Monetary Penalties Research Articles

A greener vision for vector control: The example of the Singapore dengue control programme.

Vector-borne diseases are a major cause of morbidity and mortality worldwide. Aedes-borne diseases, in particular, including dengue, chikungunya, yellow fever, and Zika, are increasing at an alarming rate due to urbanisation, population movement, weak vector control programmes, and climate change. The World Health Organization calls for strengthening of vector control programmes in line with the Global Vector Control Response (GVCR) strategy, and many vector control programmes are transitioning to this new approach. The Singapore dengue control programme, situated within the country’s larger vision of a clean, green, and sustainable environment for the health and well-being of its citizens, provides an excellent example of the GVCR approach in action. Since establishing vector control operations in the 1960s, the Singapore dengue control programme succeeded in reducing the dengue force of infection 10-fold by the 1990s and has maintained it at low levels ever since. Key to this success is consideration of dengue as an environmental disease, with a strong focus on source reduction and other environmental management methods as the dominant vector control strategy. The programme collaborates closely with other government ministries, as well as town councils, communities, the private sector, and academic and research institutions. Community engagement programmes encourage source reduction, and house-to-house inspections accompanied by a strong legislative framework with monetary penalties help to support compliance. Strong vector and epidemiological surveillance means that routine control activities can be heightened to specifically target dengue clusters. Despite its success, the programme continues to innovate to tackle challenges such as climate change, low herd immunity, and manpower constraints. Initiatives include development of novel vector controls such as Wolbachia-infected males and spatiotemporal models for dengue risk assessment. Lessons learnt from the Singapore programme can be applied to other settings, even those less well-resourced than Singapore, for more effective vector control.

Shortages of Staff in Nursing Homes During the COVID-19 Pandemic: What are the Driving Factors?

ObjectivesDuring the Coronavirus Disease 2019 (COVID-19) pandemic, US nursing homes (NHs) have been under pressure to maintain staff levels with limited access to personal protection equipment (PPE). This study examines the prevalence and factors associated with shortages of NH staff during the COVID-19 pandemic. DesignWe obtained self-reported information on staff shortages, resident and staff exposure to COVID-19, and PPE availability from a survey conducted by the Centers for Medicare and Medicaid Services in May 2020. Multivariate logistic regressions of staff shortages with state fixed-effects were conducted to examine the effect of COVID-19 factors in NHs. Setting and Participants11,920 free-standing NHs. MeasuresThe dependent variables were self-reported shortages of licensed nurse staff, nurse aides, clinical staff, and other ancillary staff. We controlled for NH characteristics from the most recent Nursing Home Compare and Certification and Survey Provider Enhanced Reporting, market characteristics from Area Health Resources File, and state Medicaid reimbursement calculated from Truven data. ResultsOf the 11,920 NHs, 15.9%, 18.4%, 2.5%, and 9.8% reported shortages of licensed nurse staff, nurse aides, clinical staff, and other staff, respectively. Georgia and Minnesota reported the highest rates of shortages in licensed nurse and nurse aides (both >25%). Multivariate regressions suggest that shortages in licensed nurses and nurse aides were more likely in NHs having any resident with COVID-19 (adjusted odds ratio [AOR] = 1.44, 1.60, respectively) and any staff with COVID-19 (AOR = 1.37, 1.34, respectively). Having 1-week supply of PPE was associated with lower probability of staff shortages. NHs with a higher proportion of Medicare residents were less likely to experience shortages. Conclusions/ImplicationsAbundant staff shortages were reported by NHs and were mainly driven by COVID-19 factors. In the absence of appropriate staff, NHs may be unable to fulfill the requirement of infection control even under the risk of increased monetary penalties.

