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Busschaert SL, Kimpe E, Gevaert T, De Ridder M, Putman K. Deep Inspiration Breath Hold in Left-Sided Breast Radiotherapy: A Balance Between Side Effects and Costs. JACC CardioOncol 2024; 6:514-525. [PMID: 39239337 PMCID: PMC11372305 DOI: 10.1016/j.jaccao.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/10/2024] [Accepted: 04/29/2024] [Indexed: 09/07/2024] Open
Abstract
Background Deep inspiration breath hold (DIBH) is an effective technique for reducing heart exposure during radiotherapy for left-sided breast cancer. Despite its benefits, cost considerations and its impact on workflow remain significant barriers to widespread adoption. Objectives This study aimed to assess the cost-effectiveness of DIBH and compare its operational, financial, and clinical outcomes with free breathing (FB) in breast cancer treatment. Methods Treatment plans for 100 patients with left-sided breast cancer were generated using both DIBH and FB techniques. Dosimetric data, including the average mean heart dose, were calculated for each technique and used to estimate the cardiotoxicity of radiotherapy. A state-transition microsimulation model based on SCORE2 (Systematic Coronary Risk Evaluation) algorithms projected the effects of DIBH on cardiovascular outcomes and quality-adjusted life-years (QALYs). Costs were calculated from a provider perspective using time-driven activity-based costing, applying a willingness-to-pay threshold of €40,000 for cost-effectiveness assessment. A discrete event simulation model assessed the impacts of DIBH vs FB on throughput and waiting times in the radiotherapy workflow. Results In the base case scenario, DIBH was associated with an absolute risk reduction of 1.72% (95% CI: 1.67%-1.76%) in total cardiovascular events and 0.69% (95% CI: 0.67%-0.72%) in fatal cardiovascular events over 20 years. Additionally, DIBH was estimated to provide an incremental 0.04 QALYs (95% CI: 0.05-0.05) per left-sided breast cancer patient over the same time period. However, DIBH increased treatment times, reducing maximum achievable throughput by 12.48% (95% CI: 12.36%-12.75%) and increasing costs by €617 per left-sided breast cancer patient (95% CI: €615-€619). The incremental cost-effectiveness ratio was €14,023 per QALY. Conclusions Despite time investments, DIBH is cost-effective in the Belgian population. The growing adoption of DIBH may benefit long-term cardiovascular health in breast cancer survivors.
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Affiliation(s)
- Sara-Lise Busschaert
- Research Centre on Digital Medicine, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Eva Kimpe
- Research Centre on Digital Medicine, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | - Thierry Gevaert
- Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Mark De Ridder
- Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Koen Putman
- Research Centre on Digital Medicine, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Franklin M, Hinde S, Hunter RM, Richardson G, Whittaker W. Is Economic Evaluation and Care Commissioning Focused on Achieving the Same Outcomes? Resource-Allocation Considerations and Challenges Using England as a Case Study. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:435-445. [PMID: 38467989 PMCID: PMC11178631 DOI: 10.1007/s40258-024-00875-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/13/2024]
Abstract
Commissioning describes the process of contracting appropriate care services to address pre-identified needs through pre-agreed payment structures. Outcomes-based commissioning (i.e., paying services for pre-agreed outcomes) shares a common goal with economic evaluation: achieving value for money for relevant outcomes (e.g., health) achieved from a finite budget. We describe considerations and challenges as to the practical role of relevant outcomes for evaluation and commissioning, seeking to bridge a gap between economic evaluation evidence and care commissioning. We describe conceptual (e.g., what are 'relevant' outcomes) alongside practical considerations (e.g., quantifying and using relevant endpoint or surrogate outcomes) and pertinent issues when linking outcomes to commissioning-based payment mechanisms, using England as a case study. Economic evaluation often focuses on a single endpoint health-focused maximand, e.g., quality-adjusted life-years (QALYs), whereas commissioning often focuses on activity-based surrogate outcomes (e.g., health monitoring), as easier-to-measure key performance indicators that are more acceptable (e.g., by clinicians) and amenable to being linked with payment structures. However, payments linked to endpoint and/or surrogate outcomes can lead to market inefficiencies; for example, when surrogates do not have the intended causal effect on endpoint outcomes or when service activity focuses on only people who can achieve prespecified payment-linked outcomes. Accounting for and explaining direct links from commissioners' payment structures to surrogate and then endpoint economic outcomes is a vital step to bridging a gap between economic evaluation approaches and commissioning. Decision-analytic models could aid this but they must be designed to account for relevant surrogate and endpoint outcomes, the payments assigned to such outcomes, and their interaction with the system commissioners purport to influence.
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Affiliation(s)
- Matthew Franklin
- Sheffield Centre for Health and Related Research (SCHARR), Division of Population Health, School of Medicine and Population Health, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Sebastian Hinde
- Centre for Health Economics (CHE), University of York, Heslington, York, YO10 5DD, UK
| | - Rachael Maree Hunter
- Research Department of Primary Care and Population Health, Royal Free Medical School, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Gerry Richardson
- Centre for Health Economics (CHE), University of York, Heslington, York, YO10 5DD, UK
| | - William Whittaker
- Division of Population Health, Health Services Research & Primary Care, Alliance Manchester Business School, Institute for Health Policy and Organisation, Oxford Road, Manchester, M13 9PL, UK
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Pineda-Antunez C, Seguin C, van Duuren LA, Knudsen AB, Davidi B, de Lima PN, Rutter C, Kuntz KM, Lansdorp-Vogelaar I, Collier N, Ozik J, Alarid-Escudero F. Emulator-Based Bayesian Calibration of the CISNET Colorectal Cancer Models. Med Decis Making 2024; 44:543-553. [PMID: 38858832 PMCID: PMC11281870 DOI: 10.1177/0272989x241255618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
PURPOSE To calibrate Cancer Intervention and Surveillance Modeling Network (CISNET)'s SimCRC, MISCAN-Colon, and CRC-SPIN simulation models of the natural history colorectal cancer (CRC) with an emulator-based Bayesian algorithm and internally validate the model-predicted outcomes to calibration targets. METHODS We used Latin hypercube sampling to sample up to 50,000 parameter sets for each CISNET-CRC model and generated the corresponding outputs. We trained multilayer perceptron artificial neural networks (ANNs) as emulators using the input and output samples for each CISNET-CRC model. We selected ANN structures with corresponding hyperparameters (i.e., number of hidden layers, nodes, activation functions, epochs, and optimizer) that minimize the predicted mean square error on the validation sample. We implemented the ANN emulators in a probabilistic programming language and calibrated the input parameters with Hamiltonian Monte Carlo-based algorithms to obtain the joint posterior distributions of the CISNET-CRC models' parameters. We internally validated each calibrated emulator by comparing the model-predicted posterior outputs against the calibration targets. RESULTS The optimal ANN for SimCRC had 4 hidden layers and 360 hidden nodes, MISCAN-Colon had 4 hidden layers and 114 hidden nodes, and CRC-SPIN had 1 hidden layer and 140 hidden nodes. The total time for training and calibrating the emulators was 7.3, 4.0, and 0.66 h for SimCRC, MISCAN-Colon, and CRC-SPIN, respectively. The mean of the model-predicted outputs fell within the 95% confidence intervals of the calibration targets in 98 of 110 for SimCRC, 65 of 93 for MISCAN, and 31 of 41 targets for CRC-SPIN. CONCLUSIONS Using ANN emulators is a practical solution to reduce the computational burden and complexity for Bayesian calibration of individual-level simulation models used for policy analysis, such as the CISNET CRC models. In this work, we present a step-by-step guide to constructing emulators for calibrating 3 realistic CRC individual-level models using a Bayesian approach. HIGHLIGHTS We use artificial neural networks (ANNs) to build emulators that surrogate complex individual-based models to reduce the computational burden in the Bayesian calibration process.ANNs showed good performance in emulating the CISNET-CRC microsimulation models, despite having many input parameters and outputs.Using ANN emulators is a practical solution to reduce the computational burden and complexity for Bayesian calibration of individual-level simulation models used for policy analysis.This work aims to support health decision scientists who want to quantify the uncertainty of calibrated parameters of computationally intensive simulation models under a Bayesian framework.
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Affiliation(s)
- Carlos Pineda-Antunez
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, United States
| | - Claudia Seguin
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States
| | - Luuk A van Duuren
- Department of Public Health, Erasmus MC Medical Center Rotterdam, The Netherlands
| | - Amy B. Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States
| | - Barak Davidi
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States
| | | | - Carolyn Rutter
- Fred Hutchinson Cancer Research Center, Hutchinson Institute for Cancer Outcomes Research, Biostatistics Program, Public Health Sciences Division, Seattle WA
| | - Karen M. Kuntz
- Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis, MN, United States
| | | | - Nicholson Collier
- Decision and Infrastructure Sciences Division, Argonne National Laboratory, Lemont, IL, United States
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, United States
| | - Jonathan Ozik
- Decision and Infrastructure Sciences Division, Argonne National Laboratory, Lemont, IL, United States
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, United States
| | - Fernando Alarid-Escudero
- Department of Health Policy, School of Medicine, Stanford University, CA, US
- Center for Health Policy, Freeman Spogli Institute, Stanford University, CA, US
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Lin Y, Hoyt AC, Manuel VG, Inkelas M, Hsu W. Using Discrete Event Simulation to Design and Assess an AI-aided Workflow for Same-day Diagnostic Testing of Women Undergoing Breast Screening. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE PROCEEDINGS. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE 2024; 2024:314-323. [PMID: 38827101 PMCID: PMC11141813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
The process of patients waiting for diagnostic examinations after an abnormal screening mammogram is inefficient and anxiety-inducing. Artificial intelligence (AI)-aided interpretation of screening mammography could reduce the number of recalls after screening. We proposed a same-day diagnostic workup to alleviate patient anxiety by employing an AI-aided interpretation to reduce unnecessary diagnostic testing after an abnormal screening mammogram. However, the potential unintended consequences of introducing this workflow in a high-volume breast imaging center are unknown. Using discrete event simulation, we observed that implementing the AI-aided screening mammogram interpretation and same-day diagnostic workflow would reduce daily patient volume by 4%, increase the time a patient would be at the clinic by 24%, and increase waiting times by 13-31%. We discuss how changing the hours of operation and introducing new imaging equipment and personnel may alleviate these negative impacts.
