Access to healthcare in Portugal:assessing geographical, organizational and financial barriers

Tese elaborada para a obtenção do grau de Doutor em Economia.Background: Healthcare is an important determinant of overall population health and the government may improve equity in health by improving access to healthcare. Methods: Three different aspects of access to healthcare in the Portuguese setting were studied: 1) geographical barriers; 2) organizational barriers; and 3) financial barriers. Geographical accessibility was analysed in the context of hospital emergency units specialised for Acute Myocardial Infarction (AMI). We analysed the impact of distance between the patients’ residence and the closest specialised hospital. The possible existence of organizational barriers was explored in terms of variation of in-hospital mortality or variation in treatment for AMI between weekdays and weekends. To assess the existence of financial barriers, we studied: 1) whether healthcare out-of-pocket payments (OOPP) in Portugal are exposing people to financial hardship; 2) the presence of unmet medical needs due to financial constraints; and 3) the determinants of OOPP. Results: The distance between the patient and the closest AMI specialised emergency unit is not a predictor of higher in-hospital mortality for patients with AMI. Also being admitted on weekends or public holidays does not predict higher in-hospital mortality for AMI. We found that OOPP are regressive overall. Also, a significant proportion of households fall close to or below the relative poverty line after accounting for OOPP (13.8%, SE=0.003) and some households already below the poverty line still pay OOPP (15.6%, SE=0.004). Almost a third of individuals reported an unmet medical need. The proportion of unmet needs is higher for individuals living in poorer households. Finally, households with at least one sick member incur higher OOPP, ceteris paribus. Conclusion: We found evidence supporting the existence of financial barriers to healthcare in Portugal, however in terms of the specific research questions, no evidence for the existence of organizational and geographical barriers was discovered.Introdução: Os cuidados de saúde são um importante determinante da saúde e o governo pode melhorar o respetivo acesso para alcançar maior igualdade dos níveis de saúde da população. Métodos: Foram estudados três diferentes aspetos do acesso aos cuidados de saúde no contexto português: 1) barreiras geográficas; 2) barreiras organizacionais; e 3) barreiras financeiras. A acessibilidade geográfica foi estudada analisando as unidades de emergência especializadas do Enfarto Agudo do Miocárdio (EAM). Analisamos o impacto da distância entre a residência do paciente e o hospital especializado mais próximo. Exploramos a possível existência de barreiras organizacionais através da variação da mortalidade intra-hospitalar ou no tratamento do EAM entre dias da semana. Para avaliar a existência de barreiras financeiras, estudamos: 1) se os pagamentos diretos em saúde (PDS) colocam os agregados familiares (AF) em dificuldades financeiras; 2) a presença de necessidades médicas não satisfeitas (unmet need) por motivos económicos; e 3) os determinantes dos PDS. Resultados: A distância entre o paciente e o hospital mais próximo com unidade de emergência especializada não é preditor de maior mortalidade intra-hospitalar para pacientes com EAM. Adicionalmente, ser admitido nos fins-de-semanas não prevê maior mortalidade intra-hospitalar por EAM. Encontramos que o PDS global sejam regressivo. Uma proporção significativa de AF encontra-se perto ou abaixo da linha de pobreza após os PDS (13,8%, SE=0,003) e alguns AF já abaixo da linha de pobreza incorrem em PDS (15,6%, SE=0,004). Quase um terço dos indivíduos que reportam uma necessidade médica reportou um unmet need, esta proporção é maior para indivíduos que vivem em AF mais desfavorecidos. Finalmente, AF com pelo menos um membro doente incorrem em PDS mais altos, ceteris paribus. Conclusão: Foi encontrada evidência sobre a existência de barreiras financeiras e, nos limites das perguntas de investigação, não encontramos evidência de barreirasN/

Hospital-acquired infections: a cost estimation for CLABSI in Portugal

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Economics from the NOVA – School of Business and EconomicsHospital-acquired infections (HAIs) are defined as system infections that neither were present nor in incubation when the patient was hospitalized. We provide an estimation of most extra direct costs (those associated to longer hospitalization), length of stay and mortality rate due to the onset of a particular HAI, the central line associated bloodstream infection (CLABSI) in a 322-bed Portuguese hospital between 2009 and 2012. Main outputs drivers are identified, then a matching estimator is implemented in order to estimate the average treatment effect (ATE) for infected patients. ATE was estimated by using two different matching criteria accounting both for personal characteristics and health status of the patients. Results are significant and in line with literature: CLABSIs result in average extra costs per patient between 7930.84€ and 11,230.42€; an extra average length of stay between 20 and 25 days; and expected difference of mortality rate between 8.58% and 18.18%. Findings- confirming expectation of higher costs associated due to these infections- have important policy implications such as decision of investing in prevention campaigns. Indeed, CLABSIs are considered highly preventable infections such that there is great potential of reducing their incidence

