Ownership, Incentives and Hospitals

This article analyzes hospital privatization by comparing costs and quality between different ownership forms. We put the attention on the distinction between public hospitals and private hospitals with public funding. Using information about Spanish hospitals, we have found that private hospitals provide services at a lower cost at expenses of lower quality. We observe that property rights theory is fulfilled at least for the Spanish hospital market. The way that Heath Authorities finance publicly funded hospitals may be responsible for the differences in incentives between public and private centers. We argue that the trade-off between costs and quality could be minimized by designing financing contracts with fixed and variable components.Privatization, Hospitals, Costs, Quality. JEL classification:I11; L15; L33

Performance evaluation of the Hilbert–Huang transform for respiratory sound analysis and its application to continuous adventitious sound characterization

© 2016. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/The use of the Hilbert–Huang transform in the analysis of biomedical signals has increased during the past few years, but its use for respiratory sound (RS) analysis is still limited. The technique includes two steps: empirical mode decomposition (EMD) and instantaneous frequency (IF) estimation. Although the mode mixing (MM) problem of EMD has been widely discussed, this technique continues to be used in many RS analysis algorithms. In this study, we analyzed the MM effect in RS signals recorded from 30 asthmatic patients, and studied the performance of ensemble EMD (EEMD) and noise-assisted multivariate EMD (NA-MEMD) as means for preventing this effect. We propose quantitative parameters for measuring the size, reduction of MM, and residual noise level of each method. These parameters showed that EEMD is a good solution for MM, thus outperforming NA-MEMD. After testing different IF estimators, we propose Kay¿s method to calculate an EEMD-Kay-based Hilbert spectrum that offers high energy concentrations and high time and high frequency resolutions. We also propose an algorithm for the automatic characterization of continuous adventitious sounds (CAS). The tests performed showed that the proposed EEMD-Kay-based Hilbert spectrum makes it possible to determine CAS more precisely than other conventional time-frequency techniques.Postprint (author's final draft

The significance of fluoride uptake and inflammation within the atherosclerotic plaque: a PET/CT analysis