Honesty Is the Best Policy

Honesty Is the Best Policy

Applying the Pre-Commitment Approach to bottom-up stress tests: A new old story

The Pre-Commitment Approach (PCA) to capital requirements was developed and promoted by the US Federal Reserve in the 1990s. The proposal was conceived as an alternative to the market-risk capital requirements based on internal models then under discussion, and eventually adopted, by the Basel Committee. Notwithstanding the Fed continued to support the PCA, the idea was abandoned, probably because it was considered too optimistic to allow banks determine the level of capital. In this paper, we study the possibility to adapt the PCA as to work as a complementary (and not alternative) tool applied to the banking book Prudential Regulation. In particular, we explore the application of this approach to a well-known issue in the context of the Stress tests: the top-down vs bottom-up debate. We focus on bottom-up stress tests and suggest creating a system of monetary penalties (charges) proportional to the difference between the expected and the realised losses of a portfolio. The charges would aim to induce model developers to reveal their best forecasts. We show that this approach can be seen as an adaptation of the pre-commitment approach (PCA) but also as an application of the penalty criterion proposed by the Italian mathematician de Finetti as the foundation of the subjectivist definition of probability. We explain how the PCA could be adapted to bottom-up stress testing and provide a practical example of the application of our proposal to the banking book. What emerges is that the PCA can indeed mitigate banks’ incentives to provide underestimated measures of risk under the adverse scenario and thus better align the incentives of banks and supervisors.

Socially optimal lockdown and travel restrictions for fighting communicable virus including COVID-19

This paper examines the socially optimal lockdown and travel (social activity) restriction policies for communicable virus including COVID-19. In our simple model, we exploit the remarkable similarity in the structure of external costs causing market failure between the socially optimal choices of the COVID-19 pandemic case and the socially optimal urban traffic congestion level. By identifying this similarity, the results obtained from our simple model allow for future pandemic researchers to use the well-established research methodologies for designing socially optimal traffic levels and associated policy tools to find the socially optimal lockdown and travel restrictions. The key results obtained from our COVID-19 model are: (1) individuals do not internalize the external cost of infection risks they impose on others and health care system when making their own travel (social-activity) decisions; In order to induce individual travel decision makers to internalize this external cost, the government actions are necessary; The travel restrictions via lockdown or monetary penalty is one form of such actions; (2) the existence of external cost implies that the socially optimal length of lockdown is always longer than the privately optimal length of the lockdown period; (3) the strictness of the travel restriction and the amount of violation penalty should be higher in the areas with high population density and in larger cities because the external cost of spreading virus by a traveler would be higher. The monetary penalty in this model resembles the classical Pigouvian tax, which should increase with the city's population, people density, and economic prosperity; (4) when a government subsidizes or fully covers medical expenses of COVID-19 patients, stricter travel restrictions with heavier penalties are required. This is to avoid crowding out of the health care system.

Consideration of Administrative Monetary Penalties in Nuclear Safety and Security

An Administrative Monetary Penalty (AMP) is a penalty imposed by the Canadian Nuclear Safety Commission (CNSC), without court involvement for a violation of a regulatory requirement. An AMP can be applied against any individual or corporation subject to the Nuclear Safety Control Act, which regulates the development, production and use of nuclear energy and the production, possession and use of nuclear and radioactive material. However, AMPs are not the same as criminal offences. They are civil sanctions which try to secure compliance through the application of monetary penalties for non-compliance with regulatory requirements. The AMP program was introduced in 2013 in Canada and to this date over 30 penalties have been issued. In all of these cases, the violations were related to handling and security of radioactive material. Based on these issued penalties investigations were conducted to discover pros and cons of the AMP system and to propose potential improvements for future implementation. This paper also addresses some of the complicated issues of the system, such as the economic aspect of the process, and the subjectivity and relative ease of issuing these penalties. In order to improve nuclear security in Canada, the regulator must be aware of possible violations of the Nuclear Safety Control Act and work on prevention of these violations. It is postulated that current AMP policy may not motivate individuals or corporations to report violations. The paper gives recommendations on modifications which could be implemented to motivate self – identification of violation, and give significant benefit to the AMP system. Other than the issued AMPs, the paper will analyze data obtained through the survey conducted on human readiness to self – identify violations in the nuclear industry under different circumstances. This confirms that the modified AMP policy would improve the body of knowledge and provide significant information on violations of the Nuclear Safety Control Act and improve nuclear security.

