Relationships between technical efficiency and the quality and costs of health care in Italy†

Objectives This paper reports the measurement of technical efficiency of Tuscan Local Health Authorities and its relationship with quality and appropriateness of care. Design First, a bias-corrected measure of technical efficiency was developed using the bootstrap technique applied to data envelopment analysis. Then, correlation analysis was used to investigate the relationships among technical efficiency, quality and appropriateness of care. Setting and Participants These analyses have been applied to the Local Health Authorities of Tuscany Region (Italy), which provide not only hospital inpatient services, but also prevention and primary care. All top managers of Tuscan Local Health Authorities were involved in selection of the inputs and outputs for calculating technical efficiency. Main Outcome Measures The main measures used in this study are volume, quality and appropriateness indicators monitored by the multidimensional performance evaluation system developed in the Tuscany Region. Results On average, Tuscan Local Health Authorities experienced 14(%) of bias-corrected inefficiency in 2007. Correlation analyses showed a significant negative correlation between per capita costs and overall performance. No correlation was found in 2007 between technical efficiency and overall performance or between technical efficiency and per capita costs. Conclusions Technical efficiency cannot be considered as an extensive measure of healthcare performance, but evidence shows that Tuscan Local Health Authorities have room for improvement in productivity levels. Indeed, correlation findings suggest that, to pursue financial sustainability, Local Health Authorities mainly have to improve their performance in terms of quality and appropriateness

a simplified procedure for base sliding evaluation of concrete gravity dams under seismic action

Possible base sliding induced by an earthquake on concrete gravity dams is obtained by a simplified procedure. The model is a nonlinear single-degree-of-freedom system which takes into account dam-water-foundation interaction based on the model developed by Fenves and Chopra (1987). The nonlinearity is in the foundation rock, since a threshold value for the sliding foundation resistance, modeled with the Mohr-Coulomb yielding criterion including a frictional and a cohesive component, is imposed. Nonlinear step by dams is obtained by a simplified procedure. The model is a nonlinear single-degree-of-freedom system which takes into account dam-water-foundation interaction based on the model developed by Fenves and Chopra (1987). The nonlinearity is in the foundation rock, since a threshold value for the sliding foundation resistance, modeled with the Mohr-Coulomb yielding criterion including a frictional and a cohesive component, is imposed. Nonlinear step by step dynamic analyses are carried out on four case studies representing typical examples of Italian concrete gravity dams by utilizing several natural earthquakes. On the basis of the obtained results, a simplified methodology to estimate residual displacement without performing nonlinear dynamic analysis is presented. An example of application using as seismic input the elastic response spectra furnished by the Italian Code is also presented

Obesity and fracture risk.

Obesity and osteoporosis are two common diseases with an increasing prevalence and a high impact on morbidity and mortality. Obese women have always been considered protected against osteoporosis and osteoporotic fractures. However, several recent studies have challenged the widespread belief that obesity is protective against fracture and have suggested that obesity is a risk factor for certain fractures. Fat and bone are linked by many pathways, which ultimately serve the function of providing a skeleton appropriate to the mass of adipose tissue it is carrying. Leptin, adiponectin, adipocytic estrogens and insulin/amylin are involved in this connection. However, excessive body fat, and particularly abdominal fat, produces inflammatory cytokines which may stimulate bone resorption and reduce bone strength. This review aimed to examine the literature data on the relationships of BMI and fat mass with factures in adult and elderly subjects. Even though the more recent studies have shown conflicting results, there is growing evidence that obesity, and particularly severe obesity, may be related to an increased risk of fracture at different skeletal sites which is partially independent from BMD. Moreover, the relationship between obesity and fracture appears to be markedly influenced by ethnicity, gender and fat distribution. Even though the incidence and the pathogenesis of fracture in obese individuals has not yet been clearly defined, the growing evidence that obesity may be related to an increased risk of fracture has important public health implications and emphasizes the need to develop effective strategies to reduce fracture risk in obese subject