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Affiliation(s)
- Yannan Lin
- Medical & Imaging Informatics, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Anne C Hoyt
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Vladimir G Manuel
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- UCLA Clinical and Translational Science Institute, Los Angeles, CA, USA
| | - Moira Inkelas
- UCLA Clinical and Translational Science Institute, Los Angeles, CA, USA
| | - William Hsu
- Medical & Imaging Informatics, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Bioengineering, University of California, Los Angeles, CA, USA
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Tian H, Su X, Hou Y. Feedback stabilization of probabilistic finite state machines based on deep Q-network. Front Comput Neurosci 2024; 18:1385047. [PMID: 38756915 PMCID: PMC11097337 DOI: 10.3389/fncom.2024.1385047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/08/2024] [Indexed: 05/18/2024] Open
Abstract
Background As an important mathematical model, the finite state machine (FSM) has been used in many fields, such as manufacturing system, health care, and so on. This paper analyzes the current development status of FSMs. It is pointed out that the traditional methods are often inconvenient for analysis and design, or encounter high computational complexity problems when studying FSMs. Method The deep Q-network (DQN) technique, which is a model-free optimization method, is introduced to solve the stabilization problem of probabilistic finite state machines (PFSMs). In order to better understand the technique, some preliminaries, including Markov decision process, ϵ-greedy strategy, DQN, and so on, are recalled. Results First, a necessary and sufficient stabilizability condition for PFSMs is derived. Next, the feedback stabilization problem of PFSMs is transformed into an optimization problem. Finally, by using the stabilizability condition and deep Q-network, an algorithm for solving the optimization problem (equivalently, computing a state feedback stabilizer) is provided. Discussion Compared with the traditional Q learning, DQN avoids the limited capacity problem. So our method can deal with high-dimensional complex systems efficiently. The effectiveness of our method is further demonstrated through an illustrative example.
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Affiliation(s)
- Hui Tian
- Key Laboratory of Industrial Internet of Things and Networked Control, Ministry of Education, Chongqing University of Posts and Telecommunications, Chongqing, China
| | - Xin Su
- Key Laboratory of Industrial Internet of Things and Networked Control, Ministry of Education, Chongqing University of Posts and Telecommunications, Chongqing, China
| | - Yanfang Hou
- School of Electrical and Electronic Engineering, Chongqing University of Technology, Chongqing, China
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Marzano L, Darwich AS, Jayanth R, Sven L, Falk N, Bodeby P, Meijer S. Diagnosing an overcrowded emergency department from its Electronic Health Records. Sci Rep 2024; 14:9955. [PMID: 38688997 PMCID: PMC11061188 DOI: 10.1038/s41598-024-60888-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/29/2024] [Indexed: 05/02/2024] Open
Abstract
Emergency department overcrowding is a complex problem that persists globally. Data of visits constitute an opportunity to understand its dynamics. However, the gap between the collected information and the real-life clinical processes, and the lack of a whole-system perspective, still constitute a relevant limitation. An analytical pipeline was developed to analyse one-year of production data following the patients that came from the ED (n = 49,938) at Uppsala University Hospital (Uppsala, Sweden) by involving clinical experts in all the steps of the analysis. The key internal issues to the ED were the high volume of generic or non-specific diagnoses from non-urgent visits, and the delayed decision regarding hospital admission caused by several imaging assessments and lack of hospital beds. Furthermore, the external pressure of high frequent re-visits of geriatric, psychiatric, and patients with unspecified diagnoses dramatically contributed to the overcrowding. Our work demonstrates that through analysis of production data of the ED patient flow and participation of clinical experts in the pipeline, it was possible to identify systemic issues and directions for solutions. A critical factor was to take a whole systems perspective, as it opened the scope to the boundary effects of inflow and outflow in the whole healthcare system.
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Affiliation(s)
- Luca Marzano
- Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden.
| | - Adam S Darwich
- Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Raghothama Jayanth
- Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden
| | | | - Nina Falk
- Uppsala University Hospital, Uppsala, Sweden
| | | | - Sebastiaan Meijer
- Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden
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Gilman SD, Gravitt PE, Paz-Soldán VA. Implementation of new technologies designed to improve cervical cancer screening and completion of care in low-resource settings: a case study from the Proyecto Precancer. Implement Sci Commun 2024; 5:35. [PMID: 38581011 PMCID: PMC10998344 DOI: 10.1186/s43058-024-00566-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 03/09/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND This case study details the experience of the Proyecto Precancer in applying the Integrative Systems Praxis for Implementation Research (INSPIRE) methodology to guide the co-development, planning, implementation, adoption, and sustainment of new technologies and screening practices in a cervical cancer screening and management (CCSM) program in the Peruvian Amazon. We briefly describe the theoretical grounding of the INSPIRE framework, the phases of the INSPIRE process, the activities within each phase, and the RE-AIM outcomes used to evaluate program outcomes. METHODS Proyecto Precancer iteratively engaged over 90 stakeholders in the Micro Red Iquitos Sur (MRIS) health network in the Amazonian region of Loreto, Perú, through the INSPIRE phases. INSPIRE is an integrative research methodology grounded in systems thinking, participatory action research, and implementation science frameworks such as the Consolidated Framework for Implementation Research. An interrupted time-series design with a mixed-methods RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) evaluation framework was used to examine the adoption of human papillomavirus (HPV) testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation, at the primary level. RESULTS This approach, blending participatory action research, implementation science, and systems-thinking, led to rapid adoption and successful implementation of the new cervical cancer screening and management program within 6 months, using an HPV-based screen-and-treat strategy across 17 health facilities in one of the largest public health networks of the Peruvian Amazon. Monitoring and evaluation data revealed that, within 6 months, the MRIS had surpassed their monthly screening goals, tripling their original screening rate, with approximately 70% of HPV-positive women reaching a completion of care endpoint, compared with around 30% prior to the new CCSM strategy. CONCLUSIONS Proyecto Precancer facilitated the adoption and sustainment of HPV testing with subsequent treatment of HPV-positive women (after visual inspection) using portable thermal ablation at the primary level. This was accompanied by the de-implementation of existing visual inspection-based screening strategies and colposcopy for routine precancer triage at the hospital level. This case study highlights how implementation science approaches were used to guide the sustained adoption of a new screen-and-treat strategy in the Peruvian Amazon, while facilitating de-implementation of older screening practices.
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Affiliation(s)
- Sarah D Gilman
- Department of Clinical Research and Leadership, The George Washington University, Washington, DC, USA
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Valerie A Paz-Soldán
- Department of Tropical Medicine and Infectious Disease, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA.
- Behavioral Sciences Research Unit, Asociación Benéfica Prisma, Lima, Peru.
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Ortiz-Barrios M, Petrillo A, Arias-Fonseca S, McClean S, de Felice F, Nugent C, Uribe-López SA. An AI-based multiphase framework for improving the mechanical ventilation availability in emergency departments during respiratory disease seasons: a case study. Int J Emerg Med 2024; 17:45. [PMID: 38561694 PMCID: PMC10986051 DOI: 10.1186/s12245-024-00626-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/28/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Shortages of mechanical ventilation have become a constant problem in Emergency Departments (EDs), thereby affecting the timely deployment of medical interventions that counteract the severe health complications experienced during respiratory disease seasons. It is then necessary to count on agile and robust methodological approaches predicting the expected demand loads to EDs while supporting the timely allocation of ventilators. In this paper, we propose an integration of Artificial Intelligence (AI) and Discrete-event Simulation (DES) to design effective interventions ensuring the high availability of ventilators for patients needing these devices. METHODS First, we applied Random Forest (RF) to estimate the mechanical ventilation probability of respiratory-affected patients entering the emergency wards. Second, we introduced the RF predictions into a DES model to diagnose the response of EDs in terms of mechanical ventilator availability. Lately, we pretested two different interventions suggested by decision-makers to address the scarcity of this resource. A case study in a European hospital group was used to validate the proposed methodology. RESULTS The number of patients in the training cohort was 734, while the test group comprised 315. The sensitivity of the AI model was 93.08% (95% confidence interval, [88.46 - 96.26%]), whilst the specificity was 85.45% [77.45 - 91.45%]. On the other hand, the positive and negative predictive values were 91.62% (86.75 - 95.13%) and 87.85% (80.12 - 93.36%). Also, the Receiver Operator Characteristic (ROC) curve plot was 95.00% (89.25 - 100%). Finally, the median waiting time for mechanical ventilation was decreased by 17.48% after implementing a new resource capacity strategy. CONCLUSIONS Combining AI and DES helps healthcare decision-makers to elucidate interventions shortening the waiting times for mechanical ventilators in EDs during respiratory disease epidemics and pandemics.
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Affiliation(s)
- Miguel Ortiz-Barrios
- Centro de Investigación en Gestión e Ingeniería de Producción (CIGIP), Universitat Politecnica de Valencia, Camino de Vera, s/n, Valencia, 46022, Spain.
