The Implications of Sequential Investment in the Property Rights Theory of the Firm

In the property rights theory of the firm, control over assets (ownership) affords bargaining power in the case of re-negotiation, providing incentives for parties to make relationship specific investments. The models predict that property rights will be allocated so as to maximise surplus generated from investment. However, these models assume that investments are made simultaneously. In this thesis I extend the standard property-rights framework to allow for sequential investment; the model allows for two investment periods. If a party invests first (ex-ante), they sink their investment before any contracting is possible. The parties that invest second (ex-post) do so after some aspects of the project are tangible, so that they can contract on (at least some) of their investment costs. As well as being empirically relevant, sequencing has several important theoretical implications. First, if a party gets to invest second, then – ceteris paribus – it has a greater incentive to invest. Second, the investment of parties that invest first are affected by a more than one influence. Anticipating higher ex-post investment, they can have a greater incentive to increase their investments. However, higher ex-post investment leads to greater costs being borne by the ex-ante investors (via the cost sharing contracts); this reduces ex-ante incentives to invest. Overall either effect can dominate so that ex-ante investment can either increase or decrease as a result of sequential investment. Third, as noted, sequencing of investment provides the possibility to (partially) contract on ex-post investment and costs. This is an additional method of providing incentives to invest, beyond the allocation of property rights themselves. Consequently, ex-post investors can be protected (and be provided incentives to invest) via these contracts, whereas ex-ante investors –who can not contract on their investments at all – are more likely to require the protection of property rights (through the allocation of asset ownership). The addition of sequential investment alters some of the predictions of the standard models. For example, previously the literature found that if all assets are complements at the margin all agents should have access to all assets (Bel (2005)). However, when investment sequencing is possible, making a control structure more inclusive (increasing the number of agents who have access to assets) can reduce the incentives of the ex-ante investors, decreasing overall surplus; this is because increasing the property rights of ex-post investors increases the marginal costs borne by ex-ante investors, effectively reducing their claim on surplus, diminishing their incentives to invest. This result contradicts Bel (2005), and shows that even when all assets are complimentary at the margin allocating access rights can be detrimental to incentives. Furthermore, if assets are substitutes at the margin then transfer of assets from ex-ante investors to ex-post investors can increase ex-ante investment and surplus. This counter intuitive result can occur in the case when decreasing ex-post investment is necessary to provide an incentive to ex-ante investors to increase their investments.Discipline of Economic

Decision-making regarding antibiotic therapy duration: An observational study of multidisciplinary meetings in the intensive care unit

Purpose: Antibiotic therapy is commonly prescribed longer than recommended in intensive care patients (ICU). We aimed to provide insight into the decision-making process on antibiotic therapy duration in the ICU. Methods: A qualitative study was conducted, involving direct observations of antibiotic decision-making during multidisciplinary meetings in four Dutch ICUs. The study used an observation guide, audio recordings, and detailed field notes to gather information about the discussions on antibiotic therapy duration. We described the participants' roles in the decision-making process and focused on arguments contributing to decision-making. Results: We observed 121 discussions on antibiotic therapy duration in sixty multidisciplinary meetings. 24.8% of discussions led to a decision to stop antibiotics immediately. In 37.2%, a prospective stop date was determined. Arguments for decisions were most often brought forward by intensivists (35.5%) and clinical microbiologists (22.3%). In 28.9% of discussions, multiple healthcare professionals participated equally in the decision. We identified 13 main argument categories. While intensivists mostly used arguments based on clinical status, clinical microbiologists used diagnostic results in the discussion. Conclusions: Multidisciplinary decision-making regarding the duration of antibiotic therapy is a complex but valuable process, involving different healthcare professionals, using a variety of argument-types to determine the duration of antibiotic therapy. To optimize the decision-making process, structured discussions, involvement of relevant specialties, and clear communication and documentation of the antibiotic plan are recommended

A survey to identify barriers of implementing an antibiotic checklist

A checklist is an effective implementation tool, but addressing barriers that might impact on the effectiveness of its use is crucial. In this paper, we explore barriers to the uptake of an antibiotic checklist that aims to improve antibiotic use in daily hospital care. We performed an online questionnaire survey among medical specialists and residents with various professional backgrounds from nine Dutch hospitals. The questionnaire consisted of 23 statements on anticipated barriers hindering the uptake of the checklist. Furthermore, it gave the possibility to add comments. We included 219 completed questionnaires (122 medical specialists and 97 residents) in our descriptive analysis. The top six anticipated barriers included: (1) lack of expectation of improvement of antibiotic use, (2) lack of expected patients' satisfaction by checklist use, (3) lack of feasibility of the checklist, (4) negative previous experiences with other checklists, (5) the complexity of the antibiotic checklist and (6) lack of nurses' expectation of checklist use. Remarkably, 553 comments were made, mostly (436) about the content of the checklist. These insights can be used to improve the specific content of the checklist and to develop an implementation strategy that addresses the identified barriers