Divergent effects of obesity on fragility fractures

Obesity was commonly thought to be advantageous for maintaining healthy bones due to the higher bone mineral density observed in overweight individuals. However, several recent studies have challenged the widespread belief that obesity is protective against fracture and have suggested that obesity is a risk factor for certain fractures. The effect of obesity on fracture risk is site-dependent, the risk being increased for some fractures (humerus, ankle, upper arm) and decreased for others (hip, pelvis, wrist). Moreover, the relationship between obesity and fracture may also vary by sex, age, and ethnicity. Risk factors for fracture in obese individuals appear to be similar to those in nonobese populations, although patterns of falling are particularly important in the obese. Research is needed to determine if and how visceral fat and metabolic complications of obesity (type 2 diabetes mellitus, insulin resistance, chronic inflammation, etc) are causally associated with bone status and fragility fracture risk. Vitamin D deficiency and hypogonadism may also influence fracture risk in obese individuals. Fracture algorithms such as FRAX® might be expected to underestimate fracture probability. Studies specifically designed to evaluate the antifracture efficacy of different drugs in obese patients are not available; however, literature data may suggest that in obese patients higher doses of the bisphosphonates might be required in order to maintain efficacy against nonvertebral fractures. Therefore, the search for better methods for the identification of fragility fracture risk in the growing population of adult and elderly subjects with obesity might be considered a clinical priority which could improve the prevention of fracture in obese individual

IMPA versus Cloud Analysis and IDA: Different Methods to Evaluate Structural Seismic Fragility

Well-known methods for seismic performance assessment, such as incremental dynamic analysis (IDA), multi-stripes analysis (MSA) and the cloud method, involve nonlinear response time-history analyses to characterize the relationship between the chosen damage measure versus intensity measure. Over the past two decades, many authors have proposed simplified procedures or nonlinear static approaches to develop fragility. In these procedures, the capacity of the system is evaluated by nonlinear static procedures (i.e., the capacity spectrum method (CSM), the N2 method, modal pushover analysis (MPA)) and the demand is derived by response spectra. In addition to the familiar ones, incremental modal pushover analysis (IMPA) is a novel nonlinear static procedure proposed in recent years, and it is used in this research to present an IM-based fragility estimation. The accuracy and effectiveness of different methods to assess vulnerability are investigated by comparing fragility curves derived by MPA-based cloud analysis, IMPA and cloud analysis against IDA. The comparison gives valuable insights on the influence of scaling on different sets of records; however, a more extended validation is needed to confirm the obtained results and draw more general conclusions. Results arise from two relatively small bins of record motions differing by ranges of Joyner-Boore distance and scattered in a range of magnitude are presented

Influenza della risposta sismica locale sul non sincronismo del moto in superficie: validazione empirica delle indicazioni normative

Nella progettazione di opere con significativo sviluppo longitudinale delle fondazioni, il moto sismico può avere caratteristiche variabili lungo lo sviluppo della struttura. Le differenze possono essere causate dalla perdita di sincronismo nella propagazione delle onde, dalle disomogeneità e discontinuità del sottosuolo e dalla diversa risposta locale del terreno. Secondo le prescrizioni delle Norme Tecniche per le Costruzioni (D.M. 14/1/2008), la valutazione degli effetti del moto asincrono indotti sulle strutture può essere effettuata combinando gli effetti dinamici con quelli pseudo-statici causati dallo spostamento relativo massimo tra due punti della struttura. Questi ultimi si possono valutare attraverso una relazione che deriva dalla soluzione di un modello analitico di propagazione delle onde sismiche (Nuti & Vanzi, 2005). Obiettivo di questo studio è verificare le regole presenti nelle NTC attraverso il confronto con valori di spostamento relativo derivanti da registrazioni accelerometriche di eventi sismici reali. L’effetto combinato dei fattori sopra menzionati è stato valutato empiricamente attraverso l’analisi del moto sismico in superficie registrato da coppie di stazioni ac-celerometriche, ubicate a distanze dell’ordine delle centinaia di metri, su terreni con caratteristiche lito-stratigrafiche corrispondenti ad un sito di riferimento (classe A della Normativa) e un sito con amplificazio-ne stratigrafica (classi B, C, D). Gli spostamenti relativi, calcolati secondo tre possibili approcci, mostrano che la formulazione analitica suggerita dalla Normativa è appropriata per descrivere la dipendenza degli spo-stamenti relativi dall’accelerazione di riferimento. Gli spostamenti calcolati secondo le prescrizioni di Nor-mativa, inoltre, risultano mediamente maggiori di quelli misurati sperimentalmente

