Pay for performance in health care: a new best practice tariff-based tool using a log-linear piecewise frontier function and a dual–primal approach for unique solutions

Health care systems worldwide have faced a problem of resources scarcity that, in turn, should be allocated to the health care providers according to the corresponding population needs. Such an allocation should be as much as effective and efficient as possible to guarantee the sustainability of those systems. One alternative to reach that goal is through (prospective) payments due to the providers for their clinical procedures. The way that such payments are computed is frequently unknown and arguably far from being optimal. For instance, in Portugal, public hospitals are clustered based on criteria related to size, consumed resources, and volume of medical acts, and payments associated with the inpatient services are equal to the smallest unitary cost within each cluster. First, there is no reason to impose a single benchmark for each inefficient hospital. Second, this approach disregards dimen sions like quality (and access) and the environment, which are paramount for fair comparisons and benchmarking exercises. This paper proposes an innovative tool to achieve best-practices tariff. This tool merges both quality and financial sustain ability concepts, attributing a hospital-specific tariff that can be different from hospital to hospital. That payment results from the combination of costs related to a set of potential benchmarks, keeping quality as high as possible and higher than a user-predefined threshold, and being able to generate considerable cost savings. To obtain those coefficients we propose and detail a log-linear piecewise frontier function as well as a dual–primal approach for unique solutions.info:eu-repo/semantics/publishedVersio

Influência francesa em África no século XXI: o caso do Níger

Dissertação de mestrado em Relações InternacionaisA presente dissertação pretende analisar a relação entre a França e o Níger no século XXI. O objetivo principal é verificar qual o grau de influência que a França dispõe atualmente no século XXI no Níger. Procuramos identificar se após mais de 60 anos das independências formais concedidas às suas ex-colónias, a França mantêm algum tipo de influência em território africano. A investigação pretende analisar os meios que o governo francês dispõe para manter ainda a sua influência na zona francófona em África. Apesar de estarmos num mundo cada vez mais globalizado, o que facilita um maior número de alternativas aos países Africanos, estes continuam a priorizar o seu relacionamento com França. Como iremos ver no decorrer desta investigação, a França exerce a sua influência através dos seus meios (políticos económicos, socioculturais, militares) de que dispõem para beneficiar-se economicamente. Esta situação acontece desde 1960 até aos dias de hoje, no entanto, em menor grau que em décadas passadas. A utilização do Franco CFA – única moeda colonial ainda em circulação - por parte das ex-colónias francesas, limita em vários aspetos os países africanos, principalmente no comércio internacional e sobretudo no desenvolvimento económico da nação. Vigoram determinadas regras desde 1945, por parte do Banco Central francês que os países devem cumprir. Apesar das independências concedidas na década de 60 e de estarmos num mundo mais globalizado, a França exerce ainda hoje, no século XXI, uma considerável influência na zona francófona.The objective of this essay is to analyse the relation between France and Niger during the XX century. The main goal is to see how many influence France has on Niger nowadays in XXI century. We try to see if after 60 years of formal independence give to their ex colonies France still having any influence in this countries/ in African territories. The investigation pretend to analyse the tools that French government has to maintain their influence in the francophone zone in Africa. Even if we are in a world more and more globalize who facilitates the communication with other countries they still prioritising the relation with France. During this essay we will see France influencing these countries through their tools (economic, political, socio-cultural and military) in order to have economical benefits. This situation occurs since 1960 but nowadays is less important than on the past. The utilization of Franc CFA - the only colonial currency in circulation at this moment - by the ex French colonies is a drawback mainly for the international exchanges and above all for the economic development. Some laws by the French central bank still into effect since 1945 and these countries had to follow them. Even after the independencies given in the 60's and being in a globalize world France still having a non-negligible influence in the francophone zone nowadays

Operational efficiency vs clinical safety, care appropriateness, timeliness, and access to health care

Health care systems face resource scarcity that may jeopardise their financial sustainability as well as the quality of delivered health care. In view of that, the association between technical efficiency, access, and quality of services should be investigated, despite some past attempts that led to mixed, unclear, and perhaps biased results. We use a dataset composed of financial resources, hospital services, appropriateness and timeliness of care, patients’ clinical safety, access to health care services, demographics, and epidemiology variables to study the aforementioned link regarding the Portuguese public hospitals (operating between 2013 and 2016). Quality and access data are aggregated into three main composite indicators, through Grey Relational Analysis (GRA). Bias- and environmentally corrected efficiency scores are estimated via bootstrap-based directional Data Envelopment Analysis. A double bootstrap algorithm is employed, using GRA-based quality indicators as predictors of technical efficiency. Evidence suggests that (1) Portuguese public hospitals exhibit low performance in terms of quality, while the different indicators present considerable correlation among them and with hospital size and patients’ complexity characteristics; (2) patients’ clinical safety, appropriateness and timeliness, as well as access to health care services are consistent and significant predictors of technical efficiency; and (3) the association between efficiency, quality, and access depends on the interaction between appropriateness, timeliness, and access. Therefore, quality and access can be improved with no efficiency sacrifice and vice versa.info:eu-repo/semantics/publishedVersio

