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Wai B, Vasarhelyi K, Rutherford AR, Buchner C, Gustafson R, Compton M, Hull M, Williams J, Barrios R. A qualitative model of the HIV care continuum in Vancouver, Canada. Health Syst (Basingstoke) 2021; 11:84-97. [PMID: 35655610 PMCID: PMC9154767 DOI: 10.1080/20476965.2021.1906762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/09/2021] [Indexed: 10/21/2022] Open
Abstract
A team of health care stakeholders and researchers collaboratively developed a qualitative model and graphic representation of the continuum of HIV care in Vancouver to inform delivery of antiretroviral therapy and other HIV health services. The model describes the patient journey through the HIV care continuum, including states of infection, health services, and care decisions. We used a Unified Modelling Language (UML) activity diagram to capture patient and provider activities and to guide the construction of a UML state machine diagram. The state machine diagram captures model agent states in a formalism that facilitates the development of system dynamics or agent-based models. These quantitative models can be applied to optimizing the allocation of resources, and to evaluate potential strategies for improved patient care and system performance. The novel approach of combining UML diagrams we present provides a general method for modelling capacity ---management strategies within complex health systems.
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Affiliation(s)
- Benny Wai
- Department of Mathematics, Simon Fraser University, Burnaby, Canada
| | - Krisztina Vasarhelyi
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
- Vancouver Coastal Health Research Institute, Vancouver Coastal Health, Vancouver, Canada
| | | | - Chris Buchner
- Population and Public Health, Fraser Health, Surrey, Canada
| | - Reka Gustafson
- Vancouver Coastal Health Research Institute, Vancouver Coastal Health, Vancouver, Canada
| | - Miranda Compton
- Vancouver Coastal Health Research Institute, Vancouver Coastal Health, Vancouver, Canada
| | - Mark Hull
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Jf Williams
- Department of Mathematics, Simon Fraser University, Burnaby, Canada
| | - Rolando Barrios
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
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Attar A, Duru G, Roblin X, Savarieau B, Brunel P, Lamure M, Peyrin-Biroulet L. Cost savings using a test-based de-escalation strategy for patients with Crohn's disease in remission on optimized infliximab: A discrete event model study. Dig Liver Dis 2019; 51:112-119. [PMID: 30268737 DOI: 10.1016/j.dld.2018.08.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Drug de-escalation is considered in Crohn's disease patients in sustained remission on optimized infliximab treatment. AIM We built a model to evaluate the magnitude of cost savings in patients' disease course with or without drug de-escalation guided by infliximab trough levels. METHODS We designed 4 virtual cohorts (P1-P4) of 10,000 patients in clinical remission on optimized infliximab treatment followed for 2 years. P1: no drug de-escalation - 10 mg/kg/8 weeks; P2: drug de-escalation from 10 mg/kg/8 weeks to 5 mg/kg/8 weeks according to trough levels; P3: no drug de-escalation - 10 mg/kg/6 weeks; and P4: drug de-escalation from 10 mg/kg/6 weeks to 10 mg/kg/8 weeks according to trough levels. For P2 and P4 cohorts, drug de-escalation was decided if trough levels were ≥7 μg/mL and no de-escalation if trough levels were <7 μg/mL. Only costs related to drug administration were considered. RESULTS The cost differences when comparing P1 versus P2 and P3 versus P4 were 7.6% and 4.6%, respectively, corresponding to costs savings of €30.5 millions and €20.3 million for 10,000 patients. CONCLUSION Over a 2-year period, infliximab de-escalation according to trough levels led to cost saving of about 6%, corresponding to around €25.4 million.