Major gaps between recommended perioperative diabetes care and current practice

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Nationwide survey of hospital antibiotic stewardship programs in France

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Choosing Wisely in Daily Practice: An Intervention Study on Antinuclear Antibody Testing by Rheumatologists

OBJECTIVE: To assess the effect of a simple intervention on antinuclear antibody (ANA) test overuse by rheumatologists. METHODS: This was an explorative, pragmatic, before-and-after, controlled implementation study among rheumatologists working at 3 rheumatology departments in secondary and tertiary care centers in The Netherlands. The intervention was given in all study centers separately and combined education with feedback. Six outcome measures describe the intervention effects: the ANA/new patient ratio (APR), difference with the target APR, percentage of positive ANA tests, percentage of repeated ANA testing, percentage of ANA-associated diseases, and APR variation between rheumatologists. Outcomes were compared between the pre- and postintervention period (both 12 months) using (multilevel) logistic regression or F testing. Results are reported together for centers 1 and 2, and separately for center 3, because ANA tests could not be linked to an individual rheumatologist in center 3. RESULTS: The APR decreased from 0.37 to 0.11 after the intervention in centers 1 and 2 (odds ratio [OR] 0.19, 95% confidence interval [95% CI] 0.17-0.22, P < 0.001) and from 0.45 to 0.30 in center 3 (OR 0.53, 95% CI 0.45-0.62, P < 0.001). The percentage of repeated ANA requests in all centers and the APR variation for centers 1 and 2 decreased significantly. Only in center 3 did the percentage of ANA-associated diseases increase significantly. CONCLUSION: A simple intervention resulted in a relevant and significant decrease in the numbers of ANA tests requested by rheumatologists, together with an improvement on 3 other outcome measures

Which determinants should be targeted to increase influenza vaccination uptake among health care workers in nursing homes?

Contains fulltext : 79833.pdf (publisher's version ) (Closed access)Although health care workers (HCWs) have been recommended to be immunized against influenza, vaccine uptake remains low. So far, research on determinants of influenza vaccination among HCWs has been limited by design, population or theoretical framework. Therefore we conducted a questionnaire study in Dutch nursing homes to assess which demographical, behavioural and organisational determinants were associated with influenza vaccine uptake among HCWs. We were able to accurately predict vaccine uptake based on a 13-item prediction model including two demographical, nine behavioural and two organisational determinants developed with data from 1,125 respondents (response rate 60%). To further increase influenza vaccine uptake, implementation programs should target these determinants

Effects of a multi-faceted program to increase influenza vaccine uptake among health care workers in nursing homes: A cluster randomised controlled trial

Despite the recommendation of the Dutch association of nursing home physicians (NVVA) to be immunized against influenza, vaccine uptake among HCWs in nursing homes remains unacceptably low. Therefore we conducted a cluster randomised controlled trial among 33 Dutch nursing homes to assess the effects of a systematically developed multi-faceted intervention program on influenza vaccine uptake among HCWs. The intervention program resulted in a significantly higher, though moderate, influenza vaccine uptake among HCWs in nursing homes. To take full advantage of this measure, either the program should be adjusted and implemented over a longer time period or mandatory influenza vaccination should be considered. (C) 2010 Elsevier Ltd. All rights reserved

Metrics to assess the quantity of antibiotic use in the outpatient setting : a systematic review followed by an international multidisciplinary consensus procedure

Objectives: Quality indicators (QIs) assessing the appropriateness of antibiotic use are essential to identify targets for improvement and guide antibiotic stewardship interventions. The aim of this study was to develop a set of QIs for the outpatient setting from a global perspective. Methods: A systematic literature review was performed by searching MEDLINE and relevant web sites in order to retrieve a list of QIs. These indicators were extracted from published trials, guidelines, literature reviews or consensus procedures. This evidence-based set of QIs was evaluated by a multidisciplinary, international group of stakeholders using a RAND-modified Delphi procedure, using two online questionnaires and a face-to-face meeting between them. Stakeholders appraised the QIs' relevance using a nine-point Likert scale. This work is part of the DRIVE-AB project. Results: The systematic literature review identified 43 unique QIs, from 54 studies and seven web sites. Twenty-five stakeholders from 14 countries participated in the consensus procedure. Ultimately, 32 QIs were retained, with a high level of agreement. The set of QIs included structure, process and outcome indicators, targeting both high- and middle- to low-income settings. Most indicators focused on general practice, addressing the common indications for antibiotic use in the community (particularly urinary and respiratory tract infections), and the organization of healthcare facilities. Twelve indicators specifically addressed outpatient parenteral antimicrobial therapy (OPAT). Conclusions: We identified a set of 32 outpatient QIs to measure the appropriateness of antibiotic use. These QIs can be used to identify targets for improvement and to evaluate the effects of antibiotic stewardship interventions