A rare cause of left upper quadrant abdominal pain

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Complessità delle operazioni contrattuali e interessi delle parti. Nuove prospettive del collegamento negoziale

2011 - 2012Le operazioni contrattuali c.d. complesse rappresentano un fenomeno di espressione dell’autonomia privata, funzionale alla soddisfazione di interessi concreti che rispecchiano o si manifestano per i contingenti aspetti della realtà socio economica. Tra le altre categorie dogmatiche anche quella del collegamento negoziale è figlia dell’esigenza di dare una sufficiente risposta alla realtà degli affari che non si lascia incanalare all’intero di una tipizzazione contrattuale talvolta insoddisfacente. L’esame della figura del collegamento negoziale si muove attraverso l’esame di singole ipotesi contrattuali, credito al consumo, leasing, handling, concessione di vendita, secondo una metodologia che dal dato normativo giunge al solo esame del dato giurisprudenziale, esaltando il ruolo dell’interprete nella valutazione degli interessi concreti. Però, di fronte all’uso indiscriminato della categoria giuridica de qua, specie nell’ambito dei contratti di impresa, ci si è chiesti, in primis, se può ancora riconoscersene l’attualità e l’utilità, nel nostro come negli esaminati ordinamenti francese e tedesco, in secundis, seppur attraverso una visione diametralmente opposta, ma supportata dall’intervento del legislatore europeo, rispetto al quale i modelli tedesco e francese risultano anticipatori, se può vagliarsi il collegamento negoziale, non più come categoria empirico-concettuale elaborata dalla dottrina e applicata dalla giurisprudenza bensì quale principio fondamentale del diritto europeo dei contratti, espressione di quell’ulteriore e oramai consolidato principio, anche in seno all’Unione Europea, rappresentato dalla libertà contrattuale. [a cura dell'autore]XI n.s

effect of temperature on production of ochratoxin a by aspergillus niger in orange juice

This challenging study was carried out to evaluate the temporal production of ochratoxin A (OTA) byAspergillus nigerATCC 16404 and wild typeA. nigerAM at different temperatures in fresh squeezed orange juice (Citrus sinensis[L.] Osbeck cv Tarocco). Each strain, inoculated into the filtered orange juice, was incubated at 4°C, 20°C, and 26°C for 28 days. In the juice, at 26°C and 20°C, the concentration ofA. nigerATCC 16404 increased by more than 2 log10up to the 21st day. At 4°C it remained constant. The microbial load ofA. nigerAM decreased at all temperatures. At 26°C, the maximum OTA accumulation found was 3.44 ng/mL on the 21st day forA. nigerATCC 16404 and 8. 44 ng/mL on the 7th day forA. nigerAM. The OTA synthesis seemed to be an intrinsic strain-dependent mechanism.A. nigerATCC 16404 produced OTA in accordance with the higher temperatures and the biomass concentrations, whereasA. nigerAM produced the toxin at all temperatures regardless of its biomass. These results showed that fresh orange juice contaminated withAspergillus nigeraggregate strains may contain OTA levels

Implications of using different methods to characterise anticoagulant control in patients with second generation mechanical heart valve prostheses.

OBJECTIVE:Characterisation of anticoagulant control is fundamental to investigations of its association with clinical outcome. Anticoagulant control depends on several factors. This paper aims to illustrate the implications of different methods for measuring and analysing anticoagulant control in patients with second generation mechanical heart valve prostheses. METHODS:International normalised ratio (INR) data collected during the 10-year follow-up of a randomised controlled trial were analysed. We considered the influence of: 3 different target INR ranges; anticoagulant control expressed as the proportion of INR readings (PoR) vs. anticoagulant control follow-up time (PoT); 3 ways of describing the profile of anticoagulant control over time. RESULTS:Different target INR ranges dramatically influenced derived measures of anticoagulant control; the PoT within the target range varied from 88% for the widest to 28% for narrowest range. Overall distributions of PoR and PoT observations were similar but differed by up to ± 20% for individuals; PoT exceeded PoR when control was good but was less than PoR when control was poor. Classifying PoT outside the target range showed that widely varying combinations of PoT too high and too low are possible across individuals. CONCLUSIONS:Researchers' choices about methods for measuring and quantifying anticoagulant control markedly influence the values derived from INR readings. The use of different methods across studies makes it difficult or impossible to compare findings and to establish an evidence base for clinical practice. Methods for quantifying anticoagulant control should be standardised