Influence of the dual combination of silymarin and (-)-epigallocatechin gallate, natural dietary flavonoids, on the pharmacokinetics of oxcarbazepine in rats

Considering the potential of flavonoids in reversing the P-glycoprotein (P-gp)–mediated multidrug resistance, this work aimed to assess the combined effects of silymarin and (-)-epigallocatechin gallate (EPG) on the pharmacokinetics of the P-gp substrates oxcarbazepine (OXC) and licarbazepine (LIC). Rats were pre-treated intraperitoneally with silymarin (25 mg/kg), EPG (25 mg/kg), silymarin/EPG (12.5/12.5 mg/kg; 6.25/18.75 mg/kg; 18.75/6.25 mg/kg) or verapamil (25 mg/kg, reference P-gp inhibitor) before the intraperitoneal administration of OXC (50 mg/kg). Pre-treatment with dual silymarin/EPG combinations originated peak plasma concentrations of OXC and LIC (pharmacologically active metabolite of OXC) similar to those achieved in the presence of verapamil (positive control). Moreover, the effects promoted by silymarin/EPG combinations on the magnitude of systemic drug exposure to OXC and LIC were also reflected in the corresponding drug levels attained in the brain (biophase). These findings evidence the synergistic effect of silymarin and EPG in enhancing the degree of systemic exposure to OXC and LIC in rats, which occurred in a comparable extent to that observed with verapamil. Hence, our findings support the combination of flavonoid-type P-gp inhibitors and P-gp substrate antiepileptic drugs as a potential therapeutic strategy for the management of pharmacoresistant epilepsy.The authors are grateful to FCT - Foundation for Science and Technology (Lisbon, Portugal) for the PhD fellowship of Ana Ferreira (SFRH/BD/84936/2012). This work was also supported by FEDER funds through the POCI - COMPETE 2020 - Operational Programme Competitiveness and Internationalization in Axis I - Strengthening research, technological development and innovation (Project POCI-01-0145-FEDER-007491) and National Funds by FCT (Project UID/Multi/00709/2013)

Customers satisfaction in pediatric inpatient services: A multiple criteria satisfaction analysis

Objective: To assess customer satisfaction determinants in a public pediatric inpatient service and propose some strategies to enhance the consumer and customer experience. Methods: We applied a Multiple Criteria Customer Satisfaction Analysis to estimate the value functions associated with each satisfaction (sub)criterion and determine the corresponding weights. We characterized satisfaction criteria (according to the Kano’s model), estimated the customers’ demanding nature and the potential improvements, and proposed strategic priorities and opportunities to enhance customer satisfaction. Main findings: Strategies for satisfaction enhancement do not depend solely on the criteria with the lowest satisfaction levels and the estimated weights, each criterion’s nature, the customers’ demanding nature, and the technical margin for improvements. Conclusions: Areas deserving attention include clinical staff’s communication skills, the non-clinical professionals’ efficiency, availability, and kindness; food quality; visits’ scheduling and quantity; and facilities’ comfort.info:eu-repo/semantics/publishedVersio