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Affiliation(s)
- Alain Attar
- Department of Gastroenterology - IBD - Nutritional Support, Beaujon Hospital, Clichy, France.
| | - Gérard Duru
- University Lyon 1, University of Lyon, France
| | - Xavier Roblin
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint-Etienne, France
| | | | - Pierre Brunel
- Department of Pharmacy, University Hospital of Saint Etienne, France
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Simulation of patient flow in multiple healthcare units using process and data mining techniques for model identification. J Biomed Inform 2018; 82:128-142. [PMID: 29753874 DOI: 10.1016/j.jbi.2018.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 04/05/2018] [Accepted: 05/09/2018] [Indexed: 01/02/2023]
Abstract
INTRODUCTION An approach to building a hybrid simulation of patient flow is introduced with a combination of data-driven methods for automation of model identification. The approach is described with a conceptual framework and basic methods for combination of different techniques. The implementation of the proposed approach for simulation of the acute coronary syndrome (ACS) was developed and used in an experimental study. METHODS A combination of data, text, process mining techniques, and machine learning approaches for the analysis of electronic health records (EHRs) with discrete-event simulation (DES) and queueing theory for the simulation of patient flow was proposed. The performed analysis of EHRs for ACS patients enabled identification of several classes of clinical pathways (CPs) which were used to implement a more realistic simulation of the patient flow. The developed solution was implemented using Python libraries (SimPy, SciPy, and others). RESULTS The proposed approach enables more a realistic and detailed simulation of the patient flow within a group of related departments. An experimental study shows an improved simulation of patient length of stay for ACS patient flow obtained from EHRs in Almazov National Medical Research Centre in Saint Petersburg, Russia. CONCLUSION The proposed approach, methods, and solutions provide a conceptual, methodological, and programming framework for the implementation of a simulation of complex and diverse scenarios within a flow of patients for different purposes: decision making, training, management optimization, and others.
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Cost-effectiveness of drug monitoring of anti-TNF therapy in inflammatory bowel disease and rheumatoid arthritis: a systematic review. J Gastroenterol 2017; 52:19-25. [PMID: 27665099 DOI: 10.1007/s00535-016-1266-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of anti-TNF is increasingly used to manage inflammatory bowel diseases (IBD) and rheumatoid arthritis (RA). The cost-effectiveness of this strategy is debated. METHODS All studies comparing the cost-effectiveness of a TDM-based strategy and an empirical dose management of anti-TNF in IBD or RA were screened. Studies were identified through the MEDLINE electronic database (up to July 2016), and annual international meeting abstracts were also manually reviewed. RESULTS Seven studies were included: two randomized controlled trials (RCTs) enrolling 332 patients [247 Crohn's disease (CD) and 85 ulcerative colitis (UC)] and five modeling approaches. Four studies included only CD patients, one included both CD and UC patients, and two included only RA patients. Three studies compared the cost-effectiveness of the two strategies in patients with secondary infliximab (IFX) failure (dose-escalation strategy), one in patients in remission on optimized IFX (de-escalation strategy), one in patients starting adalimumab, and two in patients with clinical response to maintenance anti-TNF therapy. The two RCTs demonstrated that a TDM strategy led to major cost savings, ranging from 28 to 34 %. The three modeling approaches with regard to CD patients demonstrated cost savings ranging from $5396 over a 1-year period to €13,130 per patient at 5 years of follow-up. A TDM strategy also led to major cost savings in the two modeling approaches in RA patients. CONCLUSIONS Available evidence indicates that a TDM strategy leads to major cost savings related to anti-TNF therapy in both IBD and RA patients, with no negative impact on efficacy.
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Roblin X, Attar A, Lamure M, Savarieau B, Brunel P, Duru G, Peyrin-Biroulet L. Cost savings of anti-TNF therapy using a test-based strategy versus an empirical dose escalation in Crohn's disease patients who lose response to infliximab. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2015; 3:29229. [PMID: 27123185 PMCID: PMC4802699 DOI: 10.3402/jmahp.v3.29229] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/04/2015] [Accepted: 09/23/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND The use of pharmacokinetics is associated with cost savings in anti-tumor necrosis factor (anti-TNF) therapy, but the long-term cost savings in a large cohort of Crohn's disease (CD) patients are unknown. AIM The goal of this study was to compare the cost of anti-TNF therapy in two cohorts of CD patients losing response to infliximab, one using a test-based strategy and one an empirical dose escalation. METHODS We used a selected mathematical model to describe the trajectories of CD patients based on a discrete event system. This design allowed us to track over a given period a double cohort of patients who moved randomly and asynchronously from one state to another, while keeping all the information on their entire trajectory. Both cohorts were modeled using state diagram parameters where transition probabilities from one state to another are derived from literature data. Costs were estimated based on the French health care system. RESULTS Cost savings among the 10,000 CD patients using a test-based strategy were €131,300,293 at 5 years. At 5 years the mean cost saving was €13,130 per patient. The direct cost of the test had no impact on the results until the cost per test reached €2,000. CONCLUSIONS A test-based strategy leads to major cost savings related to anti-TNF therapy in CD.
