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Multi-Principal Agency and the Compliance with Professional Guidelines in Health Systems: Economic and Regulatory Perspectives
No full textAmid the trend of rising health expenditure in developed economies, changing the healthcare
delivery models is an important point of action for service regulators to contain this trend. Such a change is mostly induced by either financial incentives or regulatory tools issued by the regulators and targeting service providers and patients. This creates a tripartite interaction between service regulators, professionals, and patients that manifests a multi-principal agent relationship, in which professionals are agents to two principals: regulators and patients.
This thesis is concerned with such a multi-principal agent relationship in healthcare and attempts to investigate the determinants of the (non-)compliance to regulatory tools in light of this tripartite relationship. In addition, the thesis provides insights into the different institutional, economic, and regulatory settings, which govern the multi-principal agent relationship in healthcare in different countries. Furthermore, the thesis provides and empirically tests a conceptual framework of the possible determinants of (non-)compliance by physicians to regulatory tools issued by the regulator.
The main findings of the thesis are first, in a multi-principal agent setting, the utilization of financial incentives to align the objectives of professionals and the regulator is important but not the only solution. This finding is based on the heterogeneity in the financial incentives provided to professionals in different health markets, which does not provide a one-size-fits-all model of financial incentives to influence clinical decisions. Second, soft law tools as clinical practice guidelines (CPGs) are important tools to mitigate the problems of the multi-principal agent setting in health markets as they reduce information asymmetries while preserving the autonomy of professionals. Third, CPGs are complex and heterogeneous and so are the determinants of (non-)compliance to them. Fourth, CPGs work but under conditions. Factors such as intra-professional competition between service providers or practitioners might lead to non-compliance to CPGs – if CPGs are likely to reduce the professional’s utility. Finally, different degrees of soft law mandate have different effects on providers’ compliance. Generally, the stronger the mandate, the stronger the compliance, however, even with a strong mandate, drivers such as intra-professional competition and co-management of patients by different professionals affected the (non-)compliance
Analyzing urban green adaptation opportunities: concepts, approaches, & strategies for existing neighborhoods
Get PDFOver the last decades, the growing evidence of human-caused climate change has raised awareness of the consequences of exceeding global temperature by 2˚C. This awareness has led to a contemporary approach to the conceptualization and management of green adaptation policies in spatial planning.
This thesis aims to develop a comprehensive methodology for assessing the adaptability of existing neighborhoods to green strategies. The reliability of the proposed method is examined in the cities of Bologna and Imola and proved to be applicable in other geoghraphical locations. This thesis integrates three key themes of conceptual and implementation principles for urban green adaptation. This thesis initially defines methods for narrowing uncertainties in urban planning energy forecasting modeling by exploring the roles of integrated energy planning. The second is by exploring green retrofitting strategies in building, this thesis examines the effects of various energy-saving factors in roofing scenarios including a green roof, rooftop greenhouse, and insolated roof. Lastly, this thesis analyzes green strategies in urban spaces to enhance thermal comfort through facing urban heat exposure related to urban heat island effects.
The roles of integrated energy policies and green strategic thinking are discussed to highlight various aspects of green adaptation on the neighborhood scale. This thesis develops approaches by which cities can face the challenges of current green urban planning and connect the conceptual and practical aspects of green spatial planning. Another point that this thesis highlight is that due to the interdependency of individuals and places, it is difficult to assure whether all the adaptation policies on a large scale are enhancing the resiliency of the neighborhood or they are simply shuffling the vulnerability through the individuals and places. Besides, it asserts that neglecting to reflect on these reallocations of the effects generates serious complications, and will result in long-term dysfunctional consequences
Information disorders, new media and freedom of speech
Get PDFL’elaborato affronta il tema della massiccia diffusione di disinformazione tramite internet sotto il profilo del diritto costituzionale, nell’ottica di indagare se le dimensioni del fenomeno richiedano l’elaborazione di principi e soluzioni nuove ovvero se i paradigmi costituzionali enucleati dalla tradizione costituzionalistica con riferimento alla libertà d’espressione forniscano gli strumenti sufficienti per un intervento efficace.