Pneumonia adquirida na comunidade : aspectos particulares da infecção no idoso

Trabalho de projecto de mestrado integrado em Medicina (Pneumologia), apresentado à Faculdade de Medicina da Universidade de CoimbraIntrodução: Devido ao envelhecimento populacional, a pneumonia adquirida na comunidade (PAC) assume uma elevada importância socioeconómica nos países desenvolvidos. Representa, actualmente, a principal causa de morte por infecções e a quinta causa de morte no geral na população geriátrica. Objectivos: A presente revisão propõe-se sistematizar o conhecimento existente acerca da PAC incidindo sobre os aspectos particulares da infecção no idoso em relação a factores de risco predisponentes, principais agentes etiológicos, métodos de diagnóstico e estratificação da gravidade, bem como estratégias de tratamento e prevenção. Desenvolvimento: As taxas de incidência, hospitalização, morbilidade e mortalidade são significativamente mais elevadas na população geriátrica em comparação com populações mais jovens. Os mecanismos responsáveis por este facto não estão totalmente compreendidos. No entanto, foram descritas na literatura alterações anátomo-fisiológicas associadas ao envelhecimento que aumentam o risco de PAC. Alguns factores de risco independentes foram também identificados. O Streptococcus pneumoniae mantém-se como o principal agente etiológico de PAC no idoso. Alguns microorganismos atípicos e patogénios emergentes, têm também importância clínica. A sintomatologia no idoso é geralmente subtil e difícil de identificar. O diagnóstico deverá ser suspeitado perante um idoso que se apresenta com febre, geralmente baixa, alteração do estado mental, falência orgânica única ou múltipla e agravamento súbito de comorbilidades. A terapêutica antimicrobiana na população geriátrica não difere significativamente de populações mais jovens. As recomendações actuais IDSA/ATS conferem uma adequada Pneumonia Adquirida na Comunidade - Aspectos Particulares da Infecção no Idoso Mestrado Integrado em Medicina - Faculdade de Medicina da Universidade de Coimbra 7 cobertura antimicrobiana na população geriátrica e, como tal, depois de realizada a avaliação da gravidade de PAC, estratificação do risco e decisão do local de tratamento, as guidelines deverão ser seguidas. A escolha do antibiótico mais adequado dentro dos propostos, deverá ser baseada nos padrões de sensibilidade antimicrobiana regionais, bem como na presença de factores de risco associados a infecção por microorganismos atípicos ou resistentes à antibioterapia empírica. A prevenção de PAC no idoso consiste em vacinação antigripal e antipneumocócica, e evicção tabágica. Modificações higiénicas e comportamentais são também importantes, apesar de menos eficazes. Conclusões: O envelhecimento populacional e o consequente aumento da prevalência de PAC devem ser preocupações actuais nos países desenvolvidos. A abordagem sistematizada ao doente idoso com PAC, através de uma adequada estratificação do risco e seguimento de guidelines internacionais, tem o potencial de melhorar os resultados da terapêutica. As medidas de prevenção devem ser activamente implementadas. Actualmente, é necessário desenvolver e implementar medidas protocoladas especificamente direccionadas ao doente idoso com PAC, que melhorem a sua abordagem clínicaIntroduction: Due to population aging, community-acquired pneumonia (CAP) imposes a high economic burden to developed countries. Currently, it represents the leading cause of death from infection and the fifth leading cause of death in the elderly. Objectives: This review updates knowledge on CAP focusing on particular aspects of the infection in the elderly considering risk factors, main etiologic agents, diagnostic workup and severity stratification, treatment strategies and prevention. Development: The rates of incidence, hospitalization, morbidity and mortality are significantly higher in the elderly when compared to younger populations. The mechanisms responsible for this fact are not fully understood. However, there are anatomical and physiological age-related changes that increase the risk of CAP. Some independent risk factors were also identified. Streptococcus pneumoniae continues to be the primary etiologic agent of CAP in the elderly. Some atypical microorganisms and emerging pathogens have also shown clinical significance. CAP’s clinical presentation in the elderly is often subtle and difficult to identify. The diagnosis should be suspected in all elderly patients who present with usually low-grade fever, altered mental status, single or multiple organ failure and sudden worsening of comorbidities. The antimicrobial therapy in the elderly does not differ significantly from younger populations. Current IDSA/ATS recommendations provide adequate antimicrobial coverage in the elderly. After severity assessment, risk stratification and treatment-site decision, guidelines for CAP must be followed. Choosing the most appropriate antibiotics should be Pneumonia Adquirida na Comunidade - Aspectos Particulares da Infecção no Idoso Mestrado Integrado em Medicina - Faculdade de Medicina da Universidade de Coimbra 9 based on local patterns of antimicrobial susceptibility and the presence of risk factors for atypical or antibiotherapy-resistant microorganisms. The main preventive measures are pneumococcal and influenza vaccination, along with smoking cessation. Hygienic and behavioral changes are also important, though less effective. Conclusions: The population aging and the consequent increase in the prevalence of CAP should be of current concern in developed countries. A systematic approach to elderly patients with CAP, through an appropriate risk stratification and adherence to established international guidelines, has the potential to improve therapy results. Preventive measures should be actively implemented. Currently, it is necessary to develop and implement measures specifically targeted to the elderly patient with CAP, in order to improve their clinical approach