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Affiliation(s)
- Xavier Roblin
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint-Etienne, France
| | - Alain Attar
- Department of Gastroenterology, IBD, Nutritional Support, Hôpital Beaujon, Clichy, France
| | | | | | - Pierre Brunel
- Pharmacy Department, University Hospital of Saint Etienne, Saint-Etienne, France
| | - Gérard Duru
- University Claude Bernard, Lyon 1, Lyon, France
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Sandak B, Huss E, Sarid O, Harel D. Computational Paradigm to Elucidate the Effects of Arts-Based Approaches and Interventions: Individual and Collective Emerging Behaviors in Artwork Construction. PLoS One 2015; 10:e0126467. [PMID: 26061736 PMCID: PMC4489499 DOI: 10.1371/journal.pone.0126467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 04/03/2015] [Indexed: 11/18/2022] Open
Abstract
Art therapy, as well as other arts-based therapies and interventions, is used to reduce pain, stress, depression, breathlessness and other symptoms in a wide variety of serious and chronic diseases, such as cancer, Alzheimer and schizophrenia. Arts-based approaches are also known to contribute to one's well-being and quality of life. However, much research is required, since the mechanisms by which these non-pharmacological treatments exert their therapeutic and psychosocial effects are not adequately understood. A typical clinical setting utilizing the arts consists of the creation work itself, such as the artwork, as well as the therapist and the patient, all of which constitute a rich and dynamic environment of occurrences. The underlying complex, simultaneous and interwoven processes of this setting are often considered intractable to human observers, and as a consequence are usually interpreted subjectively and described verbally, which affect their subsequent analyses and understanding. We introduce a computational research method for elucidating and analyzing emergent expressive and social behaviors, aiming to understand how arts-based approaches operate. Our methodology, which centers on the visual language of Statecharts and tools for its execution, enables rigorous qualitative and quantitative tracking, analysis and documentation of the underlying creation and interaction processes. Also, it enables one to carry out exploratory, hypotheses-generating and knowledge discovery investigations, which are empirical-based. Furthermore, we illustrate our method's use in a proof-of-principle study, applying it to a real-world artwork investigation with human participants. We explore individual and collective emergent behaviors impacted by diverse drawing tasks, yielding significant gender and age hypotheses, which may account for variation factors in response to art use. We also discuss how to gear our research method to systematic and mechanistic investigations, as we wish to provide a broad empirical evidence for the uptake of arts-based approaches, also aiming to ameliorate their use in clinical settings.