The increasing role of provincial administrative sanctions in Canadian impaired driving enforcement

Objective: The object of this study is to document the recent shift in Canadian impaired driving enforcement from federal criminal proceedings to provincial administrative sanctions, examine the deterrent impact of these new administrative measures, and review the numerous legal challenges that they have generated.Methods: This article highlights the expanded role of provincial administrative license suspensions (ALSs) and vehicle impoundments (AVIs) in Canadian impaired driving enforcement, summarizes the evidence of their deterrent impact, and discusses the implications of the related Canadian case law.Results: Provincial administrative sanctions have been used increasingly, both to supplement and replace federal impaired driving charges. Recent experience in British Columbia and Alberta illustrates the potential traffic safety benefits of enacting comprehensive impairment-related roadside administrative measures. In 2010, British Columbia enacted a package of roadside administrative sanctions, which included mandatory ALSs, AVIs, monetary penalties, license-reinstatement fees, and remedial programs. A study conducted two years later reported that alcohol-related fatal crashes had fallen by 52%. Alberta enacted similar provisions, and saw alcohol-related fatalities decrease by 46% within six months of the legislation coming into force. Although effective, these new roadside sanctions generated a flurry of legal challenges. The cases indicate that while the provinces have broad leeway, there are legal limits on their authority to impose onerous administrative sanctions on drivers, particularly if they are based on a single roadside alcohol or drug-screening test.Conclusions: With careful drafting, the provinces can enact cost-effective roadside administrative sanctions that have been shown to significantly reduce impaired driving deaths and injuries. The legality of any administrative sanction will likely depend on its severity, the reliability of the test or evidence upon which it is based, and the extent to which the driver has a meaningful opportunity to challenge the decision.

Collaborative multi‐aggregator electric vehicle charge scheduling with PV‐assisted charging stations under variable solar profiles

Electric vehicles (EVs) are on the path to becoming a solution to the emissions released by the internal combustion engine vehicles that are on the road. EV charging management integration requires a smart grid platform that allows for communication and control between the aggregator, consumer and grid. This study presents an operational strategy for PV-assisted charging stations (PVCSs) that allows the EV to be charged primarily by PV energy, followed by the EV station's battery storage (BS) and the grid. Multi-Aggregator collaborative scheduling is considered that includes a monetary penalty on the aggregator for any unscheduled EVs. The impact of the PVCS is compared to the case with no PV/BS is included. A variation in the PV profile is included in the evaluation to assess its impact on total profits. Profit results are compared in cases of minimum, average and maximum PV energy output. The results indicate that the inclusion of penalties due to unscheduled EVs resulted in lowered profits. Further, the profits experienced an increase as the number of EVs scheduled through PV/BS increased, implying that a lesser percentage of EVs are scheduled by the grid when a greater amount of PV and battery energy are available.

Analyzing Foundations of Imposing a Monetary Penalty on Parties to a Criminal Proceeding

The research analyzes the possible application and effectiveness of a monetary penalty as one of the most useful sanctions to maintain the established order of criminal justice, as well as develops constructive proposals to improve the criminal procedure legislation based on the conducted survey. To this end, the authors of the article have studied the criminal procedure legislation of Kazakhstan and legislation on administrative offenses, considered scientific opinions presented in numerous publications on relevant topics and conducted a comparative analysis of regulatory systems in Kazakhstan, Germany, Austria, the USA and the UK. As a result, the authors have established that one of the main reasons hindering the adequate implementation of criminal justice is the violation of obligations to participate in criminal proceedings by persons named in the Criminal Procedure Code of Kazakhstan. To maintain procedural discipline, the court is provided with ample opportunities in the form of coercive measures, including a monetary penalty. The authors have investigated the legal nature of a monetary penalty and compared it with administrative fines. The authors have considered grounds and application procedures for this sanction in the criminal procedure legislation of Kazakhstan and some foreign legal systems. The authors have determined the problems of its implementation caused by the slovenly legislation of a monetary penalty that impedes law enforcement activity. A comprehensive analysis allows developing proposals for improving the use of monetary penalties as measures of coercion for criminal cases heard in the court. If these proposals are enshrined in the existing regulatory framework and put into practice, they will strengthen the discipline of parties to criminal proceedings, ensure the strict observance of criminal proceedings and increase their general effectiveness. Due to its conclusions and proposals, the article demonstrates the novelty of the conducted research, the authors' original approach to the analysis of information and innovative ways to improve the existing legislative framework.

