CRHE Healthcare Engineering: Quantitative Decision Support Models for the Healthcare Industry Michael W. Carter Centre for Research in Healthcare Operations.

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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