among agents of the same priority type. Assuming enough richness in preferences and priorities, the converse is also true: any random assignment with these properties could be achieved through an equilibrium in a pseudomarket with priorities. If priorities are acyclical (the ordering of agents is the same for each object type), this pseudomarket achieves ex-ante efficient random assignments.

Local and global consistency properties for student placement

In the context of resource allocation on the basis of priorities, Ergin (2002) identifies a necessary and sufficient condition on the priority structure such that the student-optimal stable mechanism satisfies a consistency principle. Ergin (2002) formulates consistency as a local property based on a fixed population of agents and fixed resources -- we refer to this condition as local consistency and to his condition on the priority structure as local acyclicity. We identify a related but stronger necessary and sufficient condition (unit acyclicity) on the priority structure such that the student-optimal stable mechanism satisfies a more standard global consistency property. Next, we provide necessary and sufficient conditions for the student-optimal stable mechanism to satisfy converse consistency principles. We identify a necessary and sufficient condition (local shift-freeness) on the priority structure such that the student-optimal stable mechanism satisfies local converse consistency. Interestingly, local acyclicity implies local shift-freeness and hence the student-optimal stable mechanism more frequently satisfies local converse consistency than local consistency. Finally, in order for the student-optimal stable mechanism to be globally conversely consistent, one again has to impose unit acyclicity on the priority structure. Hence, unit acyclicity is a necessary and sufficient condition on the priority structure for the student-optimal stable mechanism to satisfy global consistency or global converse consistency.

Annual Update on Fuel Poverty and Health (2008)

This paper provides an update on the All-Ireland Policy Paper on Fuel Poverty and Health published by the Institute of Public Health in Ireland (IPH) in December 2007.Economic downturn and fluctuating fuel prices mean that for many people the challenge of fuel poverty is becoming even more immediate. Alleviating financial strain and protecting the health and social well-being of fuel-poor householders must remain a priority across government. A substantial body of research links fuel poverty to physical and mental ill-health. Older people in particular are at an increased risk of suffering from heart disease, stroke and respiratory conditions in the winter months. Research published in Northern Ireland this year has also highlighted the impact of fuel poverty on children’s health and well-being.