New technologies sustainability: monitoring and evaluation of results of interventions for the promotion of cultural heritage and the human landscape

The relationship between the development of technologies and the history of the cultural and agricultural landscape is linked to the concepts of "cultural landscape", understood as a space in continuous construction that changes with the change of individual, collective, social and cultural relationships of the inhabitants of the territory, or of the "cultural inhabitants", citizens who are producers of culture, rather than users. A vision of the "future as an open place" emerges, understood as a place of usability and sharing of all human, material and immaterial productions.Technologies, within a similar perspective, are presented as the historical evolution of téchne, whose degree of development today allows an extension of the level of human action.This study, in agreement with the scientific literature based on the use of recently developed digital models, demonstrates that the mainly agricultural territory of Basilicata, historically the site of complex social relations, has created a traditional rural society in which the concept of neighborhood and the spatial connotation also had the symbolic value of sharing knowledge and practices, relationships based on inclusiveness and sustainability. The diffusion of 5G technology is generating important cultural transformations. What used to be the neighborhood community in Matera (IT) - also following the activities launched with the CTEMT project and the social consequences of the Covid-19 pandemic - is now becoming a virtual community for sharing knowledge and practices , beliefs and values, including the use and management of cultural heritage, which takes place through the network, and therefore using applications that promote a transformative intervention of the landscape, such as to make it functional to human needs, and, at the same time, sustainable with respect to the perpetuation of ecosystem relationships.The diffusion of 5G technology, is generating important cultural transformations. What in the past was, in Matera (IT), the neighbourhood community - also as a result of the activities launched with the CTEMT project and the social consequences of the Covid-19 pandemic - now becomes a virtual community, sharing knowledge and practices, beliefs and values, including the use and management of cultural heritage, occurs through the network with the use of applications that promote accessibility and sustainability in both the urban and agricultural landscape. As argued by the International Union for Conservation of Nature (IUCN), the attention to the dynamic conservation of the landscape should not be placed so much to the "culture itself" or to the "nature itself" but rather to the relationship between these two dynamic components has been established, but also from the holistic mentioned many times, attentive to the values of identity and comforted by the knowledge and decoding of the intangible heritage, from which we deduce the active role, shared social behaviours, the mechanisms of transmission of knowledge and transgenerational awareness also thanks to the complex and fascinating universe of uses, traditions, rituals and rites that are an important tool of conscious management of the landscape and its culture. The conscious use of artificial intelligence is the concretion of the virtuous relationship between Humanism and technologies. For the biodiversity it is a support to the recognition of the species, in particular of the native ones, and it allows people to recognize themselves culturally and find into the biodiversity a collective and cultural belonging to the community and to the landscape. Therefore, thanks to the use of new technologies biodiversity becomes an historical-anthropological archive of knowledge and practices of a territory, and new technologies a powerful tool for the conservation of the cultural heritage

Emerging Molecular Technologies in Genitourinary Tumors

Non present

Brentuximab vedotin in combination with doxorubicin, vinblastine and dacarbazine for first-line treatment of stage IV HL: cost impact on subsequent lines in Italy

Introduction: This study estimates the change in the costs of second-line or later (2L+) treatments compared to the current scenario, associated with the introduction of brentuximab vedotin (Adcetris®) (BV) in combination with doxorubicin, vinblastine and dacarbazine (A+AVD) for the treatment of previously untreated (1L) patients with stage IV classical Hodgkin’s lymphoma (cHL). Methods: An economic model has been developed that estimates the variation in treatment costs of 2L+ associated with the introduction of BV in 1L from the point of view of the Italian National Health System over a time horizon of 3 years. The population eligible to receive a treatment of 2L+ has been estimated from the literature, considering an increasing consumption in the three years of A+AVD in 1L. Two main scenarios and several alternative scenarios were considered to address the uncertainty that characterizes the distribution of market shares of 2L+ treatments. Results: In the baseline scenario, over three years, the introduction of BV in 1L is associated with a cumulative reduction in treatment costs of 2L+ of € 1.74 M. In all scenarios, a reduction in treatment costs of 2L+ is confirmed, with a total saving that varies between € 5.6 M and € 1.3 M compared to the main scenarios. Conclusions: The present analysis shows that the introduction of A+AVD in 1L for the treatment of stage IV CD30+ cHL patients is associated with a reduction in treatment costs of 2L+, even if there are some limitations related to the uncertainty of real cost and population estimates