Nemo tenetur se ipsum accusare e a obrigação de sujeição a exames

O princípio nemo tenetur se ipsum accusare assume importância cabal no processo penal português, enquanto garantia do direito de defesa atribuída ao arguido. Trata-se de um princípio que assevera o direito à não obrigação de auto-incriminação, que não se encontra contemplado na Constituição da República Portuguesa, assim como na maioria das Leis fundamentais estrangeiras, mas cujo espírito se retira da conjugação de algumas disposições legais do Código de Processo Penal, motivo pelo qual é considerado um princípio constitucional não positivado. No âmbito da investigação criminal, deverão ser recolhidas provas, legais, com vista a serem valoradas, de modo a poder acusar ou absolver determinado arguido pela prática de um crime. Numa dessas formas de recolha de prova estão os exames. Resta perceber em que medida se pode obrigar um arguido a sujeitar-se a esse meio de obtenção de prova sem, concomitantemente, colidir com o seu direito à não auto-incriminação. Para isso, faremos uma abordagem doutrinal sobre o princípio em causa e regime legal dos exames para, seguidamente, passarmos à análise jurisprudencial, tanto nacional como estrangeira, culminando numa conclusão que permita encontrar o equilíbrio entre as duas realidades, a sujeição a exames e o nemo tenetur.The principle of nemo tenetur se ipsum accusare assumes full importance on the portuguese law procedure, has a right of defense assurance attributed to the defendant. It´s about a principle that asserts the right of non mandatory self-incrimination, that does not state on the Portuguese Republican Constitution, has the majority of the foreign fundamental laws, but whose spirit withdraws from the conjugation of some Criminal Procedure Code legal dispositions, reason which is considered a constitutional non-positived principle. On the matter of Criminal Investigation, there should be recovered legal proofs, in order to be valued, so that some defendant can or cannot be accused of practicing criminal activities. One way of gathering proofs are in the exams. After that we have to understand in what way we can obligate a defendant to subject himself to that procedure of getting the proof without, simultaneously, colliding with his right of non self-incrimination. For that, we will do a doctrinal approach about the principle in question and the legal exams regime so that we can pass to the jurisprudential analysis, national and foreign, culminating in a conclusion that allows us to find the balance between the two realities, the exam subjection and the nemo tenetur

HOSPITALIZATION FOR PERTUSSIS – A TEN YEARS CASUISTIC FROM A LEVEL III HOSPITAL

Introdução: A tosse convulsa continua a ser uma preocupação em idade pediátrica. Os adolescentes e adultos são reconhecidos como fonte de transmissão de doença, particularmente para lactentes sem primovacinação completa. Pretende-se caracterizar os casos de tosse convulsa sob o ponto de vista epidemiológico, clínico e terapêutico. Material e Métodos: Estudo observacional, descritivo, através da análise retrospetiva dos processos clínicos dos doentes internados por infeção por Bordetella pertussis (identificada por método de PCR) no Serviço de Pediatria de um hospital nível III entre Janeiro de 2005 e Dezembro de 2014. Resultados: Foram internados 43 doentes, com uma duração mediana de oito dias. Verificou-se maior número de internamentos nos anos de 2008 e 2012, com predomínio no Verão. Apresentavam uma mediana de idades de 2,5 meses (mínimo 12 dias, máximo 16 anos), 86,0% dos quais (n=37) eram lactentes sem primovacinação completa. Todos os doentes apresentavam tosse e 48,8% (n=21) tinham contexto sugestivo de coqueluche. Todos foram medicados com macrólido, com intervalo entre o início dos sintomas e da terapêutica, mediano de oito dias (mínimo 2; máximo 60 dias). Verificou-se coinfeção vírica em 21,6% (n=14). Dez doentes foram internados em cuidados intensivos e registaram-se dois óbitos. Discussão e Conclusões: À semelhança de outros estudos, verificou-se um pico de incidência no ano de 2012. Os lactentes foram o grupo mais vulnerável para infeção por Bordetella pertussis, com maior número de internamentos. Parecem ser necessárias novas estratégias de prevenção complementares às existentes para reduzir a ocorrência desta infeção neste grupo etário.Background: Whooping cough remains a concern in pediatric age. Adolescents and adults are recognized as a source of disease transmission, particularly for infants without complete primary immunization. The objectives of this study were to characterize clinically and epidemiologicaly hospitalized pediatric cases of pertussis. Material and methods: Retrospective, observational study of pediatric patients hospitalized at a level III Portuguese hospital with Bordetella pertussis infection confirmed by PCR DNA assay, between January 2005 and December 2014. Results: Forty-three patients were admitted with an median duration of eight days. We observed a higher number of admissions in 2008 and 2012, with majority of cases in the summer. The median age was 2,5 months old (minimum 12 days; maximum 16 years), of which 86.0% (n=37) infants without complete primary vaccination. All patients had cough and 48.8% (n=21) had an identified epidemiological contact of pertussis. All were treated with macrolides, with a mean interval between onset of symptoms and treatment of eight days (minimum 2; maximum 60 days). Viral coinfection occurred in 21.6% (n=14). Ten patients were admitted to intensive care unit and two deceased. Conclusions: Like other studies, there was a incidence peak in 2012. Infants were the most vulnerable age group to infection by Bordetella pertussis, with the highest number of hospitalizations. There is a need for additional prevention strategies to improve prevention in this age group.info:eu-repo/semantics/publishedVersio