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Affiliation(s)
- Billie Sandak
- Department of Computer Science and Applied Mathematics, Faculty of Mathematics and Computer Science, The Weizmann Institute of Science, Rehovot, Israel
| | - Ephrat Huss
- The Spitzer Department of Social Work, Faculty of Humanities & Social Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Orly Sarid
- The Spitzer Department of Social Work, Faculty of Humanities & Social Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - David Harel
- Department of Computer Science and Applied Mathematics, Faculty of Mathematics and Computer Science, The Weizmann Institute of Science, Rehovot, Israel
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Marshall DA, Burgos-Liz L, IJzerman MJ, Crown W, Padula WV, Wong PK, Pasupathy KS, Higashi MK, Osgood ND. Selecting a dynamic simulation modeling method for health care delivery research-part 2: report of the ISPOR Dynamic Simulation Modeling Emerging Good Practices Task Force. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:147-60. [PMID: 25773550 DOI: 10.1016/j.jval.2015.01.006] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
In a previous report, the ISPOR Task Force on Dynamic Simulation Modeling Applications in Health Care Delivery Research Emerging Good Practices introduced the fundamentals of dynamic simulation modeling and identified the types of health care delivery problems for which dynamic simulation modeling can be used more effectively than other modeling methods. The hierarchical relationship between the health care delivery system, providers, patients, and other stakeholders exhibits a level of complexity that ought to be captured using dynamic simulation modeling methods. As a tool to help researchers decide whether dynamic simulation modeling is an appropriate method for modeling the effects of an intervention on a health care system, we presented the System, Interactions, Multilevel, Understanding, Loops, Agents, Time, Emergence (SIMULATE) checklist consisting of eight elements. This report builds on the previous work, systematically comparing each of the three most commonly used dynamic simulation modeling methods-system dynamics, discrete-event simulation, and agent-based modeling. We review criteria for selecting the most suitable method depending on 1) the purpose-type of problem and research questions being investigated, 2) the object-scope of the model, and 3) the method to model the object to achieve the purpose. Finally, we provide guidance for emerging good practices for dynamic simulation modeling in the health sector, covering all aspects, from the engagement of decision makers in the model design through model maintenance and upkeep. We conclude by providing some recommendations about the application of these methods to add value to informed decision making, with an emphasis on stakeholder engagement, starting with the problem definition. Finally, we identify areas in which further methodological development will likely occur given the growing "volume, velocity and variety" and availability of "big data" to provide empirical evidence and techniques such as machine learning for parameter estimation in dynamic simulation models. Upon reviewing this report in addition to using the SIMULATE checklist, the readers should be able to identify whether dynamic simulation modeling methods are appropriate to address the problem at hand and to recognize the differences of these methods from those of other, more traditional modeling approaches such as Markov models and decision trees. This report provides an overview of these modeling methods and examples of health care system problems in which such methods have been useful. The primary aim of the report was to aid decisions as to whether these simulation methods are appropriate to address specific health systems problems. The report directs readers to other resources for further education on these individual modeling methods for system interventions in the emerging field of health care delivery science and implementation.
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Affiliation(s)
- Deborah A Marshall
- Health Services & Systems Research, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Lina Burgos-Liz
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maarten J IJzerman
- Department of Health Technology & Services Research, University of Twente, Enschede, The Netherlands
| | | | - William V Padula
- Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
| | - Peter K Wong
- HSHS Illinois Divisions and Medical Group, Hospital Sisters Health System, Belleville, IL, USA
| | - Kalyan S Pasupathy
- Health Care Systems Engineering Program, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | | | - Nathaniel D Osgood
- Department of Computer Science, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; Department of Community Health & Epidemiology and Bioengineering Division, Saskatoon, Saskatchewan, Canada
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Marshall DA, Burgos-Liz L, IJzerman MJ, Osgood ND, Padula WV, Higashi MK, Wong PK, Pasupathy KS, Crown W. Applying dynamic simulation modeling methods in health care delivery research-the SIMULATE checklist: report of the ISPOR simulation modeling emerging good practices task force. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:5-16. [PMID: 25595229 DOI: 10.1016/j.jval.2014.12.001] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Health care delivery systems are inherently complex, consisting of multiple tiers of interdependent subsystems and processes that are adaptive to changes in the environment and behave in a nonlinear fashion. Traditional health technology assessment and modeling methods often neglect the wider health system impacts that can be critical for achieving desired health system goals and are often of limited usefulness when applied to complex health systems. Researchers and health care decision makers can either underestimate or fail to consider the interactions among the people, processes, technology, and facility designs. Health care delivery system interventions need to incorporate the dynamics and complexities of the health care system context in which the intervention is delivered. This report provides an overview of common dynamic simulation modeling methods and examples of health care system interventions in which such methods could be useful. Three dynamic simulation modeling methods are presented to evaluate system interventions for health care delivery: system dynamics, discrete event simulation, and agent-based modeling. In contrast to conventional evaluations, a dynamic systems approach incorporates the complexity of the system and anticipates the upstream and downstream consequences of changes in complex health care delivery systems. This report assists researchers and decision makers in deciding whether these simulation methods are appropriate to address specific health system problems through an eight-point checklist referred to as the SIMULATE (System, Interactions, Multilevel, Understanding, Loops, Agents, Time, Emergence) tool. It is a primer for researchers and decision makers working in health care delivery and implementation sciences who face complex challenges in delivering effective and efficient care that can be addressed with system interventions. On reviewing this report, the readers should be able to identify whether these simulation modeling methods are appropriate to answer the problem they are addressing and to recognize the differences of these methods from other modeling approaches used typically in health technology assessment applications.