In tale ottica, il lavoro premette una ricostruzione del fenomeno della disinformazione nel tentativo di individuare il perimetro socio-cognitivo e tecnologico entro cui la medesima prolifera, descrivendo gli elementi che distinguono l’informazione diffusa dai nuovi media rispetto a quella veicolata dai media mainstream. Ciò premesso, lo studio passa a delineare lo “statuto costituzionale” del falso, indagando la rilevanza che la menzogna assume sotto il profilo costituzionale nel suo rapporto con la libertà di manifestazione del pensiero negli ordinamenti interno, europeo e statunitense. L’analisi prosegue poi con l’esame delle politiche di contrasto alla disinformazione introdotte da singoli Stati (prevalentemente Germania, Francia e Italia), Unione europea, e piattaforme, con l’obiettivo di mettere in luce vantaggi e limiti dei modelli di eteroregolamentazione, coregolamentazione e autoregolamentazione. Da ultimo, l’elaborato scompone alcune delle azioni e misure passate in rassegna e le analizza con la lente d’ingrandimento della libertà di manifestazione del pensiero, ordinandone i contenuti secondo la specifica propensione a comprimere la libertà d’espressione. L’indagine si conclude con alcuni brevi spunti conclusivi che evidenziano l’esigenza, in base ai principi costituzionali analizzati, che eventuali interventi normativi siano se del caso volti alla regolazione delle piattaforme, ovvero dei “contenitori”, lasciano i contenuti al libero scambio delle idee.The dissertation addresses the issue of the massive dissemination of disinformation through the Internet from the perspective of constitutional law, investigating whether the scale of the phenomenon requires the elaboration of new principles and solutions or whether the constitutional paradigms enunciated by the constitutionalist tradition with reference to freedom of expression provide sufficient tools for effective intervention.
The paper premises a reconstruction of the disinformation phenomenon in an attempt to identify the socio-cognitive and technological perimeter within which it proliferates, describing the elements that distinguish the information disseminated by the new media from that conveyed by mainstream media. That said, the study goes on to outline the "constitutional status" of falsehood, investigating the constitutional relevance of falsehood in its relationship with freedom of manifestation of thought in domestic, European and U.S. legal systems. The analysis then continues examining policies to counter disinformation introduced by individual states (mainly Germany, France, and Italy), the European Union, and platforms, with the aim of highlighting advantages and limitations of models of regulation, co-regulation, and self-regulation. Lastly, the paper breaks down some of the actions and measures reviewed and analyzes them through the magnifying glass of freedom of speech, sorting their contents according to their specific propensity to compress freedom of expression. The dissertation ends with some brief remarks highlighting the need, based on the constitutional principles analyzed, for any regulatory interventions to be eventually aimed at regulating platforms, i.e., "containers," leaving content to the free exchange of ideas
Populism as a battlefield Populist actors and their representation on social and legacy media during the european parliament elections 2019 in Finland, Italy and the Netherlands
Get PDFThe objective of the present research is to describe and explain populist actors and populism as a concept and their representation on social and legacy media during the 2019 EU elections in Finland, Italy and The Netherlands. This research tackles the topic of European populism in the context of political communication and its relation to both the legacy and digital media within the hybrid media system.
Departing from the consideration that populism and populist rhetoric are challenging concepts to define, I suggest that they should be addressed and analyzed through the usage of a combination of methods and theoretical perspectives, namely Communication Studies, Corpus Linguistics, Political theory, Rhetoric and Corpus-Assisted Discourse Studies. This thesis considers data of different provenance. On the one hand, for the Legacy media part, newspapers articles were collected in the three countries under study from the 1st until the 31st of May 2019. Each country’s legacy system is represented by three different quality papers and the articles were collected according to a selection of keywords (European Union Elections and Populism in each of the three languages). On the other hand, the Digital media data takes into consideration Twitter tweets collected during the same timeframe based on particular country-specific hashtags and tweets by identified populist actors.
