Post on 26-Mar-2015
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Healthcare Engineering: Quantitative Decision Support
Models for the Healthcare Industry
Michael W. CarterCentre for Research in Healthcare Operations
Mechanical and Industrial Engineering
University of Toronto
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Outline• Brief Overview of the Health Care Industry
• Why do we need engineers?
• Some application examples
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The Importance of Health Care
Health care is North America’s largest single industry.
Estimated total spending in Canada was $183 billion (CN) in 2009. ($2.5 trillion in the US)
In Canada, in 2009, $5,452 per person was spent on health care compared to $8,047 in US
International TrendsHealth Spending as a % of GDP
5
10
15
20
80 82 84 86 88 90 92 94 96 98 '00
'02
'04
'06
% G
DP
US
Canada
France
Germany
UK
NetherlandsJapan
Mexico
Belgium
OECD web site: www.oecd.org Oct 2007
Unfair Comparison:More $ doesn’t = better health?
Life Expectancy 2003
65.0 70.0 75.0 80.0 85.0 90.0
United StatesGermany
FranceNetherlands
United KingdomNew Zealand
CanadaAustralia
SwitzerlandSweden
Japan
Women Men
Infant Mortality per 1,000 live births 2003
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0
Japan
Sweden
France
Germany
Switzerland
Australia
Netherlands
United Kingdom
Canada
New Zealand
United States
Health Care Delivery (% Public Payor in 2007)
Public Payor
Private Payor
Mix
Public Provider
UK (82), Japan (81)
Sweden (82) Holland (75)
Private Provider
Canada (70%), Germany (77) France (79)
United States (45)
Mix ** Most OECD states allow wealthy to opt out. of public system **
Commonwealth Fund Overall Ranking 2007
AUST. CAN. GER N.Z. U.K. U.S.
OVERALL RANKING (2007) 3.5 5 2 3.5 1 6
Quality Care 4 6 2.5 2.5 1 5
Right Care 5 6 3 4 2 1
Safe Care 4 5 1 3 2 6
Coordinated Care 3 6 4 2 1 5
Patient-Centered Care 3 6 2 1 4 5
Access 3 5 1 2 4 6
Efficiency 4 5 3 2 1 6
Equity 2 5 4 3 1 6
Long, Healthy, and Productive Lives 1 3 2 4.5 4.5 6
Health Expenditures per Capita, 2004 $2,876* $3,165 $3,005* $2,083 $2,546 $6,102
1.0-2.66
2.67-4.33
4.34-6.0
Country Rankings
* 2003 dataSource: Calculated by Commonwealth Fund based on the Commonwealth Fund 2004 International Health Policy Survey, the Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults, the 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, and the Commonwealth Fund Commission on a High Performance Health System National Scorecard.
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Systemic Hospital Issues:The Four Faces of Health Care*
Health care is a business, but...
Multiple decision makers.Conflicting goals,
incentives.Social “good”.No market, no manager.
Managers
Control
Nursing
Care
Trustees
Community
Doctors
Cure
StatusCoalition
InsiderCoalition
ContainmentCoalition
ClinicalCoalition*Glouberman & Mintzberg, 2001
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The Four Faces of Health Care* The same divisions apply
to the overall social health system!
Health Authorities Insurance
Public Control
LTC, Primary
Community Care
Elected Officials
Community Involvement
Acute Hospital
Acute Cure
*Glouberman & Mintzberg, 2001
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Some success stories
• Ontario Waitlist Forecast
• System Dynamics: Cardiac Surgeons
• Ministry of Health and Long Term Care and the Local Health Integration Networks (LHINs)
• Cancer Care Ontario: Chemo Therapy Centres
• Surgical Planning: Orthopaedic
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Ontario Waitlist Initiative
• Target to reduce wait times to benchmarks for five priority areas:
Cardiac, Cataract, Cancer, Hip & Knee Replacement, MRI/CT
• Problem: How many (cataracts) do we need to do to meet bench mark (90% wait less than 26 weeks) by March 2007?