- Department of Productivity and Innovation, Universidad de la Costa CUC, Barranquilla, 080002, Colombia.
| | - Antonella Petrillo
- Department of Engineering, University of Naples "Parthenope", Naples, Italy
| | - Sebastián Arias-Fonseca
- Department of Productivity and Innovation, Universidad de la Costa CUC, Barranquilla, 080002, Colombia
| | - Sally McClean
- School of Computing, Ulster University, Belfast, BT15 1ED, UK
| | - Fabio de Felice
- Department of Engineering, University of Naples "Parthenope", Naples, Italy
| | - Chris Nugent
- School of Computing, Ulster University, Belfast, BT15 1ED, UK
| | - Sheyla-Ariany Uribe-López
- Academic Multidisciplinary Division of Jalpa de Mendez, Juarez Autonomous University of Tabasco, Jalpa de Mendez, Tabasco, Mexico
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Gye A, Lourenco RDA, Goodall S. Discrete Event Simulation to Incorporate Infusion Wait-Time When Assessing Cost-Effectiveness of a Chimeric-Antigen Receptor T Cell Therapy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:415-424. [PMID: 38301961 DOI: 10.1016/j.jval.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 12/21/2023] [Accepted: 01/11/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVES The main objective was to use discrete event simulation to model the impact of wait-time, defined as the time between leukapheresis and chimeric antigen receptor (CAR-T) infusion, when assessing the cost-effectiveness of tisagenlecleucel in young patients with relapsed/refractory acute lymphoblastic leukemia. METHODS The movement of patients through the model was determined by parametric time-to-event distributions, with the competing risk of an event determining the costs and quality-adjusted life-years (QALYs) assigned. Cost-effectiveness was expressed using the incremental cost-effectiveness ratio (ICER) for tisagenlecleucel compared with chemotherapy over the lifetime. RESULTS The base case generated a total of 5.79 QALYs and $622 872 for tisagenlecleucel and 1.19 QALYs and $181 219 for blinatumomab, resulting in an ICER of $96 074 per QALY. An increase in mean CAR-T wait-time to 6.20 months reduced the benefit and costs of tisagenlecleucel to 2.78 QALYs and $294 478 because of fewer patients proceeding to infusion, reducing the ICER to $71 112 per QALY. Alternatively, when the cost of tisagenlecleucel was assigned pre-infusion in sensitivity analysis, the ICER increased with increasing wait-time. CONCLUSIONS Under a payment arrangement where CAR-T cost is incurred post-infusion, the loss of benefit to patients is not reflected in the ICER. This may be misguiding to decision makers, where cost-effectiveness ratios are used to guide resource allocation. discrete event simulation is an important tool for economic modeling of CAR-T as it is amenable to capturing the impact of wait-time, facilitating better understanding of factors affecting service delivery and consequently informed decision making to deliver faster access to CAR-T for patients.
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Affiliation(s)
- Amy Gye
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW, Australia.
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW, Australia
| | - Stephen Goodall
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW, Australia
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Marshall DA, Tagimacruz T, Barber CEH, Cepoiu-Martin M, Lopatina E, Robert J, Lupton T, Patel J, Mosher DP. Intended and unintended consequences of strategies to meet performance benchmarks for rheumatologist referrals in a centralized intake system. J Eval Clin Pract 2024; 30:199-208. [PMID: 37723891 DOI: 10.1111/jep.13926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/29/2023] [Accepted: 09/02/2023] [Indexed: 09/20/2023]
Abstract
RATIONALE Timely assessment of a chronic condition is critical to prevent long-term irreversible consequences. Patients with inflammatory arthritis (IA) symptoms require diagnosis by a rheumatologist and intervention initiation to minimize potential joint damage. With limited rheumatologist capacity, meeting urgency wait time benchmarks can be challenging. We investigate the impact of the maximum wait time guarantee (MWTG) policy and referral volume changes in a rheumatology central intake (CI) system on meeting this challenge. METHODS We applied a system simulation approach to model a high-volume CI rheumatology clinic. Model parameters were based on the referral and triage data from the CI and clinic appointment data. We compare the wait time performance of the current distribution policy MWTG and when referral volumes change. RESULTS The MWTG policy ensures 100% of new patients see a rheumatologist within their urgency wait time benchmark. However, the average wait time for new patients increased by 51% (178-269 days). A 10% decrease in referrals resulted in a 76% decrease on average wait times (178-43 days) for new patients and an increase in the number of patients seen by a rheumatologist within 1 year of the initial visit. CONCLUSION An MWTG policy can result in intended and unintended consequences-ensuring that all patients meet the wait time benchmarks but increasing wait times overall. Relatively small changes in referral volume significantly impact wait times. These relationships can assist clinic managers and policymakers decide on the best approach to manage referrals for better system performance.
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Affiliation(s)
- Deborah A Marshall
- McCaig Bone and Joint Health Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Toni Tagimacruz
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Claire E H Barber
- McCaig Bone and Joint Health Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Canada Strategic Clinical Networks, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Medicine, Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Monica Cepoiu-Martin
- McCaig Bone and Joint Health Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Elena Lopatina
- McCaig Bone and Joint Health Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jill Robert
- Surgery and Bone & Joint Strategic Clinical Network™, Alberta Health Services, Edmonton, Alberta, Canada
| | - Terri Lupton
- Department of Medicine, Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jatin Patel
- Strategic Clinical Network™, Alberta Health Services, Edmonton, Alberta, Canada
| | - Diane P Mosher
- Department of Medicine, Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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11
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Pineda-Antunez C, Seguin C, van Duuren LA, Knudsen AB, Davidi B, de Lima PN, Rutter C, Kuntz KM, Lansdorp-Vogelaar I, Collier N, Ozik J, Alarid-Escudero F. Emulator-based Bayesian calibration of the CISNET colorectal cancer models. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.02.27.23286525. [PMID: 36909607 PMCID: PMC10002763 DOI: 10.1101/2023.02.27.23286525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Purpose To calibrate Cancer Intervention and Surveillance Modeling Network (CISNET) 's SimCRC, MISCAN-Colon, and CRC-SPIN simulation models of the natural history colorectal cancer (CRC) with an emulator-based Bayesian algorithm and internally validate the model-predicted outcomes to calibration targets. Methods We used Latin hypercube sampling to sample up to 50,000 parameter sets for each CISNET-CRC model and generated the corresponding outputs. We trained multilayer perceptron artificial neural networks (ANN) as emulators using the input and output samples for each CISNET-CRC model. We selected ANN structures with corresponding hyperparameters (i.e., number of hidden layers, nodes, activation functions, epochs, and optimizer) that minimize the predicted mean square error on the validation sample. We implemented the ANN emulators in a probabilistic programming language and calibrated the input parameters with Hamiltonian Monte Carlo-based algorithms to obtain the joint posterior distributions of the CISNET-CRC models' parameters. We internally validated each calibrated emulator by comparing the model-predicted posterior outputs against the calibration targets. Results The optimal ANN for SimCRC had four hidden layers and 360 hidden nodes, MISCAN-Colon had 4 hidden layers and 114 hidden nodes, and CRC-SPIN had one hidden layer and 140 hidden nodes. The total time for training and calibrating the emulators was 7.3, 4.0, and 0.66 hours for SimCRC, MISCAN-Colon, and CRC-SPIN, respectively. The mean of the model-predicted outputs fell within the 95% confidence intervals of the calibration targets in 98 of 110 for SimCRC, 65 of 93 for MISCAN, and 31 of 41 targets for CRC-SPIN. Conclusions Using ANN emulators is a practical solution to reduce the computational burden and complexity for Bayesian calibration of individual-level simulation models used for policy analysis, like the CISNET CRC models. In this work, we present a step-by-step guide to constructing emulators for calibrating three realistic CRC individual-level models using a Bayesian approach.
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Affiliation(s)
- Carlos Pineda-Antunez
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, United States
| | - Claudia Seguin
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States
| | - Luuk A van Duuren
- Department of Public Health, Erasmus MC Medical Center Rotterdam, The Netherlands
| | - Amy B. Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States
| | - Barak Davidi
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States
| | | | - Carolyn Rutter
- Fred Hutchinson Cancer Research Center, Hutchinson Institute for Cancer Outcomes Research, Biostatistics Program, Public Health Sciences Division, Seattle WA
| | - Karen M. Kuntz
- Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis, MN, United States
| | | | - Nicholson Collier
- Decision and Infrastructure Sciences Division, Argonne National Laboratory, Lemont, IL, United States
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, United States
| | - Jonathan Ozik
- Decision and Infrastructure Sciences Division, Argonne National Laboratory, Lemont, IL, United States
- Consortium for Advanced Science and Engineering, University of Chicago, Chicago, IL, United States
| | - Fernando Alarid-Escudero
- Department of Health Policy, School of Medicine, Stanford University, CA, US
- Center for Health Policy, Freeman Spogli Institute, Stanford University, CA, US
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Huang SW, Weng SJ, Chiou SY, Nguyen TD, Chen CH, Liu SC, Tsai YT. A Study on Decision-Making for Improving Service Efficiency in Hospitals. Healthcare (Basel) 2024; 12:405. [PMID: 38338290 PMCID: PMC10855065 DOI: 10.3390/healthcare12030405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/19/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
The provision of efficient healthcare services is essential, driven by the increasing demand for healthcare resources and the need to optimize hospital operations. In this context, the motivation to innovate and improve services while addressing urgent concerns is critical. Hospitals face challenges in managing internal dispatch services efficiently. Outsourcing such services can alleviate the burden on hospital staff, reduce costs, and introduce professional expertise. However, the pressing motivation lies in enhancing service quality, minimizing costs, and exploring innovative approaches. With the rising demand for healthcare services, there is an immediate need to streamline hospital operations. Delays in internal transportation services can have far-reaching implications for patient care, necessitating a prompt and effective solution. Drawing upon dispatch data from a healthcare center in Taiwan, this study constructed a decision-making model to optimize the allocation of hospital service resources. Employing simulation techniques, we closely examine how hospital services are currently organized and how they work. In our research, we utilized dispatch data gathered from a healthcare center in Taichung, Taiwan, spanning from January 2020 to December 2020. Our findings underscore the potential of an intelligent dispatch strategy combined with deployment restricted to the nearest available workers. Our study demonstrates that for cases requiring urgent attention, delay rates that previously ranged from 5% to 34% can be notably reduced to a much-improved 3% to 18%. However, it is important to recognize that the realm of worker dispatch remains subject to a multifaceted array of influencing factors. It becomes evident that a comprehensive dispatching mechanism must be established as part of a broader drive to enhance the efficiency of hospital service operations.