Glosa do wyroku Naczelnego Sądu Administracyjnego z dnia 25 kwietnia 2018 r. (II GSK 2337/16)

<p>The subject of this gloss is the judgement of the Supreme Administrative Court in case of imposing an administrative monetary penalty for movement of non-normative vehicle on public road in which the judgement of Voivodeship Administrative Court in Warsaw was set aside and return the case for re-examination. In this judgement, the formation of the court, in a way going against the previous line of jurisprudence, stated that decoding the meaning of “axle load provided for a given road” may result from the application of a functional interpretation driectives, and thus, the basis for its determination may also be the regulation of the Minister of Infrastructure of 31 December 2002 on the Technical Conditions of Vehicles and the Scope of Their Necessary Equipment. The content of the sentence itself and the reasons for the judgement do not allow for its approval, therefore the gloss has a critical character.</p>

The Admissibility of Mitigation of the Administrative Monetary Penalty for the Occupation of the Road Lane without Permission in the Light of Article 189D of the Code of Administrative Procedure

It should be noted that not every monetary penalty can be mitigated pursuant to article 189d of the Code of Administrative Procedure – if special provisions include premises which should be followed by the authority in the course of imposing a penalty, then it is impossible to make auxiliary use of the guidelines expressed in the Code (following the principle lex specialis derogat legi generali). Pursuant to article 40 (12) of the Act on Public Roads, the occupation of the road lane for non-road purposes without appropriate permission is punishable with an administrative monetary penalty. In this article, the authors discuss the admissibility of mitigation of the administrative monetary penalty for the occupation of the road lane in the light of article 189d of the Code of Administrative Procedure.

Strict liability Regime in Poland

The article focuses on administrative violations, which are considered to be based on strict (or objective) liability model. Due to the lack of in-depth scholarly analysis of administrative liability, its principles had to be developed in the case-law of the Constitutional Tribunal, which influences the decisions of administrative courts. The recently introduced provisions of the Code of Administrative Procedure concerning administrative monetary penalties are also analysed. The conformity of this model with the guarantees provided by the European Convention on Human Rights is examined, as well. The analysis leads to the conclusion that three exculpatory circumstances are recognized in this regime: force majeure, necessity and ensuring the standard of diligence established by the Constitutional Tribunal.

Preventing hospital readmissions: A transitions of care coordination framework

Hospital readmissions (HRAs) have attracted significant worldwide interest because of the high associated costs. In the United States, HRAs have additional financial and legislative connotations, including monetary penalties to facilities across the nation. The transitions of care programmes are one of the most innovative hospital management initiatives in the current century to combat HRAs during the first month of discharge, increase customer satisfaction and facilitate a quicker and safer patient recovery in the community. Researchers around the world have been studying the implementation of similar programmes to tackle the problem. However, multiple studies have produced distinctive, controversial and conflicting outcomes following partial initiatives. The need for a customisable standard model is evident. This study discusses the scholarly justifications and international experiences for reducing HRAs and attempts to fill this gap proposing a transitions of care coordination framework (TCCF). The conceptual framework promotes the consolidation and standardisation of a series of organisational, financial and managerial initiatives and represents the first step towards the development, implementation and evaluation of transitions of care programmes in multiplayer health systems. The TCCF summarises important general strategies for the design of a transitional health programme and the barriers and challenges that anticipate its implementation. Additional investigation will facilitate the identification of and validate the necessary strategies, tools, metrics, processes and procedures to operationalise the concept.