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Data Requirements for Prediction
• Current Patient Arrival Rate
• Projected Future Arrival Rate
• Current Waitlist
• Distribution of Patients on Waitlist (Priority)
• Surgical Volumes (Service Rates)
• Future Funded Surgical Volumes
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Observed Waitlist Approximation
Cutoff Point
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Recent Ontario Performance• Oct./Nov./Dec. 2009 (all priorities)
– Hips – 23 weeks (Ont. target 90% in 26 weeks)– Knees – 26 weeks (target 26)– Cataracts – 16 weeks (target 26)– Breast cancer – 5 weeks (target 12)– Colorectal cancer – 6 weeks (target 12)– Cardiac Bypass – 8 weeks (target 26)– MRI – 16.6 weeks (target 4)– CT – 7 weeks (target 4)www.health.gov.on.ca
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Health Human Resources Modelling
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Modeling the Future of Canadian Cardiac Surgery Workforce Using
System Dynamics
Michael Carter1,Chris Feindel2,Timothy Latham2 & Sonia Vanderby1
1Centre for Research in Healthcare Engineering, University of Toronto2Canadian Society of Cardiac Surgeons
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In Canada only 5 out of 11 slots were filled in 2009 matchI
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Retiring Surgeon Population Demand patterns …
CABG Non-CABG
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• Will there be a future shortage of surgeons?
• Specialty selection decisions being made based on current situation– Current oversupply; unemployed grads– Education Process > 10 years
CRHE Causal Loop (Influence) Diagram
StudentPopulation
Practicing SurgeonPopulation
Average ClinicalProductivity per
surgeon
Total SurgicalCapacity
Demand-SupplyGap
Surgical Demandper capita
GeneralPopulation
Total SurgicalDemand
InternationalMedical Graduates
Student Population Module
Surgeon Population Module
Demand Module
Clinical Productivity Module
IMG Module
CRHE Scenario Testing
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May 20, 2009 Operations Research & Patient Flow
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Other System Dynamics Projects• Alberta Health & Wellness
– Model for demand for GPs for next ten years
• Ontario MOHLTC– Model impact of “Aging at Home” strategy– Model of mental health strategies
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abuse
trauma
healthyenvironment
Income level
chronic disease+
+
-
Demand forsupport/care
availability ofgambling
+
age
symptomidentification
education &skills of
providers
public educationof MHA
+
likelihood ofseeking care
+
+
stigma
sense ofisolation/community
transportationbarriers/physical
isolation
disability
+
ability to pay forcare
out-of-pocketmedical costs
duration, continuity & comprehensiven
ess of care
+
effectiveness of care
+
costs of care
quality ofrelationships
major lifetransitions
Likelihood &influence of family
support/ intervention+
-
languagebarriers
culture
+?
?
availability ofsettlement support
-
-
divorce/break-ups
+
suicide rate
+
+
# of singleparentfamilies
+
ability to attendschool & work
physical health
homelessness
education/traininglevel
sense ofcommunity/school
attachment
rurality ?
level ofschool/community
involvement +
opportunities forschool/community
involvement
+
coordination &effectiveness of
community planning
involvement ingambling
++
national/regionaleconomic strength
availability ofcare/supportaccessibility of
care/support
awareness of care &support options
+
+
+
availability ofparenting
classes/daycare/ECE
+
-
workload /provider
nutrition & healthylifestyle
-+
-+
situational stress +
+
likelihood of beingeligible for care care eligibility
requirements
-
ED arrivals
-
+
-
+
+
ability to find ajob
contacts withjustice system
demand for lawenforcement
+
wage/salary
ability to keepjob
productivity
availability of MHAtreatment in EDs
+
availabilityof jobs
willingness tofind job
demand for legalassistance
+
ODSP eligibilityrequirements
eligibility for andamount of ODSP
received
ED staffturnover
appropriateness ofreferrals
+
+
use of evidencebased care+
+
outcome monitoring& reporting
+
research &development of care
standards
+
use of commonassessment & intake
procedures
+
providerincentives
?
?
?
prestige/reputation
funding regime &duration
??
adverseselection
?
collaboration &coordination of
care
+
+
-
+
?