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Affiliation(s)
- Su-Wen Huang
- Department of General Affairs, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (S.-W.H.); (S.-Y.C.)
- Department of Information Management, Chaoyang University of Technology, Taichung 41349, Taiwan
| | - Shao-Jen Weng
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung 40704, Taiwan; (S.-J.W.); (C.-H.C.)
| | - Shyue-Yow Chiou
- Department of General Affairs, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (S.-W.H.); (S.-Y.C.)
| | - Thi-Duong Nguyen
- Department of Business Administration, National Chung Hsing University, Taichung 402202, Taiwan;
| | - Chih-Hao Chen
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung 40704, Taiwan; (S.-J.W.); (C.-H.C.)
| | - Shih-Chia Liu
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung 40704, Taiwan; (S.-J.W.); (C.-H.C.)
| | - Yao-Te Tsai
- Department of Information Management, National Kaohsiung University of Science and Technology, Kaohsiung 82445, Taiwan
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13
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Bathe J, Renner HJ, Watzinger S, Olave-Rojas D, Hannappel L, Wnent J, Nickel S, Gräsner JT. [The SCATTER project: computer-based simulation in the strategic transfer of intensive care patients]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2024; 67:215-224. [PMID: 38153419 PMCID: PMC10834643 DOI: 10.1007/s00103-023-03811-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 11/20/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND The need for a concept for the nationwide strategic transfer of critical care patients in Germany was highlighted during the COVID-19 (coronavirus disease 2019) pandemic. Despite the cloverleaf concept developed specifically for this purpose, the transfer of large numbers of critical care patients represents a major challenge. With the help of a computer simulation, the SCATTER research project uses a fictitious example to test, develop, and recommend transfer strategies. METHOD The simulation was programmed after collecting procedural and structural data on critical care transports within Germany. The simulation allows altering various parameters and testing different transfer scenarios. In a fictitious scenario, nationwide transfers starting from Schleswig-Holstein were simulated and evaluated using predetermined criteria. RESULTS In the case of ground-based transfers, it became apparent that, depending on the selected target region, not all patients could be transferred due to the limited range of ground-based vehicles. Although a higher number of patients can be transferred by air, this is associated with additional gurney changes and potential risk to the patient. A distance-dependent transport strategy led to the identical results as purely air-bound transport, since air-bound transport was always chosen due to the long distances. DISCUSSION The simulation can be used to develop recommendations and to draw important conclusions from different transfer strategies.
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Affiliation(s)
- Janina Bathe
- Institut für Rettungs- und Notfallmedizin, Campus Kiel und Campus Lübeck, Universitätsklinikum Schleswig-Holstein, Arnold-Heller-Str. 3, Haus 808, 24105, Kiel, Deutschland.
| | - Hanna-Joy Renner
- Institut für Rettungs- und Notfallmedizin, Campus Kiel und Campus Lübeck, Universitätsklinikum Schleswig-Holstein, Arnold-Heller-Str. 3, Haus 808, 24105, Kiel, Deutschland
| | - Sven Watzinger
- Institut für Operations Research - Diskrete Optimierung und Logistik, Karlsruher Institut für Technologie, Karlsruhe, Deutschland
| | - David Olave-Rojas
- Institut für Operations Research - Diskrete Optimierung und Logistik, Karlsruher Institut für Technologie, Karlsruhe, Deutschland
| | - Leonie Hannappel
- Institut für Rettungs- und Notfallmedizin, Campus Kiel und Campus Lübeck, Universitätsklinikum Schleswig-Holstein, Arnold-Heller-Str. 3, Haus 808, 24105, Kiel, Deutschland
- Fachgruppe Intensivmedizin, Infektiologie und Notfallmedizin (Fachgruppe COVRIIN), Fachgebiet ZBS 7 - Strategie und Einsatz, Koordination: Robert Koch-Institut, Berlin, Deutschland
| | - Jan Wnent
- Institut für Rettungs- und Notfallmedizin, Campus Kiel und Campus Lübeck, Universitätsklinikum Schleswig-Holstein, Arnold-Heller-Str. 3, Haus 808, 24105, Kiel, Deutschland
- Fachgruppe Intensivmedizin, Infektiologie und Notfallmedizin (Fachgruppe COVRIIN), Fachgebiet ZBS 7 - Strategie und Einsatz, Koordination: Robert Koch-Institut, Berlin, Deutschland
- School of Medicine, University of Namibia, Windhoek, Namibia
- Klinik f. Anästhesiologie und Operative Intensivmedizin, Campus Kiel, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Stefan Nickel
- Institut für Operations Research - Diskrete Optimierung und Logistik, Karlsruher Institut für Technologie, Karlsruhe, Deutschland
| | - Jan-Thorsten Gräsner
- Institut für Rettungs- und Notfallmedizin, Campus Kiel und Campus Lübeck, Universitätsklinikum Schleswig-Holstein, Arnold-Heller-Str. 3, Haus 808, 24105, Kiel, Deutschland
- Fachgruppe Intensivmedizin, Infektiologie und Notfallmedizin (Fachgruppe COVRIIN), Fachgebiet ZBS 7 - Strategie und Einsatz, Koordination: Robert Koch-Institut, Berlin, Deutschland
- Klinik f. Anästhesiologie und Operative Intensivmedizin, Campus Kiel, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
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Lin W, Zhang L, Wu S, Yang F, Zhang Y, Xu X, Zhu F, Fei Z, Shentu L, Han Y. Optimizing the management of electrophysiology labs in Chinese hospitals using a discrete event simulation tool. BMC Health Serv Res 2024; 24:67. [PMID: 38216934 PMCID: PMC10787488 DOI: 10.1186/s12913-024-10548-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 01/02/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND The growing demand for electrophysiology (EP) treatment in China presents a challenge for current EP care delivery systems. This study constructed a discrete event simulation (DES) model of an inpatient EP care delivery process, simulating a generalized inpatient journey of EP patients from admission to discharge in the cardiology department of a tertiary hospital in China. The model shows how many more patients the system can serve under different resource constraints by optimizing various phases of the care delivery process. METHODS Model inputs were based on and validated using real-world data, simulating the scheduling of limited resources among competing demands from different patient types. The patient stay consists of three stages, namely: the pre-operative stay, the EP procedure, and the post-operative stay. The model outcome was the total number of discharges during the simulation period. The scenario analysis presented in this paper covers two capacity-limiting scenarios (CLS): (1) fully occupied ward beds and (2) fully occupied electrophysiology laboratories (EP labs). Within each CLS, we investigated potential throughput when the length of stay or operative time was reduced by 10%, 20%, and 30%. The reductions were applied to patients with atrial fibrillation, the most common indication accounting for almost 30% of patients. RESULTS Model validation showed simulation results approximated actual data (137.2 discharges calculated vs. 137 observed). With fully occupied wards, reducing pre- and/or post-operative stay time resulted in a 1-7% increased throughput. With fully occupied EP labs, reduced operative time increased throughput by 3-12%. CONCLUSIONS Model validation and scenario analyses demonstrated that the DES model reliably reflects the EP care delivery process. Simulations identified which phases of the process should be optimized under different resource constraints, and the expected increases in patients served.
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Affiliation(s)
- Wenjuan Lin
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Lin Zhang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Shuqing Wu
- Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Fang Yang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yueqing Zhang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xiaoying Xu
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Fei Zhu
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Zhen Fei
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Lihua Shentu
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yi Han
- Health Economic Research Institute, Sun Yat-sen University, 132 East Waihuan Road, Guangzhou, Guangdong Province, 510006, PR China.
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Hebaish Y, Chatterjee S, Deegear J, Rucker M, Aprahamian H, Ntaimo L. A data-driven simulation approach to quantify the effect of group counseling on system performance of college counseling centers. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2023:1-15. [PMID: 37856364 DOI: 10.1080/07448481.2023.2252916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/20/2023] [Indexed: 10/21/2023]
Abstract
Objective: To investigate the effectiveness, from a system's perspective, of offering group counseling options in college counseling centers. Methods: We achieve this through a data-driven simulation-based approach with the aim of providing administrators with a quantitative tool that informs their decision-making process. Results: Our simulation experiments reveal that offering group counseling options without resource reallocation does not have the desired positive impact on the system's performance. However, with resource reallocation, our results demonstrate that the introduction of group counseling options can significantly improve the performance of the system by as much as 40%. Conclusions: Group counseling options, coupled with proper resource reallocation strategies, are effective in reducing access time of first-time patients by as much as 40%. The effect of group counseling is highly dependent on both the number of offered groups as well as their scheduling policy. Scheduling policies have to be scrutinized in light of their resulting group waiting time and resource-utilization efficiency.