A Labor of Love

In recent weeks I have been involved in a labor of love. I have a treasure trove of more than 400 letters written by my father to his mother during his service in World War II, and I have been transcribing them. This has been an experience like none other for me: reading them is like visiting a foreign country that looks strangely familiar at every turn. At this stage in my transcribing, dad and his peers are currently in training at Coleman Field in Coleman, TX, in 1943 to be U.S. Army Air Forces (USAAF) pilots. (The USAAF did not become an independent entity — the U.S. Air Force of today — until September 18, 1947.) His view of being part of the colossal catastrophe of WWII, of being a 20-year-old with his buddies experiencing it all, is fascinating. What he thought and felt before being the recipient of the forces of life that shaped him — before meeting my mother, before knowing me — has been a humbling revelation. What I have discovered thus far is that these green, mostly small-town and rural boys had a vision. They wanted to change and shape America and the world for the better. The word “stewardship” has come to mind for me. The Oxford Dictionary defines stewardship as “the job of supervising or taking care of something.” History shows us that they did indeed take care of something as part of the Greatest Generation. Getting to know these kids who changed the world through their stewardship has prompted a challenge to me: What is my stewardship mission? My answer is to make the post-acute and long-term care space safer, more compassionate, more evidence based — and just all-around better. I choose to do this with stewardship through AMDA – The Society for Post-Acute and Long-Term Care Medicine and the Foundation for PALTC Medicine, and I extend that challenge to you. Your Foundation, the Society’s Board of Directors, and the American Board of PALTC Medicine (ABPLM) continue to align our goals. By cooperating on projects and with funding from the Foundation, we can improve the workforce in geriatrics and demonstrate the value of PALTC clinicians to improving the quality of care. This is stewardship in action. The final proposals for such collaborative efforts are pending, but the potential projects are listed below. The Society’s Board of Directors will:•Develop an accurate registry of skilled nursing facility medical directors across the country.•Create a template for AMDA-related entities to access civil monetary penalty funds (this will vary by state) to use in their quality-improvement activities.•Provide training to clinicians to assume leadership roles in PALTC. ABPLM will:•Continue efforts to raise the visibility of PALTC medical directors and clinicians. This year we will continue to move forward with projects beneficial to the Society’s membership, research, and the Foundation:•Neurologist Ilo Leppik, MD, will be administering a written survey to the membership on epilepsy care in long-term care. He will make a significant donation to the Foundation for our efforts and a donation to the Society per survey completed. Survey takers will receive complimentary access to a recording of the billing and coding session from the conference (a $20 value). Please support the Society, your Foundation, and better epilepsy care by taking the survey.•The Society has a new Learning Management System site up and running. In addition to our popular continuing medical education topics such as billing and coding, it will have a non-CME page, separated by a firewall from the CME topics, where nonbranded state educational disease information from the Society’s Industry Advisory Board partners will reside.•Your Foundation is sponsoring two speakers at the Annual Conference in Chicago: the Friday plenary session presenter, and the speaker who will follow the Anne-Marie Filkin Lecture on Sunday.•No discussion of the Annual Conference is complete without mentioning the Futures Program. Again, your Foundation will be sponsoring this special “meeting within a meeting.” With your support we continue to invest in the future of PALTC through the Futures Program. The Foundation and I look forward to seeing you all in Chicago. We hope to interact with each of you at the “Wall of Caring” to unleash our inner stewardship. Dr. Lett has practiced in the PALTC continuum for more than three decades as a hands-on clinician and medical director. He has served AMDA in multiple capacities including as president, on multiple committees, and is the current chair of the Foundation for PALTC Medicine.

Penalties for Emergency Medical Treatment and Labor Act Violations Involving Obstetrical Emergencies

IntroductionThe Emergency Medical Treatment and Labor Act (EMTALA) was intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (ED). While controversies exist regarding the scope of the law, there is no question that EMTALA applies to active labor, a key tenet of the statute and the only medical condition – labor – specifically included in the title of the law. In light of rising maternal mortality rates in the United States, further exploration into the state of emergency obstetrical (OB) care is warranted. Understanding civil monetary penalty settlements levied by the Office of the Inspector General (OIG) related to EMTALA violations involving labor and other OB emergencies will help to inform the current state of access to and quality of OB emergency care.MethodsWe reviewed descriptions of all EMTALA-related OIG civil monetary penalty settlements from 2002–2018. OB-related cases were identified using keywords in settlement descriptions. We described characteristics of settlements including the nature of the allegation and compared them with non-OB settlements.ResultsOf 232 EMTALA-related OIG settlements during the study period, 39 (17%) involved active labor and other OB emergencies. Between 2002 and 2018 the proportion of settlements involving OB emergencies increased from 17% to 40%. Seven (18%) of these settlements involved a pregnant minor. Most OB cases involved failure to provide screening exam (82%) and/or stabilizing treatment (51%). Failure to arrange appropriate transfer was more common for OB (36%) compared with non-OB settlements (21%) (p = 0.041). Fifteen (38%) involved a provider specifically directing a pregnant woman to proceed to another hospital, typically by private vehicle.ConclusionDespite inclusion of the term “labor” in the law’s title, one in six settlements related to EMTALA violations involved OB emergencies. One in five settlements involved a pregnant minor, indicating that providers may benefit from education regarding obligations to evaluate and stabilize minors absent parental consent. Failure to arrange appropriate transfer was more common among OB settlements. Findings suggesting need for providers to understand EMTALA-specific requirements for appropriate transfer and for EDs at hospitals without dedicated OB services to implement policies for evaluation of active labor and protocols for transfer when indicated.