Background and aims: Atherosclerosis is a vessel disease, having a relatively early onset and a slow progression, and is currently the first cause for morbidity and mortality worldwide. Patients with atherosclerosis are usually classified according to their cardiovascular risk; however, tools to characterize the atherosclerotic plaque or to predict its progression are presently missing. In this thesis, we present a novel approach to this issue, by applying multimodal (CT- ad PET-based) imaging, in synergy with segmentation analysis, to the atherosclerotic plaques. Materials and Methods: Patients were recruited from three different databases retrospectively and then assigned to three different study populations. Population A consisted of 51 patients (19 females, mean age 69\uf0b19 years, range 49-82), submitted to 18F-NaF-PET/CT (NaF-PET). Each patient underwent at least 2 Naf-PET, spaced on average 14 months apart. In each patient, a VOI was placed on each visible CT plaque, using a CT-iso-contour approach; mean blood-pool normalized SUV (TBR), mean HU and Agaston-like calcification score (CS) were computed. TBR was compared with the mean percent variation of HU and CS, normalized for elapsed time between NaF-PETs (NDHU% and NDCS%, respectively). Whole-aorta TBR was then compared to whole-aorta NDCS%. Population B included 79 patients (51 women, 70.8 \ub18 years) who underwent NaF-PET. Plaque analysis was performed as described above. An in-house software application was used to identify and segment the trabecular bone semi-automatically. TBR and HU of trabecular bone were compared to the ones of arterial plaques. Population C consisted of twenty-seven patients (12 males, mean age 69.4 \ub1 8, range 56-87), who underwent a 18F-FDG and a 68Ga-DOTATOC PET/CT within a two-weeks period Cardiovascular risk score was estimated in all patients; TBRmax and TBRmean was calculated in a large VOI, placed on the aorta, in FDG and DOTATOC scans. Results: In population A, mean HU and CS significantly increased from the first to the second PET/CT (p<0.001). A tight and direct correlation was noted between TBR in the plaques in the baseline PET and both NDHU% (R=0.67, p<0.01) and NDCS% (R=0,7, p<0.001). Whole-aorta TBR correlated with NDCS% in the entire vessel (R=0,85, p<0.001). In the population B, mean plaque density showed an inverse association with vertebral HU density (R=-0.56, p<0.01). Plaque and trabecular bone TBR were directly and closely correlated (R=0.63 and p<0.001). At univariate analysis, mean HU density of aortic plaque was not predicted by any of the cardiovascular risk factor or by age; conversely, it was related to its own TBR (p=<0.001) as well as by trabecular bone TBR. In population C, the mean of TBRmax was significantly higher in 68Ga-DOTATOC PET, when compared to FDG (5,7\ub13,1 Vs. 2\ub11,2, p<0.01). A tight and direct correlation was noted between FDG TBRmean and CV risk score (R=0.82, p<0.001), as well as between 68Ga-DOTATOC TBRmean and CV risk score (R=0.81, p<0.001). Average TBRmax of 68Ga-DOTATOC was slightly higher in DM patients when compared to the non-diabetic ones (6\ub12.1 Vs. 4,9\ub10,9, p<0.05). Conclusions: PET/CT with NaF can predict subsequent plaque evolution: in particular, plaque displaying a higher uptake have a greater progression of calcification at follow-up. Observing the behavior of skeletal bone might represent a new window for assessing the plaques\ub4 characteristics. Inflammation within the plaque can be detected by 18F-FDG and by 68Ga-DOTATOC, the latter tracer might perform better, especially in diabetic patients. Overall PET techniques could display a great relevance in diverse research fields, such as assessment of therapy effectiveness and identification of vulnerable plaques; further study could allow the possibly enabling a patient-centered treatment and improving therapy outcomes as well as quality of life.application of this methods to larger population

Impact of close and positive margins in transoral laser microsurgery for TIS-T2 glottic cancer

Introduction: Transoral laser microsurgery (TLM) represents one of the most effective treatment strategies for us 12 glottic squamous cell carcinomas (SCC). The prognostic influence of close/positive margins is still debated, and the role of narrow band imaging (NBI) in their intraoperative definition is still to be validated on large cohort of patients. This study analyzed the influence of margin status on recurrence-free survival (RFS) and disease specific survival (DSS).Methods: We retrospectively studied 507 cases of pTis-Tib (Group A) and 127 cases of pT2 (Group B) glottic SCC. We identified the following margin status: negative (n = 232), close superficial (n = 79), close deep (CD) (n = 35), positive single superficial (n = 146), positive multiple superficial (n = 94), and positive deep (n = 48) and analyzed their impact on RFS and DSS. Close margins were defined by tumor-margin distance &lt;1 mm. PreTLM margins were defined by white light in 323 patients, whereas NBI was employed in 311 patients.Results: In Group A, DSS and RFS were reduced in positive multiple superficial and positive deep margins (DSS = 96.1 and 97%, both p &lt; 0.05; RFS = 72%, p &lt; 0.001 and 75.8%, p &lt; 0.01). In Group B, DSS was reduced in positive multiple superficial margins (82.4%, p &lt; 0.05). RFS was reduced in positive single superficial, positive multiple superficial, and positive deep margins (62.5, 41.2, and 53.3%, p &lt; 0.01). In the entire population, RFS was reduced in CD margins (77.1%, p &lt; 0.05). Use of NBI led to improvement in RFS and DSS.Conclusion: The study indicates that close and positive single superficial margins do not affect DSS. By contrast, all types of margin positivity predict the occurrence of relapses, albeit with different likelihood, depending on stage/margin type. CD margins should be considered as a single risk factor. Use of NBI granted better intraoperative margins definition

Los caminos de la expansión de China por el mundo

Reseña de: Hauter, François, Planète Chinoise, Ed. Carnets Nord, París, 200