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Affiliation(s)
- Youssef Hebaish
- Department of Industrial and Systems Engineering, Texas A&M University, College Station, Texas, USA
| | - Sohom Chatterjee
- Department of Industrial and Systems Engineering, Texas A&M University, College Station, Texas, USA
| | - James Deegear
- Counseling and Psychological Services, Texas A&M University, College Station, Texas, USA
| | - Miles Rucker
- Counseling and Psychological Services, Texas A&M University, College Station, Texas, USA
| | - Hrayer Aprahamian
- Department of Industrial and Systems Engineering, Texas A&M University, College Station, Texas, USA
| | - Lewis Ntaimo
- Department of Industrial and Systems Engineering, Texas A&M University, College Station, Texas, USA
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16
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Gilman SD, Gravitt PE, Paz-Soldán VA. Implementation of new technologies designed to improve cervical cancer screening and completion of care in low-resource settings: A case study from the Proyecto Precancer. RESEARCH SQUARE 2023:rs.3.rs-3093534. [PMID: 37461540 PMCID: PMC10350167 DOI: 10.21203/rs.3.rs-3093534/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Background This case study details the experience of the Proyecto Precancer in applying the Integrative Systems Praxis for Implementation Research (INSPIRE) research methodology to guide the co-development, planning, implementation, adoption, and sustainment of new technologies and screening practices in a cervical cancer screening and management program in the Peruvian Amazon. We briefly describe the theoretical grounding of the INSPIRE framework, the phases of the INSPIRE process, the activities within each phase, and the RE-AIM outcomes used to evaluate program outcomes. Methods Proyecto Precancer iteratively engaged over 90 stakeholders in the Micro Red Iquitos Sur (MRIS) health network in the Amazonian region of Loreto, Perú through the INSPIRE phases. INSPIRE is an integrative research methodology grounded in systems thinking, participatory action research, and implementation science frameworks such as the Consolidated Framework for Implementation Research. An interrupted time-series design with a mixed-methods RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) evaluation framework was used to examine the adoption of molecular-based primary cervical cancer screening using HPV-testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation at the primary level. Results The participatory and system-thinking-oriented approach led to rapid adoption and successful implementation of the new cervical cancer screening and management program within 6 months, using an HPV-based screen-and-treat strategy across 17 health facilities in one of the largest public health networks of the Peruvian Amazon. Monitoring and evaluation data revealed that, within 6 months, the MRIS had surpassed their monthly screening goals, tripling their original screening rate, with approximately 70% of HPV-positive women reaching a completion of care endpoint, compared with around 30% prior to the new CCSM strategy. Conclusions Proyecto Precancer facilitated the adoption and sustainment of molecular-based primary cervical cancer screening using HPV-testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation at the primary level and the de-implementation of existing visual inspection-based screening strategies and colposcopy for routine precancer triage at the hospital level. This case study shows how PP used implementation science approaches to guide the adoption of a new screen-and-treat strategy in the Peruvian Amazon, while facilitating de-implementation of older screening practices.
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Probst C, Buckley C, Lasserre AM, Kerr WC, Mulia N, Puka K, Purshouse RC, Ye Y, Rehm J. Simulation of Alcohol Control Policies for Health Equity (SIMAH) Project: Study Design and First Results. Am J Epidemiol 2023; 192:690-702. [PMID: 36702471 PMCID: PMC10423629 DOI: 10.1093/aje/kwad018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 09/15/2022] [Accepted: 01/20/2023] [Indexed: 01/28/2023] Open
Abstract
Since about 2010, life expectancy at birth in the United States has stagnated and begun to decline, with concurrent increases in the socioeconomic divide in life expectancy. The Simulation of Alcohol Control Policies for Health Equity (SIMAH) Project uses a novel microsimulation approach to investigate the extent to which alcohol use, socioeconomic status (SES), and race/ethnicity contribute to unequal developments in US life expectancy and how alcohol control interventions could reduce such inequalities. Representative, secondary data from several sources will be integrated into one coherent, dynamic microsimulation to model life-course changes in SES and alcohol use and cause-specific mortality attributable to alcohol use by SES, race/ethnicity, age, and sex. Markov models will be used to inform transition intensities between levels of SES and drinking patterns. The model will be used to compare a baseline scenario with multiple counterfactual intervention scenarios. The preliminary results indicate that the crucial microsimulation component provides a good fit to observed demographic changes in the population, providing a robust baseline model for further simulation work. By demonstrating the feasibility of this novel approach, the SIMAH Project promises to offer superior integration of relevant empirical evidence to inform public health policy for a more equitable future.
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Affiliation(s)
- Charlotte Probst
- Correspondence to Dr. Charlotte Probst, Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Ursula-Franklin Street, Toronto, ON M5S 2S1, Canada (e-mail: )
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Ortiz-Barrios M, Arias-Fonseca S, Ishizaka A, Barbati M, Avendaño-Collante B, Navarro-Jiménez E. Artificial intelligence and discrete-event simulation for capacity management of intensive care units during the Covid-19 pandemic: A case study. JOURNAL OF BUSINESS RESEARCH 2023; 160:113806. [PMID: 36895308 PMCID: PMC9981538 DOI: 10.1016/j.jbusres.2023.113806] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 01/18/2023] [Accepted: 02/23/2023] [Indexed: 06/18/2023]
Abstract
The Covid-19 pandemic has pushed the Intensive Care Units (ICUs) into significant operational disruptions. The rapid evolution of this disease, the bed capacity constraints, the wide variety of patient profiles, and the imbalances within health supply chains still represent a challenge for policymakers. This paper aims to use Artificial Intelligence (AI) and Discrete-Event Simulation (DES) to support ICU bed capacity management during Covid-19. The proposed approach was validated in a Spanish hospital chain where we initially identified the predictors of ICU admission in Covid-19 patients. Second, we applied Random Forest (RF) to predict ICU admission likelihood using patient data collected in the Emergency Department (ED). Finally, we included the RF outcomes in a DES model to assist decision-makers in evaluating new ICU bed configurations responding to the patient transfer expected from downstream services. The results evidenced that the median bed waiting time declined between 32.42 and 48.03 min after intervention.
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Affiliation(s)
- Miguel Ortiz-Barrios
- Department of Productivity and Innovation, Universidad de la Costa CUC, Barranquilla 080002, Colombia
| | - Sebastián Arias-Fonseca
- Department of Productivity and Innovation, Universidad de la Costa CUC, Barranquilla 080002, Colombia
| | - Alessio Ishizaka
- NEOMA Business School, 1 rue du Maréchal Juin, Mont-Saint-Aignan 76130, France
| | - Maria Barbati
- Department of Economics, University Ca' Foscari, Cannaregio 873, Fondamenta San Giobbe, 30121 Venice, Italy
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APLUS: A Python library for usefulness simulations of machine learning models in healthcare. J Biomed Inform 2023; 139:104319. [PMID: 36791900 DOI: 10.1016/j.jbi.2023.104319] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
Despite the creation of thousands of machine learning (ML) models, the promise of improving patient care with ML remains largely unrealized. Adoption into clinical practice is lagging, in large part due to disconnects between how ML practitioners evaluate models and what is required for their successful integration into care delivery. Models are just one component of care delivery workflows whose constraints determine clinicians' abilities to act on models' outputs. However, methods to evaluate the usefulness of models in the context of their corresponding workflows are currently limited. To bridge this gap we developed APLUS, a reusable framework for quantitatively assessing via simulation the utility gained from integrating a model into a clinical workflow. We describe the APLUS simulation engine and workflow specification language, and apply it to evaluate a novel ML-based screening pathway for detecting peripheral artery disease at Stanford Health Care.
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Kakad M, Utley M, Dahl FA. Using stochastic simulation modelling to study occupancy levels of decentralised admission avoidance units in Norway. Health Syst (Basingstoke) 2023; 12:317-331. [PMID: 37860598 PMCID: PMC10583632 DOI: 10.1080/20476965.2023.2174453] [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: 03/23/2021] [Accepted: 01/26/2023] [Indexed: 02/17/2023] Open
Abstract
Identifying alternatives to acute hospital admission is a priority for many countries. Over 200 decentralised municipal acute units (MAUs) were established in Norway to divert low-acuity patients away from hospitals. MAUs have faced criticism for low mean occupancy and not relieving pressures on hospitals. We developed a discrete time simulation model of admissions and discharges to MAUs to test scenarios for increasing absolute mean occupancy. We also used the model to estimate the number of patients turned away as historical data was unavailable. Our experiments suggest that mergers alone are unlikely to substantially increase MAU absolute mean occupancy as unmet demand is generally low. However, merging MAUs offers scope for up to 20% reduction in bed capacity, without affecting service provision. Our work has relevance for other admissions avoidance units and provides a method for estimating unconstrained demand for beds in the absence of historical data.
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Affiliation(s)
- Meetali Kakad
- Health Services Research Unit, Akershus University Hospital Trust, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Martin Utley
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Fredrik A. Dahl
- Health Services Research Unit, Akershus University Hospital Trust, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Image Analysis and Earth Observation, Norwegian Computing Centre, Oslo, Norway
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Puka K, Buckley C, Mulia N, Purshouse RC, Lasserre AM, Kerr W, Rehm J, Probst C. Behavioral stability of alcohol consumption and socio-demographic correlates of change among a nationally representative cohort of US adults. Addiction 2023; 118:61-70. [PMID: 35975709 PMCID: PMC9722571 DOI: 10.1111/add.16024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 08/03/2022] [Indexed: 01/03/2023]
Abstract
AIMS To estimate the probability of transitioning between different categories of alcohol use (drinking states) among a nationally representative cohort of United States (US) adults and to identify the effects of socio-demographic characteristics on those transitions. DESIGN, SETTING AND PARTICIPANTS Secondary analysis of data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a prospective cohort study conducted in 2001-02 and 2004-05; a US nation-wide, population-based study. Participants included 34 165 adults (mean age = 45.1 years, standard deviation = 17.3; 52% women). MEASUREMENTS Alcohol use was self-reported and categorized based on the grams consumed per day: (1) non-drinker (no drinks in past 12 months), (2) category I (women = ≤ 20; men = ≤ 40), (3) category II (women = 21-40; men = 41-60) and (4) category III (women = ≥ 41; men = ≥ 61). Multi-state Markov models estimated the probability of transitioning between drinking states, conditioned on age, sex, race/ethnicity and educational attainment. Analyses were repeated with alcohol use categorized based on the frequency of heavy episodic drinking. FINDINGS The highest transition probabilities were observed for staying in the same state; after 1 year, the probability of remaining in the same state was 90.1% [95% confidence interval (CI) = 89.7%, 90.5%] for non-drinkers, 90.2% (95% CI = 89.9%, 90.5%) for category I, 31.8% (95% CI = 29.7, 33.9%) category II and 52.2% (95% CI = 46.0, 58.5%) for category III. Women, older adults, and non-Hispanic Other adults were less likely to transition between drinking states, including transitions to lower use. Adults with lower educational attainment were more likely to transition between drinking states; however, they were also less likely to transition out of the 'weekly HED' category. Black adults were more likely to transition into or stay in higher use categories, whereas Hispanic/Latinx adults were largely similar to White adults. CONCLUSIONS In this study of alcohol transition probabilities, some demographic subgroups appeared more likely to transition into or persist in higher alcohol consumption states.