A fine predicament: Conditioning, compliance and consequences in a labeled cash transfer program

Abstract The Kenya Cash Transfer Programme for Orphans and Vulnerable Children (CT-OVC) presents a valuable opportunity to examine the effects of imposing monetary penalties for noncompliance with conditions in cash transfer programs, in contrast to providing only guidance (or “labeling”) for cash transfer use. We take advantage of random assignment to a conditional arm within the CT-OVC treatment locations to understand the impact of imposing conditions with penalties on program beneficiaries, as well as how this effect varies by household wealth. Program beneficiaries (orphans and vulnerable children) were expected to visit health facilities for immunizations, growth monitoring and nutrition supplements and to enroll in and attend school. We find little difference in program outcomes between households in the conditional treatment arm compared to those in the treatment arm with labeling only (in which information was provided about these expectations but compliance was not monitored). However, among the poorest CT-OVC beneficiaries, assignment to the conditional arm was associated with penalty fines and a significant decrease in non-food consumption. This suggests that in comparison to labeled cash transfers, conditional cash transfers may produce unintended, regressive policy effects for the most vulnerable participants.

Cyber Security: Effects of Penalizing Defenders in Cyber-Security Games via Experimentation and Computational Modeling.

Cyber-attacks are deliberate attempts by adversaries to illegally access online information of other individuals or organizations. There are likely to be severe monetary consequences for organizations and its workers who face cyber-attacks. However, currently, little is known on how monetary consequences of cyber-attacks may influence the decision-making of defenders and adversaries. In this research, using a cyber-security game, we evaluate the influence of monetary penalties on decisions made by people performing in the roles of human defenders and adversaries via experimentation and computational modeling. In a laboratory experiment, participants were randomly assigned to the role of “hackers” (adversaries) or “analysts” (defenders) in a laboratory experiment across three between-subject conditions: Equal payoffs (EQP), penalizing defenders for false alarms (PDF) and penalizing defenders for misses (PDM). The PDF and PDM conditions were 10-times costlier for defender participants compared to the EQP condition, which served as a baseline. Results revealed an increase (decrease) and decrease (increase) in attack (defend) actions in the PDF and PDM conditions, respectively. Also, both attack-and-defend decisions deviated from Nash equilibriums. To understand the reasons for our results, we calibrated a model based on Instance-Based Learning Theory (IBLT) theory to the attack-and-defend decisions collected in the experiment. The model’s parameters revealed an excessive reliance on recency, frequency, and variability mechanisms by both defenders and adversaries. We discuss the implications of our results to different cyber-attack situations where defenders are penalized for their misses and false-alarms.

Corporate irresponsibility and stock price crash risk

AbstractWe investigate the impact of corporate irresponsibility on future stock price crash by employing a unique dataset of 1,529 penalties imposed on 411 United States (U.S.) firms, from 2003 to 2015. We provide robust evidence that the total amount of penalties (in U.S. dollars) imposed on firms are negatively associated with firm‐specific future stock price crash risk. Our findings are consistent with the following view that imposition of penalties remove uncertainty about a particular firm's future, investors please that the case is closed, the firm successfully manages the aftermath of misconduct and the firm's financial gains are often larger compared to the total cost of the penalty imposed. Moreover, we find corporate social responsibility (CSR) to be a channel through which penalties impact stock price crash risk. Our findings demonstrate that the negative association between monetary penalties and stock price crash risk is more pronounced in the postfinancial crisis and in environmentally sensitive firms.