In order to meet the objective of this study, three research questions are posed and the analysis leading to the results are exhaustively presented and further discussed. The results of this research provide valuable and novel insights on how populism as a theme and a concept is being portrayed in the context of the European elections both in legacy and digital media and political communication in general
Basic income between workfare and labour changes: a labour law perspective
Get PDFL'elaborato analizza il tema del reddito di cittadinanza, nella sue diverse accezioni, indagandone le interferenze con la disciplina giulavoristica e previdenziale alla luce delle metamorfosi del lavoro. Dopo aver ricostruito la genealogia del concetto di lavoro e, con esso, dei sistemi di sicurezza sociale, esaminiamo de jure condito le misure di sostegno al reddito in Italia, con particolare accento sulla tutela contro la disoccupazione e sul reddito di cittadinanza, senza trascurare, nondimeno, le misure straordinarie messe in campo durante l'emergenza pandemica. Infine, chiedendoci quale significato assuma oggi il lavoro in un contesto caratterizzato da flessibilità e precarietà, analizzeremo dapprima le possibilità di riforma delle misure vigenti nel nostro ordinamento (dagli ammortizzatori sociali al reddito di cittadinanza), spingendoci poi de jure condendo verso la possibile declinazione di un reddito di base incondizionato, provando a ripensare alcune tradizionali categorie giuslavoristiche, a partire dalle nozioni di mansione, tempo di lavoro e retribuzione, chiedendoci se il lavoro possa avere un orizzonte di senso che vada oltre il fare in cambio di un salario.The paper analyses the issue of basic income, in its different meanings, investigating its implications for labour and social security regulations in the framework of labour metamorphosis. After reconstructing the genealogy of the concept of work and, with it, of social security systems, we examine de jure condito the income support measures in Italy, with particular emphasis on unemployment protection and citizenship income, without neglecting, however, the extraordinary measures put in place during the pandemic emergency. Finally, wondering what meaning work has today in a context characterised by flexibility and precariousness, we will first analyse the possibilities of reforming the measures currently in use in Italy (from social safety nets to citizenship income). We will then move towards the possible declination of an unconditional basic income, trying to rethink some of the classic categories of labour law, starting with the notions of jobs, working time and pay, asking ourselves whether work can have a horizon of meaning that goes beyond doing something in exchange for a wage
Challenge on healthcare services (demography, epidemiology, COVID-19) and the hopitals response. The case study of the S. Orsola Hospital in Bologna
Get PDFI sistemi sanitari sono messi sotto stress da fattori diversi che possono essere sintetizzati schematizzando il problema in pressioni sistemiche e pressioni pandemiche leggendole secondo due vettori paralleli: fattori modificabili e fattori non modificabili.
I fattori non modificabili sono legati alla condizione socio-demografica di una popolazione (reddito pro-capite, livello di istruzione) e alle caratteristiche individuali dei pazienti che accedono ai servizi (condizioni di moltimorbidità, fragilità, età, sesso) mentre i fattori modificabili sono legati al modello organizzativo del servizio regionale e Aziendale. I fattori modificabili sono quelli che leggendo i fattori non modificabili possono adattarsi al contesto specifico e con gradi di flessibilità variabile rispondere alle domande emergenti. Il tradizionale approccio ospedaliero, ancora in gran parte basato su modelli organizzativi funzionalmente e strutturalmente chiusi, costruiti attorno alle singole discipline, non si è rivelato in grado di rispondere adeguatamente da solo a questi bisogni di salute complessi che necessitano di una presa in carico multidisciplinare e coordinata tra diversi setting assistenziali.
La pandemia che ha portato in Italia ad avere più di 8 milioni di contagiati ha esacerbato problemi storici dei sistemi sanitari. Le Regioni e le Aziende hanno fronteggiato un doppio binario di attività vedendo ridursi l’erogazione di servizi per i pazienti non Covid per far fronte all’incremento di ricoveri di pazienti Covid.