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Affiliation(s)
- Klajdi Puka
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Charlotte Buckley
- Department of Automatic Control and Systems Engineering, University of Sheffield, UK
| | - Nina Mulia
- Alcohol Research Group, Public Health Institute, Emeryville, CA, USA
| | - Robin C. Purshouse
- Department of Automatic Control and Systems Engineering, University of Sheffield, UK
| | - Aurélie M. Lasserre
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON
| | - William Kerr
- Alcohol Research Group, Public Health Institute, Emeryville, CA, USA
| | - Jürgen Rehm
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
- Center for Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Program on Substance Abuse and WHO CC, Public Health Agency of Catalonia, Barcelona, Spain
- Dalla Lana School of Public Health and Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
- Department of Psychiatry, University of Toronto, Toronto, ON
| | - Charlotte Probst
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON
- Department of Psychiatry, University of Toronto, Toronto, ON
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
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22
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Marshall DA, Tagimacruz T, Cepoiu-Martin M, Robert J, Ring B, Burston M, Higgins S, Hess M, White J. A Simulation Modelling Study of Referral Distribution Policies in a Centralized Intake System for Surgical Consultation. J Med Syst 2022; 47:4. [PMID: 36585480 DOI: 10.1007/s10916-022-01897-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 12/01/2022] [Indexed: 01/01/2023]
Abstract
Delays beyond recommended wait times, especially for specialist services, are associated with adverse health outcomes. The Alberta Surgical Initiative aims to improve the referral wait time-the time between a referral is received at the central intake to the time a specialist sees the patient. Using the discrete event simulation modelling approach, we evaluated and compared the impact of four referral distribution policies in a central intake system on three system performance measures (number of consultations, referral wait time and surgeon utilization). The model was co-designed with clinicians and clinic staff to represent the flow of patients through the system. We used data from the Facilitated Access to Surgical Treatment (FAST) centralized intake referral program for General Surgery to parameterize the model. Four distribution policies were evaluated - next-available-surgeon, sequential, "blackjack," and "kanban." A sequential distribution of referrals for surgical consultation among the surgeons resulted in the worst performance in terms of the number of consultations, referral wait time and surgeon utilization. The three other distribution policies are comparable in performance. The "next available surgeon" model provided the most efficient and robust model, with approximately 1,000 more consultations, 100 days shorter referral time and a 14% increase in surgeon utilization. Discrete event simulation (DES) modelling can be an effective tool to illustrate and communicate the impact of the referral distribution policy on system performance in terms of the number of consultations, referral wait time and surgeon utilization.
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Affiliation(s)
- Deborah A Marshall
- Cumming School of Medicine, McCaig Bone and Joint Health Institute, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z, Canada.
| | - Toni Tagimacruz
- Cumming School of Medicine, McCaig Bone and Joint Health Institute, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z, Canada
| | - Monica Cepoiu-Martin
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jill Robert
- Surgery, Alberta Health Services, Bone & Joint Strategic Clinical NetworkTM, Alberta, Canada
| | - Bernice Ring
- Surgery Strategic Clinical NetworkTM, Alberta Health Services, Alberta, Canada
| | | | - Suzanne Higgins
- Surgery Strategic Clinical NetworkTM, Alberta Health Services, Alberta, Canada
| | | | - Jonathan White
- Surgery Strategic Clinical NetworkTM, Alberta Health Services, Alberta, Canada
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23
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Lebcir R, Yakutcan U, Demir E. A decision support tool with health economic modelling for better management of DVT patients. HEALTH ECONOMICS REVIEW 2022; 12:65. [PMID: 36567380 PMCID: PMC9790817 DOI: 10.1186/s13561-022-00412-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 12/08/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Responding to the increasing demand for Deep Vein Thrombosis (DVT) treatment in the United Kingdom (UK) at times of limited budgets and resources is a great challenge for decision-makers. Therefore, there is a need to find innovative policies, which improve operational efficiency and achieve the best value for money for patients. This study aims to develop a Decision Support Tool (DST) that assesses the impact of implementing new DVT patients' management and care policies aiming at improving efficiency, reducing costs, and enhancing value for money. METHODS With the involvement of stakeholders from a number of DVT services in the UK, we developed a DST combining discrete event simulation (DES) for DVT pathways and the Socio Technical Allocation of Resources (STAR) approach, an agile health economics technique. The model was inputted with data from the literature, local datasets from DVT services, and interviews conducted with DVT specialists. The tool was validated and verified by various stakeholders and two policies, namely shifting more patients to community services (CSs) and increasing the usage of the Novel Oral Anticoagulant (NOAC) drug were selected for testing on the model. RESULTS Sixteen possible scenarios were run on the model for a period of 5 years and generated treatment activity, human resources, costing, and value for money outputs. The results indicated that hospital visits can be reduced by up to 50%. Human resources' usage can be greatly lowered driven mainly by offering NOAC treatment to more patients. Also, combining both policies can lead to cost savings of up to 50%. The STAR method, which considers both service and patient perspectives, produced findings that implementing both policies provide a significantly higher value for money compared to the situation when neither is applied. CONCLUSIONS The combination of DES and STAR can help decision-makers determine the interventions that have the highest benefits from service providers' and patients' perspectives. This is important given the mismatch between care demand and resources and the resulting need for improving operational and economic outcomes. The DST tool has the potential to inform policymaking in DVT services in the UK to improve performance.
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Affiliation(s)
- Reda Lebcir
- University of Hertfordshire, Hatfield, AL10 9AB UK
| | | | - Eren Demir
- University of Hertfordshire, Hatfield, AL10 9AB UK
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24
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Improving service efficiency and throughput of cardiac surgery patients using Monte Carlo simulation: a queueing setting. Sci Rep 2022; 12:21217. [PMID: 36481779 PMCID: PMC9731950 DOI: 10.1038/s41598-022-25689-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
Bed occupancy rate (BOR) is important for healthcare policymakers. Studies showed the necessity of using simulation approach when encountering complex real-world problems to plan the optimal use of resources and improve the quality of services. So, the aim of the present study is to estimate average length of stay (LOS), BOR, bed blocking probability (BBP), and throughput of patients in a cardiac surgery department (CSD) using simulation models. We studied the behavior of a CSD as a complex queueing system at the Farshchian Hospital. In the queueing model, customers were patients and servers were beds in intensive care unit (ICU) and post-operative ward (POW). A computer program based on the Monte Carlo simulation, using Python software, was developed to evaluate the behavior of the system under different number of beds in ICU and POW. The queueing simulation study showed that, for a fixed number of beds in ICU, BOR in POW decreases as the number of beds in POW increases and LOS in ICU increases as the number of beds in POW decreases. Also, based on the available data, the throughput of patients in the CSD during 800 days was 1999 patients. Whereas, the simulation results showed that, 2839 patients can be operated in the same period. The results of the simulation study clearly demonstrated the behavior of the CSD; so, it must be mentioned, hospital administrators should design an efficient plan to increase BOR and throughput of patients in the future.
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25
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Hou W, Qin S, Thompson CH. Effective Response to Hospital Congestion Scenarios: Simulation-Based Evaluation of Decongestion Interventions. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16348. [PMID: 36498419 PMCID: PMC9737001 DOI: 10.3390/ijerph192316348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
Hospital overcrowding is becoming a major concern in the modern era due to the increasing demand for hospital services. This study seeks to identify effective and efficient ways to resolve the serious problem of congestion in hospitals by testing a range of decongestion strategies with simulated scenarios. In order to determine more efficient solutions, interventions with smaller changes were consistently tested at the beginning through a simulation platform. In addition, the implementation patterns were investigated, which are important to hospital managers with respect to the decisions made to control hospital congestion. The results indicated that diverting a small number of ambulances seems to be more effective and efficient in congestion reduction compared to other approaches. Furthermore, instead of implementing an isolated approach continuously, combining one approach with other strategies is recommended as a method for dealing with hospital overcrowding.
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Affiliation(s)
- Wanxin Hou
- School of Information Science and Technology, Research Centre for Intelligent Information Technology, Nantong University, Nantong 226019, China
| | - Shaowen Qin
- College of Science and Engineering, Flinders University, Adelaide 5042, Australia
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26
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Rositch AF, Singh A, Lahrichi N, Paz-Soldan VA, Kohler-Smith A, Gravitt P, Gralla E. Planning for resilience in screening operations using discrete event simulation modeling: example of HPV testing in Peru. Implement Sci Commun 2022; 3:65. [PMID: 35715830 PMCID: PMC9204370 DOI: 10.1186/s43058-022-00302-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/27/2022] [Indexed: 12/04/2022] Open
Abstract
Background The World Health Organization (WHO) has called for the elimination of cervical cancer. Unfortunately, the implementation of cost-effective prevention and control strategies has faced significant barriers, such as insufficient guidance on best practices for resource and operations planning. Therefore, we demonstrate the value of discrete event simulation (DES) in implementation science research and practice, particularly to support the programmatic and operational planning for sustainable and resilient delivery of healthcare interventions. Our specific example shows how DES models can inform planning for scale-up and resilient operations of a new HPV-based screen and treat program in Iquitos, an Amazonian city of Peru. Methods Using data from a time and motion study and cervical cancer screening registry from Iquitos, Peru, we developed a DES model to conduct virtual experimentation with “what-if” scenarios that compare different workflow and processing strategies under resource constraints and disruptions to the screening system. Results Our simulations show how much the screening system’s capacity can be increased at current resource levels, how much variability in service times can be tolerated, and the extent of resilience to disruptions such as curtailed resources. The simulations also identify the resources that would be required to scale up for larger target populations or increased resilience to disruptions, illustrating the key tradeoff between resilience and efficiency. Thus, our results demonstrate how DES models can inform specific resourcing decisions but can also highlight important tradeoffs and suggest general “rules” for resource and operational planning. Conclusions Multilevel planning and implementation challenges are not unique to sustainable adoption of cervical cancer screening programs but represent common barriers to the successful scale-up of many preventative health interventions worldwide. DES represents a broadly applicable tool to address complex implementation challenges identified at the national, regional, and local levels across settings and health interventions—how to make effective and efficient operational and resourcing decisions to support program adaptation to local constraints and demands so that they are resilient to changing demands and more likely to be maintained with fidelity over time.