Non-synchronous earthquake motion in bridges design

The study aims to further develop, with respect to previous findings, and validate structural design criteria which account for the effects of earthquakes spatial variability. In past works [Nuti, C. and Vanzi. I. (2004) & (2005); Carnevale, L. et al. (2010)] the two simplest forms of this problem were dealt with: differential displacements between two points belonging to the soil or to two single degree of freedom structures. Existing codes appear indeed improvable on this aspect. For the differential displacements of two points on the ground, these results are generalized with different response spectra and validated using (indeed a small set of) real recordings. For the experimental validation, the first obtained results point towards an acceptable agreement of model vs. experimental results [Tropeano, G. et al. (2011)]. In any case, results indicate that the design codes can be improved on this topic, both for the two points (e.g. simply supported decks) and the multiple points (e.g. continuous decks on multiple piers) cases

Undiagnosed vertebral fractures influence quality of life in postmenopausal women with reduced ultrasound parameters.

Osteoporosis, a multifactorial systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to increased bone fragility, is a worldwide public health problem. Vertebral fractures affect approximately 20% of postmenopausal women and are a hallmark of osteoporosis, but they may pass unnoticed, although they may lead to long-term immobility and disability. The aims of the present study were (1) to determine the prevalence and the severity of vertebral fractures in a large cohort of Italian women aged 60 years or older with reduced values of quantitative ultrasound parameters; and (2) to assess whether vertebral fractures and other variables may be associated with health-related quality of life. A total of 2450 women without back pain aged 60 years or older, after the completion of the Quality of Life Questionnaire of the European Foundation for Osteoporosis QUALEFFO, underwent quantitative ultrasound evaluation of the calcaneus; in those with a stiffness t-score of a parts per thousand currency sign -2 (n = 1194), radiographic evaluation of the thoracic and lumbar spine was carried out and then quantitative morphometry was performed by dedicated software (MorphoXpress). The radiographic analysis was carried out on 885 women who presented films of adequate quality. Multivariate regression was used to adjust for confounding variables. Of those who underwent radiographic analysis, 681 had no vertebral fractures, and 204 women (23.1%) had one or more previously undiagnosed vertebral fractures. The prevalence of previously undiagnosed vertebral fractures increased with advancing age with more than 30% of women older than 75 years having at least one fracture. Older age, body mass index, and severe vertebral fractures were independently associated with a worse total QUALEFFO score. We found that approximately one in four women showed evidence of undiagnosed vertebral fractures, and there was a strong age effect trend. Moreover, the severity grade of vertebral fractures, more than the number of fractures, was associated with a worsening of health-related quality of life as assessed by QUALEFFO. These findings confirm the clinical relevance of an early diagnosis of vertebral fractures and seem to support the usefulness of quantitative ultrasound measurements in the stratification of postmenopausal women at increased fracture risk

IMPAβ: Incremental modal pushover analysis for bridges

In the present study, the incremental modal pushover analysis (IMPAβ), a pushover-based approach already proposed and applied to buildings by the same authors, was revised and proposed for bridges (IMPAβ). Pushover analysis considers the effects of higher modes on the structural response. Bridges are structurally very different from multi-story buildings, where multimodal pushover (MPA) has been developed and is currently used. In bridges, consideration for higher modes is often necessary: The responses of some structural elements of the bridge (e.g., piers) influence the overall bridge response. Therefore, the failure of these elements can determine the failure of the whole structure, even if they give a small contribution total base shear. Incremental dynamic analysis (IDA) requires input accelerograms for high intensities, which are rare in the databases, while scaling of generated accelerograms with a simple increment of the scaling acceleration is not appropriate. This fact renders IDA, which is by its nature time-consuming, not straightforward. On the contrary, the change of input spectrum required by IMPA is simple. IMPAβ also utilizes a simple complementary method coupled to MPA, to obtain bounds at very high seismic intensities. Finally, the two incremental methods based on static nonlinear and dynamic nonlinear analyses are compared