+
+
-
+
+-
+
eligibility for andamount of OW received
-+
+
+
+
+
+
+
-
-
+
-
+ delaysobtaining care+
+
+
+
+
-
+
-
+
+
-
+
?
+
+
+
+
-
-
+
change in MH&A
ability to obtain & affordinsurance (auto & home)ability to afford &
maintain appropriatehousing
discrimination
sexualorientation
use of alcohol, tobacco,other substances
personalinvolvement in care
Level of carerequired
provider attitude
work relatedmedicalbenefits
OW eligibilityrequirements
ability to affordeducation &
training
eligibilityrequirements oftuition supports
manageability ofMHA
availability ofsubstances
genetics/familyhistory of MH&A2
likelihood of seekingfinancial supports
awareness of financialsupport options
acessibility offinancial supports
demands ofhome life
reliance oninformal/family care
providers
likelihood of"sticking with" care
life skills &abilities
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Local Health Integration Networks (LHINs)
Planning Tools for “Aging at Home”
GIS models of Supply & DemandAli Esensoy, Agnita Pal & Mike Carter
Demand Estimation
Estimated Adult Day Program Demand in TC LHIN
Adult Day Program Supply in TC LHIN
Cluster Analysis of ADP Gap in TC LHIN
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Cancer Care Ontario
How many medical oncologists do we need in Ontario?
Graham Woodward, Adriane Castellino,
Matt Nelson & Mike Carter
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HHR Model
How are teams of providers configured in chemo clinics?
How are responsibilities/tasks distributed among providers? (i.e., Who does what?)
Focus on functions that could be performed by more than one type of provider
Are there differences among sites? Best practice
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Systemic treatment
Suspicion of cancer and diagnosis
Consult Chemo treatment
Well-follow-up
End-of-life care
No
Biopsy
Staging tests
Check in with med onc
APNGPOOnc Onc Onc
APN
GPO
Cancer in remission?
Yes
Yes
Can refer to a Medical Oncologist or a Hematology Oncologist
Palliative Care
Systemic Treatment Visits by Provider
Onc
Oncologist may or not be present
May or may not be necessary
APN
Palliative MD
Pharm APNGPO
Pharm
Urgent care & symptom
management
APN Onc
GPO
Follow up with oncologist Onc
Discharge back to family practitioner
Usually performed by family doctor and/or surgeon
Onc
Pharm
Pharm
Further treatment? NoRe-stage cancer
Palliative Care
Onc
Onc
Onc
Onc
Oncologist must be present
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Data Collection
• Each centre has different people doing the tasks.
• Need rough estimate of time required for each task by type of patient (expert opinion)
• Only trying to get a high level sense of who does what to answer questions like: – “How many Medical Oncologists do we need at this
centre?”
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Integer Programming Models
1. Given current volume and mix of patients, determine “ideal” provider configuration.
2. Given current set of providers, how many patients can be treated? (% of current volume)
3. How many providers are needed under different models of care?
4. How do sites compare to each other in terms of resource use? (Best Practice.)
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Surgical Planning & Scheduling
Sherry Weaver, Daphne Sniekers, Dionne Aleman, Solmaz Azari-Rad,
Carolyn Busby & Mike Carter
CRHE Several current projects• Western Canada Wait List: Orthopaedic surgery
– Alberta Bone & Joint Health Institute: Calgary, Edmonton, Winnipeg
– Bone & Joint Canada
• General Perioperative Simulation– Hamilton, UHN, St. Mike’s, Mt. Sinai, William Osler
(Brampton Civic & Etobicoke General)
• Sunnybrook Health Sciences– Urgent Ortho & Smoothing Resource Use
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Conclusions
• Health Care is major industry
• The current system is not sustainable
• Quantitative methods (Operational Research) can help
• The health care industry is beginning to recognize the value of systems thinking
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Opportunities for Operations Research?
Watch your newspaper:
• Patient flow → Supply Chain
• ED Wait times → Queueing/Simulation
• Surgical Wait Lists → Better scheduling
• Infectious Diseases → Logistics, Modelling
• Health Human Resources → Forecasting