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27
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Hassanzadeh H, Khanna S, Boyle J, Jensen F, Murdoch A. New bed configurations and discharge timing policies: A hospital‐wide simulation. Emerg Med Australas 2022; 35:434-441. [PMID: 36377221 DOI: 10.1111/1742-6723.14135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/25/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Optimising patient flow is becoming an increasingly critical issue as patient demand fluctuates in healthcare systems with finite capacity. Simulation provides a powerful tool to fine-tune policies and investigate their impact before any costly intervention. METHODS A hospital-wide discrete event simulation is developed to model incoming flow from ED and elective units in a busy metropolitan hospital. The impacts of two different policies are investigated using this simulation model: (i) varying inpatient bed configurations and a load sharing strategy among a cluster of wards within a medical department and (ii) early discharge strategies on inpatient bed access. Several clinically relevant bed configurations and early discharge scenarios are defined and their impact on key performance metrics are quantified. RESULTS Sharing beds between wards reduced the average and total ED length of stay (LOS) by 21% compared to having patients queue for individual wards. The current baseline performance level could be maintained by using fewer beds when the load sharing approach was imposed. Earlier discharge of inpatients resulted in reducing average patient ED LOS by approximately 16% and average patient waiting time by 75%. Specific time-based discharge targets led to greater improvements in flow compared to blanket approaches of discharging all patients 1 or 2 hours earlier. CONCLUSIONS ED access performance for admitted patients can be improved by modifying downstream capacity or inpatient discharge times. The simulation model was able to quantify the potential impacts of such policies on patient flow and to provide insights for future strategic planning.
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Affiliation(s)
- Hamed Hassanzadeh
- The Australian e‐Health Research Centre, Commonwealth Scientific and Industrial Research Organisation Brisbane Queensland Australia
| | - Sankalp Khanna
- The Australian e‐Health Research Centre, Commonwealth Scientific and Industrial Research Organisation Brisbane Queensland Australia
| | - Justin Boyle
- The Australian e‐Health Research Centre, Commonwealth Scientific and Industrial Research Organisation Brisbane Queensland Australia
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28
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Smith AF, Frempong SN, Sharma N, Neal RD, Hick L, Shinkins B. An exploratory assessment of the impact of a novel risk assessment test on breast cancer clinic waiting times and workflow: a discrete event simulation model. BMC Health Serv Res 2022; 22:1301. [PMID: 36309678 PMCID: PMC9617530 DOI: 10.1186/s12913-022-08665-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background Breast cancer clinics across the UK have long been struggling to cope with high demand. Novel risk prediction tools – such as the PinPoint test – could help to reduce unnecessary clinic referrals. Using early data on the expected accuracy of the test, we explore the potential impact of PinPoint on: (a) the percentage of patients meeting the two-week referral target, and (b) the number of clinic ‘overspill’ appointments generated (i.e. patients having to return to the clinic to complete their required investigations). Methods A simulation model was built to reflect the annual flow of patients through a single UK clinic. Due to current uncertainty around the exact impact of PinPoint testing on standard care, two primary scenarios were assessed. Scenario 1 assumed complete GP adherence to testing, with only non-referred cancerous cases returning for delayed referral. Scenario 2 assumed GPs would overrule 20% of low-risk results, and that 10% of non-referred non-cancerous cases would also return for delayed referral. A range of sensitivity analyses were conducted to explore the impact of key uncertainties on the model results. Service reconfiguration scenarios, removing individual weekly clinics from the clinic schedule, were also explored. Results Under standard care, 66.3% (95% CI: 66.0 to 66.5) of patients met the referral target, with 1,685 (1,648 to 1,722) overspill appointments. Under both PinPoint scenarios, > 98% of patients met the referral target, with overspill appointments reduced to between 727 (707 to 746) [Scenario 1] and 886 (861 to 911) [Scenario 2]. The reduced clinic demand was sufficient to allow removal of one weekly low-capacity clinic [N = 10], and the results were robust to sensitivity analyses. Conclusion The findings from this early analysis indicate that risk prediction tools could have the potential to alleviate pressure on cancer clinics, and are expected to have increased utility in the wake of heightened pressures resulting from the COVID-19 pandemic. Further research is required to validate these findings with real world evidence; evaluate the broader clinical and economic impact of the test; and to determine outcomes and risks for patients deemed to be low-risk on the PinPoint test and therefore not initially referred. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08665-0.
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Baxendale B, Evans K, Cowley A, Bramley L, Miles G, Ross A, Dring E, Cooper J. GENESISS 1-Generating Standards for In-Situ Simulation project: a scoping review and conceptual model. BMC MEDICAL EDUCATION 2022; 22:479. [PMID: 35725432 PMCID: PMC9208746 DOI: 10.1186/s12909-022-03490-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/23/2022] [Indexed: 05/04/2023]
Abstract
BACKGROUND In-Situ Simulation (ISS) enables teams to rehearse and review practice in the clinical environment to facilitate knowledge transition, reflection and safe learning. There is increasing use of ISS in healthcare organisations for which patient safety and quality improvement are key drivers. However, the effectiveness of ISS interventions has not yet been fully demonstrated and requires further study to maximise impact. Cohesive programmatic implementation is lacking and efforts to standardise ISS terms and concepts, strengthen the evidence base and develop an integrated model of learning is required. The aim of this study was to explore the current evidence, theories and concepts associated with ISS across all areas of healthcare and develop a conceptual model to inform future ISS research and best practice guidance. METHODS A scoping review was undertaken with stakeholder feedback to develop a conceptual model for ISS. Medline, OpenGrey and Web of Science were searched in September 2018 and updated in December 2020. Data from the included scoping review studies were analysed descriptively and organised into categories based on the different motivations, concepts and theoretical approaches for ISS. Categories and concepts were further refined through accessing stakeholder feedback. RESULTS Thirty-eight papers were included in the scoping review. Papers reported the development and evaluation of ISS interventions. Stakeholder groups highlighted situations where ISS could be suitable to improve care and outcomes and identified contextual and practical factors for implementation. A conceptual model of ISS was developed which was organised into four themes: 1. To understand and explore why systematic events occur in complex settings; 2.To design and test new clinical spaces, equipment, information technologies and procedures; 3. To practice and develop capability in individual and team performance; 4. To assess competency in complex clinical settings. CONCLUSIONS ISS presents a promising approach to improve individual and team capabilities and system performance and address the 'practice-theory gap'. However, there are limitations associated with ISS such as the impact on the clinical setting and service provision, the reliance of having an open learning culture and availability of relevant expertise. ISS should be introduced with due consideration of the specific objectives and learning needs it is proposed to address. Effectiveness of ISS has not yet been established and further research is required to evaluate and disseminate the findings of ISS interventions.
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Affiliation(s)
- Bryn Baxendale
- Trent Simulation & Clinical Skills Centre, Nottingham University Hospitals NHS Trust, Nottingham, Notts UK
| | - Kerry Evans
- Institute of Care Excellence, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alison Cowley
- Nottingham University Hospitals NHS Trust, Research and Innovation, Nottingham, UK
| | - Louise Bramley
- Institute of Care Excellence, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Guilia Miles
- Trent Simulation & Clinical Skills Centre, Nottingham University Hospitals NHS Trust, Nottingham, Notts UK
| | - Alastair Ross
- Glasgow Dental School, University of Glasgow, Glasgow, UK
| | - Eleanore Dring
- Institute of Care Excellence, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanne Cooper
- Institute of Care Excellence, Nottingham University Hospitals NHS Trust, Nottingham, UK
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30
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Lam SSW, Pourghaderi AR, Abdullah HR, Nguyen FNHL, Siddiqui FJ, Ansah JP, Low JG, Matchar DB, Ong MEH. An Agile Systems Modeling Framework for Bed Resource Planning During COVID-19 Pandemic in Singapore. Front Public Health 2022; 10:714092. [PMID: 35664119 PMCID: PMC9157760 DOI: 10.3389/fpubh.2022.714092] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background The COVID-19 pandemic has had a major impact on health systems globally. The sufficiency of hospitals' bed resource is a cornerstone for access to care which can significantly impact the public health outcomes. Objective We describe the development of a dynamic simulation framework to support agile resource planning during the COVID-19 pandemic in Singapore. Materials and Methods The study data were derived from the Singapore General Hospital and public domain sources over the period from 1 January 2020 till 31 May 2020 covering the period when the initial outbreak and surge of COVID-19 cases in Singapore happened. The simulation models and its variants take into consideration the dynamic evolution of the pandemic and the rapidly evolving policies and processes in Singapore. Results The models were calibrated against historical data for the Singapore COVID-19 situation. Several variants of the resource planning model were rapidly developed to adapt to the fast-changing COVID-19 situation in Singapore. Conclusion The agility in adaptable models and robust collaborative management structure enabled the quick deployment of human and capital resources to sustain the high level of health services delivery during the COVID-19 surge.