When and what to test for: A cost-effectiveness analysis of febrile illness test-and-treat strategies in the era of responsible antibiotic use.

BackgroundFebrile illness caused by viral and bacterial diseases (e.g., dengue and leptospirosis) often have similar symptoms and are difficult to differentiate without diagnostic tests. If not treated appropriately, patients may experience serious complications. The question of what diagnostic tests to make available to providers in order to inform antibiotic therapy remains an open problem for health services facing limited resources.Methods and findingsWe formulated the problem of minimizing the weighted average of antibiotic underuse and overuse to inform the optimal diagnostic test and antibiotic treatment options for given occurrence probabilities of several bacterial and viral infections. We modeled the weight of antibiotic overuse as a monetary penalty per unnecessarily administered course, which we varied in both the base case and sensitivity analysis. Detailed Markov cohort models of febrile illness progression were used to estimate the weight of antibiotic underuse. The model accounted for multiple infections simultaneously and incorporated test, treatment, and other direct and indirect costs, as well as the effect of delays in seeking care and test turnaround times. We used the Markov models to numerically estimate disability-adjusted life years (DALYs), pre-penalty costs, and likelihood of antibiotics overuse per patient for fifteen different strategies in two example settings in Thailand, one with a higher probability of bacterial infections (Northern Thailand, Scenario A) and one with a higher probability of viral infections (Bangkok, Scenario B). We found that empirical antibiotic treatment to all patients always incurs the lowest pre-penalty cost (Scenario A: $47.5/patient, $100.6/patient, $149.5/patient for patients seeking care on day one, day four, and day ten respectively; Scenario B: $94.1/patient, $108.7/patient, $122.1/patient on day one, day four, and day ten respectively), and the lowest DALYs, (Scenario A: 0.2 DALYs/patient, 0.9 DALYs/patient, 1.7 DALYs/patient on day one, day four, and day ten, respectively; Scenario B: 0.5 DALYs/patient, 0.7 DALYs/patient, 0.9 DALYs/patient on day one, day four, and day ten, respectively). However, such strategy resulted in the highest proportion of antibiotic overuse per patient (Scenario A: 38.1%, 19.3%, 7.5% on day one, day four, and day ten, respectively; Scenario B: 82.9%, 42.1%, 16.3% on day one, day four, and day ten, respectively). Consequently, empirical antibiotic treatment became suboptimal with antibiotic overuse penalties above $12,800/course, $18,400/course, $23,900/course for patients presenting on day one, day four, and day ten in Scenario A and above $1,100/course, $1,500/course, $1,600/course for patients presenting on day one, day four, and day ten in Scenario B.ConclusionsEmpirical antibiotic treatment to all patients provided the best outcomes if antibiotic overuse was not the primary concern or if presenting with viral disease (such as dengue) was unlikely. Empirical antibiotic treatment to severe patients only was in most cases not beneficial. Otherwise, strategies involving diagnostic tests became optimal. In particular, our results indicated that single test strategies (bacterial RDT or viral PCR) were optimal in regions with a greater probability of presenting with viral infection. PCR-led strategies (e.g., parallel bacterial PCR, or multiplex PCR) are robust under parameter uncertainty (e.g., with uncertain disease occurrence probabilities).

A Tale of Two Enforcement Venues: Determinants and Consequences of the SEC’s Choice of Enforcement Venue After the Dodd-Frank Act

The Dodd-Frank Act allows the SEC to choose either an internal administrative proceeding or a federal district court as an enforcement venue for resolving violations of federal securities laws. I first document that the SEC increased the use of administrative proceedings after Dodd-Frank. I next examine the determinants and consequences of the SEC’s choice of enforcement venue after the Dodd-Frank Act. Results show that more material cases are 28% to 35% more likely to be assigned to federal courts, and politically connected defendants are about 14% more likely to be routed to administrative proceedings. While monetary penalties by venue are statistically indifferent, politically connected defendants in administrative proceedings are associated with lower penalties. Additionally, I find that administrative proceedings process cases 27 times faster than federal courts. This study suggests that the SEC’s private incentives affect its enforcement venue selection and possibly enforcement outcomes. When the political and economic costs (benefits) are greater, the SEC is more likely to use administrative proceedings (federal courts).