Il Policlinico S. Orsola ha in questa congiuntura storica sviluppato un progetto di miglioramento del percorso del paziente urgente coinvolgendo i professionisti e dando loro strumenti operativi di analisi del problema e metodi per identificare risposte efficaci.
Riprendendo infine la distinzione tra pressioni modificabili e non modificabili il lavoro mostra che dall’analisi delle cause profonde dei nodi critici del percorso del paziente si possono identificare soluzioni che impattino sugli aspetti organizzativi (modificabili) personalizzando l’approccio per il singolo paziente (non modificabile) in un’ottica patient centred.Healthcare systems are affected by different factors can be summarized in systemic pressures and pandemic pressures. These factors can be “non-modifiable” and are linked to the socio-demographic condition of a population and to the individual characteristics of the patients or “modifiable” and are linked to the organizational model of the healthcare services.
The traditional hospital approach, largely based on functionally and structurally closed organizational models, developed around single disciplines, has not still delivered an effective response to these complex needs.
The Covid-19 pandemic with more than 8 million infected in Italy has exacerbated historical problems of the health systems. Local health Authorities have faced a double track of activities: Covid emergency trying to avoid a significant reduction in the provision of services for non-Covid patients.
At this historical juncture, the S. Orsola Polyclinic has developed a project to improve patients pathway involving professionals giving them operational tools for analyzing the problem and methods for identifying effective responses.
This work shows that from the root causes analysis of the different steps of the patient's path, it is possible to identify solutions that impact on the organizational aspects (modifiable) by tailoring the approach for the individual patient (not modifiable) in a patient-centered perspective
Investigating the mechanisms of Moraxella catarrhalis resistance to oxidative stress
Get PDFMoraxella catarrhalis (Mcat) represents a human pathogen implicated in debilitating diseases, such as Chronic Obstructive Pulmonary Disease (COPD). One of the hallmarks of COPD is the excessive neutrophil oxidative stress mediated by reactive oxygen species (ROS). Mcat shows a higher innate level of resistance to exogenous oxidative stress compared to the co-infecting human airways pathogens such as non-typeable Haemophilus influenzae (NTHi) but the underlying mechanisms are currently not well defined.
In this thesis, we demonstrated that, differently from NTHi, Mcat was able to directly interfere with ROS production and ROS-related responses such as neutrophil extracellular traps (NET) and autophagy in differentiated neutrophilic-like dHL-60 cells and primary cells. The underlying mechanisms were shown to be phagocytosis/opsonins-independent but contact-dependent, due to the engagement of the immunosuppressive receptors. Indeed, we identified that through OmpCD porin, Mcat was able to engage Siglec inhibitory receptors suppressing ROS generation by the host cells. Furthermore, Mcat provided a safer niche for the co-infecting NTHi bacterium which was otherwise susceptible to the host antimicrobial arsenal.
Subsequently, to deeply characterize the Mcat global transcriptional response to oxidative stress, an RNA-Seq experiment was performed on exponentially growing bacteria exposed to sublethal amounts of H2O2 or CuSO4, stimuli that the pathogens experienced once they are phagocytosed. We unraveled a previously unidentified common transcriptional program following H2O2 and CuSO4 exposure, demonstrating a similar defense mechanism to the stress conditions encountered in neutrophils. We ascertained new crucial factors for this pathogen response and established a novel in vivo Mcat infection model, using the invertebrate Galleria mellonella. Actually, we observed that deletion mutants of genes implicated in oxidative stress resistance exhibited reduced virulence. In conclusion, this work represents an important step in the understanding of Mcat innate resistance mechanisms to oxidative stress and further elucidate the virulence mechanisms during infection
Towards automation of constellation management with analytical models for collision avoidance
Get PDFThe growing interest for constellation of small, less expensive satellites is bringing space junk and traffic management to the attention of space community.
