Exploring the determinants of private healthcare providers' market power: A performance-based perspective.

This research focuses on market power in the private healthcare sector. This topic has been poorly explored by the extant literature and the reasons mainly rely on the peculiarities of the sector and the specific market. In fact, health providers' market power is influenced by multiple factors and by the fact that prices are often regulated by national or regional public authorities. To fill this gap, the article explores the relationship between performance characteristics and health providers' market power, measured through the Lerner index. The research is based on the analysis of panel data for 437 Italian private healthcare providers over the period 2012-2020. To explore the determinants of health providers' market power, this research employs System-generalized method of moments (SYS-GMM) estimation models. The results highlight a significant and non-linear relationship between market power and process performance, as well as with gender diversity. Intangible assets are another input variable that has a significant and positive relationship with market power. The study contributes to the identification of the performance characteristics driving health providers' market power.

Changing therapeutic strategies and persistence to disease-modifying treatments in a population of multiple sclerosis patients from Veneto region, Italy.

BACKGROUND: The availability of new disease-modifying treatments (DMTs) in the last years has changed the therapeutic strategies used in Multiple Sclerosis (MS). We aimed to describe trend in DMTs utilization and persistence to treatment in a large sample of patients attending 10 MS centres from four provinces of Veneto, Italy. METHODS: Demographic, clinical and DMTs information of patients regularly followed from January 2011 to August 2018 were recorded and analysed. Persistence at 12, 24 months and at last follow-up was assessed by Kaplan Meier survival analysis. Multivariable Cox- proportional hazard model was used to identify predictors of persistence. RESULTS: Of 3025 MS patients 65.7% were in treatment al last follow-up. Dimethylfumarate (DMF) was the most prescribed single drug among first-line and fingolimod among second-line DMTs. In the cohort of 1391 cases starting any DMT since 2011 12.9% stopped within 6 months, 24% within 12 and 40.3% within 24 months. Disease duration > 5 years at therapy start was predictive of greater risk of discontinuation, while age and sex were not. DMF use was predictive of higher persistence at 12 and 24 months, but not at last follow-up when azathioprine and glatiramer acetate showed the highest persistence compared to other DMTs. Side effects represented the main reason of discontinuation. CONCLUSION: The use of the new oral DMTs greatly increased since their approval but persistence in the long-term is not better than with old drugs. The treatment choice is still a challenge both for patients and their doctors.

The effect of repetitive transcranial magnetic stimulation on motor performance, fatigue and quality of life in amyotrophic lateral sclerosis.

BACKGROUND: The treatment of amyotrophic lateral sclerosis (ALS) is still disappointing. Repetitive transcranial magnetic stimulation (rTMS) has been suggested to modify the rate of disease progression in ALS. OBJECTIVE: In a pilot controlled study, we tested the effect of 5-Hz rTMS on motor performance, fatigue and quality of life (QoL) in ALS. METHODS: Ten ALS patients underwent a two-week period of daily active or sham 5-Hz rTMS. Outcome measures were assessed with functional, fatigue and QoL scales. Muscle strength was evaluated with the MRC scale and measured with isometric and isokinetic dynamometer. RESULTS: Significant difference at the end of rTMS treatment was found for QoL, maximum voluntary isometric contraction and isokinetic average power when comparing active vs sham treatment. These changes were transitory and outcome measures were not significant two weeks after discontinuation of rTMS. CONCLUSIONS: Though preliminary, our results suggest that 5-Hz rTMS may improve motor function and QoL in ALS. The present data indicate the need of a double-blind therapeutic trial of rTMS in ALS.

Abnormal cutaneomotor integration in patients with cerebellar syndromes: a transcranial magnetic stimulation study.

