Operations Research in Health Care or Who Let the Engineer Into the Hospital?

Transcription

1 Operations Research in Health Care or Who Let the Engineer Into the Hospital? Michael W. Carter Health Care Resource Modelling Group Mechanical and Industrial Engineering University of Toronto 1

2 Outline Intro to Health Industry Some application examples 2

3 The Importance of Health Care Health care is North America s largest single industry. Total spending in Canada was $123 billion (CN) in ($1.6 trillion in the US) In Canada, in 2003, $3,001 US per person was spent on health care compared to $5,635 in US) $ Billions $ per person Total $ $/Person 3

4 International Trends % GDP Health Spending as a % of GDP US Canada France Germany UK Netherlands Japan Mexico Belgium '00 '02 '04 OECD web site: Apr 2006

5 % GDP 2003 United Switzerland Germany Iceland Norway France Greece Canada Netherlands Portugal Belgium Sweden Australia Denmark Italy Hungary New Zealand Japan United Spain Czech Austria Turkey Ireland Finland Luxembourg Poland Mexico Slovak Korea OECD web site: Jan

6 $US Per Capita (PPP) 2003 U.S. Switzerland Germany Iceland Norway France Greece Canada Netherlands Portugal Belgium Sweden Australia Denmark Italy Hungary N.Z. Japan U.K. Spain Czech Rep. Austria Turkey Ireland Finland Luxembourg Poland Mexico Slovak Rep. Korea OECD web site: Jan

7 Unfair Comparison: More $ doesn t = better health? Japan Sweden Switzerland Australia Canada New Zealand United Kingdom Netherlands France Germany United States Life Expectancy Women Men 7

8 Infant Mortality per 1,000 live births 2003 United States New Zealand Canada United Kingdom Netherlands Australia Switzerland Germany France Sweden Japan

9 United States Health Risks (Percent of Population) Australia Canada Netherlands Obese (BMI>30) Over weight (BMI>25) Tobacco France Japan

10 Health Care Delivery (% Public Payor in 2003) Public Provider Private Provider Mix Public Payor UK (83), Japan (81) Canada (70%), Germany (78) France (76) ** Most OECD states allow wealthy to opt out. of public system ** Private Payor United States (44) Mix Sweden (85) Holland (62) 10

11 Canadian Medicare (very brief) Providers are private. Covered if: Medically necessary Done in a hospital Done by a doctor 1990 Internationally recognized leader 2000 We had slipped significantly 2006? Major funding increases - improving 11

12 Systemic Hospital Issues: The Four Faces of Health Care* Health care is a business, but... Containment Coalition It is a business unlike all others. Trustees Community Managers Control Multiple decision makers. Conflicting goals, incentives. Status Coalition Doctors Cure Nursing Care Insider Coalition Social good. No market, no manager. Clinical Coalition *Glouberman & Mintzberg,

13 The Four Faces of Health Care* The same divisions apply to the overall social health system! Elected Officials Community Involvement Health Authorities Insurance Public Control Acute Hospital Acute Cure LTC, Primary Community Care *Glouberman & Mintzberg,

14 Toddler s Creed If I want it, it s mine. If I give it to you and change my mind later, it s mine. If I can take it away from you, it s mine. If I had it a little while ago, it s mine. If it s mine, it will never belong to anybody else, no matter what. If we are building something together, all the pieces are mine. If it looks just like mine, it is mine. Source: Parenting Department, Toronto Board Of Education 14

15 Optimisation in Health Care Two main criteria: Minimize Cost per visit/episode? average annual cost? Maximize Quality for the particular episode? quality of life? 15

16 Have you ever counted them? Nuclear Medicine at William Osler Endocrinology at the Cleveland Clinc 16

17 Cardiac Surgery Simulation Hamilton Health Sciences Opening fourth cardiac OR in Spring 2006 How should OR time be allocated? How many beds are required in ICU/ward? What if? Simulation tool 17

18 Surgery Grouping Cardiac Surgery N>4000 No Redo/ Combined Redo/ Combined CABG VALVE COTHR CONGD CAVLV AORTA CABG VALVE AORTA CAVLV COTHR CABG 1,2,3 TVR,AVR CONGD COTHR CABG 4,5,6,7 MVR 18