At the same time, the continuous quest for more efficient propulsion systems put the spotlight on electric (low thrust) propulsion as an appealing solution for collision avoidance.
Starting with an overview of the current techniques for conjunction assessment and avoidance, we then highlight the possible problems when a low thrust propulsion is used.
The need for accurate propagation model shows up from the conducted simulations. Thus, aiming at propagation models with low computational burden, we study the available models from the literature and propose an analytical alternative
to improve propagation accuracy.
The model is then tested in the particular case of a tangential maneuver. Results show that the proposed solution significantly improve on state of the art methods and is a good candidate to be used in collision avoidance operations.
For instance to propagate satellite uncertainty or optimizing avoidance maneuver when conjunction occurs within few (3-4) orbits from measurements time
Electrospun hierarchical artificial muscle for soft robotics applications
Get PDFNowadays, one of the most ambitious challenges in soft robotics is the development of actuators capable to achieve performance comparable to skeletal muscles. Scientists have been working for decades, inspired by Nature, to mimic both their complex structure and their perfectly balanced features in terms of linear contraction, force-to-weight ratio, scalability and flexibility.
The present Thesis, contextualized within the FET open Horizon 2020 project MAGNIFY, aims to develop a new family of innovative flexible actuators in the field of soft-robotics. For the realization of this actuator, a biomimetic approach has been chosen, drawing inspiration from skeletal muscle. Their hierarchical fibrous structure was mimicked employing the electrospinning technique, while the contraction of sarcomeres was designed employing chains of molecular machines, supramolecular systems capable of performing movements useful to execute specific tasks. The first part deals with the design and production of the basic unit of the artificial muscle, the artificial myofibril, consisting in a novel electrospun core-shell nanofiber, with elastomeric shell and electrically conductive core, coupled with a conductive coating, for the realization of which numerous strategies have been investigated. The second part deals instead with the integration of molecular machines (provided by the project partners) inside these artificial myofibrils, preceded by the study of several model molecules, aimed at simulating the presence of these molecular machines during the initial phases of the project. The last part concerns the realization of an electrospun multiscale hierarchical structure, aimed at reproducing the entire muscle morphology and fibrous organization. These research will be joined together in the near future like the pieces of a puzzle, recreating the artificial actuator most similar to biological muscle ever made, composed of millions of artificial myofibrils, electrically activated in which the nano-scale movement of molecular machines will be incrementally amplified to the macro-scale contraction of the artificial muscle
Evaluation of deambulation in a protected environment and in the public green in limb amputated subjects treated through a new osteointegration method
Get PDFThe limb amputation is one of the oldest surgical procedures performed and it still represents an event that drastically changes the life of an individual. Despite the technological progress, the difficulties related to the realization and daily use of the socket remain very common. Among the different technologies adopted in the prosthetic field, this project focused on the osseointegration technique. This technique consists in implanting a stem within the medullary canal of the amputated skeletal segment that extends outside the amputation stump with a prosthesis, later connected to the metal extension. The objective of this PhD project is to treat and to evaluate selected patients with osseointegrated prosthetic implants for the treatment of lower limb amputations.
Patients are recruited at the Rizzoli Orthopaedic Institute and at the Prosthesis - INAIL center of Vigorso (Budrio) during outpatient visits, while the surgical procedure is performed by the same expert surgeon in the II Orthopaedic and Traumatology Clinic of the Rizzoli Orthopaedic Institute.
The project is still ongoing, to date three patients had completed both procedures, but due to various personal problems, just one of them is included in the analysis. This patient increased his percentage of prosthesis use and the level of mobility with an overall improvement of quality of live after the procedure.
The osseointegration technique represents a promising alternative method of treatment for amputees who are not satisfied with their socket prosthesis. In the coming years it will continue the collection of clinical, radiographic and kinematic data of subjects undergoing this procedure in order to perform a long-term monitoring of both clinical outcomes and quality of life