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Affiliation(s)
- Deborah A Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Division of Rheumatology, Department of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada; Alberta Bone & Joint Health Institute, University of Calgary, Calgary, AB, Canada.
| | - Lina Burgos-Liz
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maarten J IJzerman
- Department of Health Technology & Services Research, University of Twente, Enschede, The Netherlands
| | - Nathaniel D Osgood
- Department of Computer Science, Health & Epidemiology and Bioengineering Division, University of Saskatchewan, Saskatoon, SK, Canada; Department of Community, Health & Epidemiology and Bioengineering Division, University of Saskatchewan, Saskatoon, SK, Canada
| | - William V Padula
- Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
| | | | - Peter K Wong
- HSHS Illinois Divisions & Medical Group, Hospital Sisters Health System, Belleville, IL, USA
| | - Kalyan S Pasupathy
- Health Care Systems Engineering Program, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - William Crown
- Health Care Policy & Research, Health Care Systems Engineering Program, Mayo Clinic, Rochester, MN, USA
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Bratsas C, Bamidis P, Kehagias DD, Kaimakamis E, Maglaveras N. Dynamic composition of semantic pathways for medical computational problem solving by means of semantic rules. IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE : A PUBLICATION OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY 2011; 15:334-343. [PMID: 21335316 DOI: 10.1109/titb.2010.2091645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This paper presents a semantic rule-based system for the composition of successful algorithmic pathways capable of solving medical computational problems (MCPs). A subset of medical algorithms referring to MCP solving concerns well-known medical problems and their computational algorithmic solutions. These solutions result from computations within mathematical models aiming to enhance healthcare quality via support for diagnosis and treatment automation, especially useful for educational purposes. Currently, there is a plethora of computational algorithms on the web, which pertain to MCPs and provide all computational facilities required to solve a medical problem. An inherent requirement for the successful construction of algorithmic pathways for managing real medical cases is the composition of a sequence of computational algorithms. The aim of this paper is to approach the composition of such pathways via the design of appropriate finite-state machines (FSMs), the use of ontologies, and SWRL semantic rules. The goal of semantic rules is to automatically associate different algorithms that are represented as different states of the FSM in order to result in a successful pathway. The rule-based approach is herein implemented on top of Knowledge-Based System for Intelligent Computational Search in Medicine (KnowBaSICS-M), an ontology-based system for MCP semantic management. Preliminary results have shown that the proposed system adequately produces algorithmic pathways in agreement with current international medical guidelines.
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Affiliation(s)
- Charalampos Bratsas
- Lab of Medical Informatics, Medical School, Aristotle University of Thessaloniki, Greece.
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Authoring and verification of clinical guidelines: A model driven approach. J Biomed Inform 2010; 43:520-36. [DOI: 10.1016/j.jbi.2010.02.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 02/12/2010] [Accepted: 02/28/2010] [Indexed: 11/23/2022]
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Systematic review of the use of computer simulation modeling of patient flow in surgical care. J Med Syst 2009; 35:1-16. [PMID: 20703590 DOI: 10.1007/s10916-009-9336-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 06/21/2009] [Indexed: 10/20/2022]
Abstract
Computer simulation has been employed to evaluate proposed changes in the delivery of health care. However, little is known about the utility of simulation approaches for analysis of changes in the delivery of surgical care. We searched eight bibliographic databases for this comprehensive review of the literature published over the past five decades, and found 34 publications that reported on simulation models for the flow of surgical patients. The majority of these publications presented a description of the simulation approach: 91% outlined the underlying assumptions for modeling, 88% presented the system requirements, and 91% described the input and output data. However, only half of the publications reported that models were constructed to address the needs of policy-makers, and only 26% reported some involvement of health system managers and policy-makers in the simulation study. In addition, we found a wide variation in the presentation of assumptions, system requirements, input and output data, and results of simulation-based policy analysis.
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