19 Surgery Grouping Cardiac Surgery Intermediate 322 mins n= Major mins n=116 Major mins n=60 Minor 244 mins n= In-btwn 284 mins n=

20 Surgery Duration Distribution Minor 246 mins n= In-btwn 285 mins n= More Surgery duration (mins) Surgery duration (mins) Intermediate 337 mins n= Surgery Duration (mins) Major 461 mins n=220 Surgery Duration (mins)

21 Performance Indicators Number of cases completed/year Cancellation rates Lack of ICU/ ward bed Out of scheduled time More urgent case took precedent Operating room utilization Under-utilization (hours/week) Overtime (hours/week) Ward bed utilization (ICU & CSU) 21

22 Can we book surgery differently? Undertime & Overtime (hour/day) hour OR Undertime Overtime Total Cancellations Total Cancellations (Cases/year) major1 + 1 minor 1 intermediate + 1 in-between 1 intermediate + 1 minor 2 in-between 1 in-between + 1 minor Combinations 22 0

23 Planning ICU and Ward Capacity unit/year ICUcancel (# cancellations) CSUover (# days exceeded 30 beds) 0 Mon Tue Wed Thu Fri Sat Sun 23

24 Strategic Hospital Planning Model Mid 1990 s 3 year cuts of 18% John Blake Ph.D. thesis - Mt. Sinai Hosp Understand relationship between revenues, costs, resources. Mathematical model Goal Programming formulation 24

25 Problem Statement Identify a case mix for physicians that: Enables the hospital to break even. Provides physicians with a stable income. Allows physicians, as much as is possible, to perform their target mix of cases. 25

26 Two Goal Programming Models Volume model: Fix the cost of each CMG Determine the case mix that meets targets Cost model: Fix the case mix (volume) for each CMG (at current levels) Determine the cost reductions necessary to meet targets 26

27 Project Results Used during 1996 (plan for 11% cut) Intuition at hospital: Retain clinically important services (oncology) Eliminate unimportant services (dental, ENT, ophthalmology) Model recommendations: increase dental/eye/ent decrease thoracic, oncology Thoracic surgery was eliminated in

28 System Dynamics Simulation for Cardiac Resource Allocation at Trillium Health Center Somayeh Sadat, Caroline Chan, Michael Carter 28

29 Cardiology at Trillium Community Hospital which also serves as the regional cardiac care centre for communities west of Toronto, Ontario Conducts 10% of all cardiac procedures in Ontario Performs more than 7,000 cardiac surgeries annually Performs unique procedure: beating heart surgery 29

30 Cardiac Patient Flow at Trillium ED LOS P1 <effect of cardiologist availability on patient transfers> Other Acute Hospitals Emergency Department Heart Function Clinic <Effect of CSPU nurse ratio> Physician's Office <Effect of CSPU beds utilization ratio> ED2CSPU CSPU CCU Cardiac OR CARU2C or CARU2D CSSU CSICU Medicine Units Day Surgery Rehabilitation Alternative Level of Care 30

31 Western Canada Wait List Project Wait lists are anecdotal! Plus, every doc has his/her own priority WCWL has developed standard priority instruments But, how will that help reduce wait times? Need to develop models of resources to predict impact on wait times. 31

32 Some Current Projects ED Simulation (10 Ontario hospitals) Patient Centred Care Princess Margaret Queueing model for CBS blood inventory CPOE evaluation Clinical Managers workload measurement OR scheduling & peri-operative simulation Fracture clinic scheduling 32

33 Some Current Projects (cont) Diagnostic imaging scheduling HIV/AIDS funding allocation in Africa Bed allocation Ambulance drop-off delays Early speech & language therapy Surgical equipment processing 33

34 Conclusions Health Care is major industry There are plenty of Operations Research problems in this field There are very few people who devote their major research effort to O.R. in health care 34

35 Readings Operations Research and Health Care: A Handbook of Methods and Applications Series : International Series in Operations Research and Management Science, Vol. 70 Brandeau, Margaret L.; Sainfort, Francois; Pierskalla, William P. (Eds.) 2004, 872 p. 35