OBJECTIVE: To examine the sensorimotor interactions in cerebellar patients. METHODS: We investigated the effects of electrical stimulation of the second (D2) and fifth (D5) fingers on the amplitude of motor evoked potentials (MEPs) in response to transcranial magnetic stimulation and transcranial electrical stimulation (TES) in the relaxed right abductor digiti minimi muscles of 7 patients with cerebellar syndromes and of 14 age-matched controls. The digital stimulation was set at 3 times the sensory threshold and preceded brain stimulation at interstimulus intervals (ISIs) ranging from 10 to 100 ms. RESULTS: D5 stimulation produced significant MEP inhibition in normal subjects at ISIs of 20-50 ms, while D2 stimulation resulted in a non-significant inhibitory trend with the same intervals. In contrast, digital stimulation had no effect on MEP amplitude in cerebellar patients. A significant difference was found between patients and controls at ISIs of 20-50 ms with D5 stimulation. The difference in amplitude of MEPs conditioned by D5 and D2 stimulation was statistically significant between patients and controls at ISIs of 30 and 50 ms. TES conditioning induced MEP inhibition only at ISIs <40 ms. CONCLUSIONS: Digital stimulation would appear to modulate motor system excitability less effectively in cerebellar patients. MEP inhibition by cutaneous afferences is reduced in response to stimulation of contiguous, as well as non-contiguous fingers. The difference between the conditioning effects of the two fingers is also decreased, and therefore the somatotopic distribution of cutaneomotor inhibition is absent in patients. These abnormalities may contribute to the genesis of cerebellar motor symptoms and their time course suggests involvement of subcortical and cortical sites.

Different mechanisms contribute to motor cortex hyperexcitability in amyotrophic lateral sclerosis.

OBJECTIVES: Different physiological approaches demonstrated motor system hyperexcitability in amyotrophic lateral sclerosis (ALS), probably reflecting excitotoxic mechanisms. Transcranial magnetic stimulation (TMS) showed that both increased excitability of corticomotoneurons and reduced intracortical inhibition (ICI) contribute to motor cortex hyperexcitability, but the importance of these factors in inducing this cortical dysfunction is unknown. The aim of the study was to establish how different mechanisms interact to promote motor system hyperexcitability in ALS in relation to clinical features. METHODS: The resting motor threshold (RMT), the motor evoked potential (MEP) recruitment curve and the cortical silent period (CSP) to single-pulse TMS were evaluated in 35 patients with ALS. Early ICI and intracortical facilitation (ICF) and late ICI were evaluated by paired TMS. RESULTS: The main abnormal TMS findings were: (a) a steeper MEP recruitment curve associated with a lowering of the RMT; (b) reduced or even absent early and late ICI; (c) reduced CSP lengthening with increasing TMS intensity. ICF was not affected. RMT increased and the MEP recruitment curve became less steep with longer disease duration, but they did not correlate with the motor deficit, the type of motoneuron affection and the decrease of ICI. Impairment of early and late ICI were significantly correlated to each other, to disease severity and to clinical evidence of upper motor neuron involvement. CONCLUSIONS: Different and partially independent mechanisms contribute to motor cortex hyperexcitability in ALS. The increased gain in MEP recruitment with a lowering of the RMT appears to be a primary event reflecting an increase in the strength of corticospinal projections, probably related to changes in the ion-channel permeability of the neuronal membrane. On the other hand, inhibitory functions linked to multiple neurotransmitter systems decline with disease progression. Both depletion of specific subpopulations of intracortical GABAergic neurons and mechanisms involved in motor cortex reorganization following progressive neuronal loss have been considered to account for the impaired inhibition. The clarification of the importance of these factors in the pathogenesis of ALS may have diagnostic and therapeutic implications.

Changes in motor cortex inhibition over time in patients with amyotrophic lateral sclerosis.

Abnormal balance between intracortical inhibitory and excitatory mechanisms has been found to contribute to the genesis of motor cortex hyperexcitability in amyotrophic lateral sclerosis (ALS), but data are lacking on the role of these abnormalities in the pathophysiology of the disease. We evaluated the resting motor threshold (RMT), the cortical silent period (CSP) to single-pulse transcranial magnetic stimulation (TMS), early intracortical inhibition (ICI), early intracortical facilitation (ICF) and late ICI to paired-pulse TMS in 40 patients with ALS. These parameters were correlated with disease duration and clinical features. They were also monitored over time in selected patients. The main abnormal TMS findings were: (a). reduced or even absent early and late ICI; six out of 9 patients, with normal early ICI at the first recording, developed abnormal ICI after several months; (b). reduced cortical silent period duration with increasing TMS intensity. ICF and RMT were not affected. Impairment of early and late ICI correlated significantly with disease duration, the diagnostic categories and the clinical evidence of upper motor neuron involvement. The alteration of different cortical inhibitory functions seems to take place with disease progression, rather than being the primary event in the pathogenesis of ALS. The impaired inhibition is considered as being due to both depletion of specific subpopulations of intracortical GABAergic neurons and mechanisms involved in motor cortex reorganization following progressive neuronal loss. Clarification of the importance of these factors in the pathogenesis of the disease may have diagnostic and therapeutic implications.