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Affiliation(s)
- Sean Shao Wei Lam
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Health Services Research Centre, Singapore Health Services, Singapore, Singapore.,SingHealth Duke NUS Academic Medical Centre, Health Services Research Institute, Singapore, Singapore.,Lee Kong Chian School of Business, School of Computing and Information Systems, Singapore Management University, Singapore, Singapore
| | - Ahmad Reza Pourghaderi
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Health Services Research Centre, Singapore Health Services, Singapore, Singapore.,SingHealth Duke NUS Academic Medical Centre, Health Services Research Institute, Singapore, Singapore
| | | | - Francis Ngoc Hoang Long Nguyen
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore.,SingHealth Duke NUS Academic Medical Centre, Health Services Research Institute, Singapore, Singapore
| | | | - John Pastor Ansah
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Residential College 4, National University of Singapore, Singapore, Singapore
| | - Jenny G Low
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore.,Programme in Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore
| | - David Bruce Matchar
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Department of Internal Medicine (General Internal Medicine), Duke University Medical School, Durham, NC, United States.,Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Health Services Research Centre, Singapore Health Services, Singapore, Singapore.,SingHealth Duke NUS Academic Medical Centre, Health Services Research Institute, Singapore, Singapore.,Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
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31
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Skarda I, Asaria M, Cookson R. Evaluating childhood policy impacts on lifetime health, wellbeing and inequality: Lifecourse distributional economic evaluation. Soc Sci Med 2022; 302:114960. [PMID: 35477060 DOI: 10.1016/j.socscimed.2022.114960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 03/04/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
We introduce and illustrate a new framework for distributional economic evaluation of childhood policies that takes a broad and long view of the impacts on health, wellbeing and inequality from a cross-sectoral whole-lifetime perspective. Total lifetime benefits and public cost savings are estimated using lifecourse microsimulation of diverse health, social and economic outcomes for each individual in a general population birth cohort from birth to death. Cost-effectiveness analysis, policy targeting analysis and distributional analysis of inequality impacts are then conducted using an index of lifetime wellbeing that allow comparisons of both value-for-money (efficiency) and distributional impact (equity) from a cross-sectoral lifetime perspective. We illustrate how this framework can be applied in practice by re-evaluating a training programme in England for parents of children at risk of conduct disorder. Our illustration uses a simple index of lifetime wellbeing based on health-related quality of life and consumption, but other indices could be used based on other kinds of outcomes data such as life satisfaction or multidimensional quality of life. We create the detailed underpinning data needed to apply the framework by using a previously published meta-analysis of randomised controlled trials to estimate the short-term effects and a previously published lifecourse microsimulation model to extrapolate the long-term effects.
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Affiliation(s)
- Ieva Skarda
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK.
| | - Miqdad Asaria
- Department of Health Policy, Cowdray House, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Richard Cookson
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
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Aguiar M LG, Rentería RR, Catumba-Ruiz J, Barrera JO, Redondo JM. Use of discrete event simulation and genetic algorithms to estimate the necessary resources to respond in a timely manner in the Medical Emergency System in Bogotá. Medwave 2022; 22:e8718. [PMID: 35435889 DOI: 10.5867/medwave.2022.03.002100] [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: 02/17/2021] [Accepted: 03/02/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Bogotá has a Medical Emergency System of public and private ambulances that respond to health incidents. However, its sufficiency in quantity, type and location of the resources demanded is not known. Objective Based on the data from the Medical Emergency System of Bogotá, Colombia, we first sought to characterize the prehospital re- sponse in cardiac arrest and determine with the model which is the least number of resources necessary to respond within eight minutes, taking into account their location, number, and type. Methods A database of incidents reported in administrative records of the district health authority of Bogotá (2014 to 2017) was obtained. Based on this information, a hybrid model based on discrete event simulation and genetic algorithms was designed to establish the amount, type and geographic location of resources according to the frequencies and typology of the events. Results From the database, Bogotá presented 938 671 ambulances dispatches in the period. 47.4% high priority, 18.9% medium and 33.74% low. 92% of these corresponded to 15 of 43 medical emergency codes. The response times recorded were longer than expected, especially in out-of-hospital cardiac arrest (median 19 minutes). In the proposed model, the best scenario required at least 281 ambulances, medicalized and basic in a 3:1 ratio, respectively, to respond in adequate time. Conclusions Results suggest the need for an increase in the resources that respond to these incidents to bring these response times to the needs of our population.
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Affiliation(s)
- Leonar G Aguiar M
- Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia; Departamento de Medicina Interna, Hospital Universitario San Ignacio, Bogotá, Colombia. Address: Transversal 4 #42-00 Bogotá, Colombia. . ORCID: 0000-0002-5372-2459
| | - Rafael R Rentería
- Universidad Nacional Abierta y a Distancia, Bogotá, Colombia. ORCID: 0000-0002-5857-9153
| | - Jorge Catumba-Ruiz
- International Research Center for Applied Complexity Sciences, Bogotá, Colombia. ORCID: 0000-0002-0506-6258
| | - José O Barrera
- Secretaría Distrital de Salud, Bogotá, Colombia. ORCID: 0000-0002-4223-8602
| | - Johan M Redondo
- Facultad de Ciencias Económicas y Administrativas, Universidad Católica de Colombia, Bogotá, Colombia. ORCID: 0000-0002-9427-1324
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Al-Kaf A, Jayaraman R, Demirli K, Simsekler MCE, Ghalib H, Quraini D, Tuzcu M. A critical review of implementing lean and simulation to improve resource utilization and patient experience in outpatient clinics. TQM JOURNAL 2022. [DOI: 10.1108/tqm-11-2021-0337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe purpose of this paper is to explore and critically review the existing literature on applications of Lean Methodology (LM) and Discrete-Event Simulation (DES) to improve resource utilization and patient experience in outpatient clinics. In doing, it is aimed to identify how to implement LM in outpatient clinics and discuss the advantages of integrating both lean and simulation tools towards achieving the desired outpatient clinics outcomes.Design/methodology/approachA theoretical background of LM and DES to define a proper implementation approach is developed. The search strategy of available literature on LM and DES used to improve outpatient clinic operations is discussed. Bibliometric analysis to identify patterns in the literature including trends, associated frameworks, DES software used, and objective and solutions implemented are presented. Next, an analysis of the identified work offering critical insights to improve the implementation of LM and DES in outpatient clinics is presented.FindingsCritical analysis of the literature on LM and DES reveals three main obstacles hindering the successful implementation of LM and DES. To address the obstacles, a framework that integrates DES with LM has been recommended and proposed. The paper provides an example of such a framework and identifies the role of LM and DES towards improving the performance of their implementation in outpatient clinics.Originality/valueThis study provides a critical review and analysis of the existing implementation of LM and DES. The current roadblocks hindering LM and DES from achieving their expected potential has been identified. In addition, this study demonstrates how LM with DES combined to achieve the desired outpatient clinic objectives.
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Hantel A, McManus ML, Wadleigh M, Cotugno M, Abel GA. Impact of Allocation on Survival During Intermittent Chemotherapy Shortages: A Modeling Analysis. J Natl Compr Canc Netw 2022; 20:335-341.e17. [PMID: 35390765 PMCID: PMC10983800 DOI: 10.6004/jnccn.2021.7047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/20/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intermittent shortages of chemotherapeutics used to treat curable malignancies are a worldwide problem that increases patient mortality. Although multiple strategies have been proposed for managing these shortages (eg, prioritizing patients by age, scarce treatment efficacy per volume, alternative treatment efficacy difference), critical clinical dilemmas arise when selecting a management strategy and understanding its impact. PATIENTS AND METHODS We developed a model to compare the impact of different allocation strategies on overall survival during intermittent chemotherapy shortages and tested it using vincristine, which was recently scarce for 9 months in the United States. Demographic and treatment data were abstracted from 1,689 previously treated patients in our tertiary-care system; alternatives were abstracted from NCCN Clinical Practice Guidelines in Oncology for each disease and survival probabilities from the studies cited therein. Modeled survival was validated using SEER data. Nine-month shortages were modeled for all possible supply levels. Pairwise differences in 3-year survival and risk reductions were calculated for each strategy compared with standard practice (first-come, first-served) for each 50-mg supply increment, as were supply thresholds above which each strategy maintained survival similar to scenarios without shortages. RESULTS A strategy prioritizing by higher vincristine efficacy per volume and greater alternative treatment efficacy difference performed best, improving survival significantly (P<.01) across 86.5% of possible shortages (relative risk reduction, 8.3%; 99% CI, 8.0-8.5) compared with standard practice. This strategy also maintained survival rates similar to a model without shortages until supply fell below 72.2% of the amount required to treat all patients, compared with 94.3% for standard practice. CONCLUSIONS During modeled vincristine shortages, prioritizing patients by higher efficacy per volume and alternative treatment efficacy difference significantly improved survival over standard practice. This approach can help optimize allocation as intermittent chemotherapy shortages continue to arise.
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Affiliation(s)
- Andrew Hantel
- Division of Population Sciences, Dana-Farber Cancer Institute
- Division of Inpatient Oncology, Dana-Farber Cancer Institute
| | | | - Martha Wadleigh
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute
| | - Michael Cotugno
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Gregory A. Abel
- Division of Population Sciences, Dana-Farber Cancer Institute
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute
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Sala F, Quarto M, D’Urso G. Simulation Study of the Impact of COVID-19 Policies on the Efficiency of a Smart Clinic MRI Service. Healthcare (Basel) 2022; 10:healthcare10040619. [PMID: 35455797 PMCID: PMC9030171 DOI: 10.3390/healthcare10040619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 12/02/2022] Open
Abstract
The present study examines the impact of the policies against the proliferation of SARS-CoV-2 on outpatient facilities through a direct comparison of the key performance indicators measured in an ordinary and pandemic scenario. The subject of the analysis is a diagnostic imaging department of a Smart Clinic (SC) of Gruppo San Donato (GSD). The operations are virtually replicated through a Discrete-Event Simulation (DES) software called FlexSim Healthcare. Operational and productivity indicators are defined and quantified. As hypothesized, anti-contagious practices affect the normal execution of medical activities and their performance, resulting in an unpleasant scenario compared to the baseline one. A reduction in the number of diagnoses by 19% and a decrease in the utilization rate of the diagnostic machine by 21% are shown. Consequently, the development of strategies that restore balance and improve the execution of outpatient activities in a pandemic setting is necessary.
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Hulzen G, Martin N, Depaire B, Souverijns G. Supporting Capacity Management Decisions in Healthcare using Data-Driven Process Simulation. J Biomed Inform 2022; 129:104060. [DOI: 10.1016/j.jbi.2022.104060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 03/04/2022] [Accepted: 03/26/2022] [Indexed: 10/18/2022]
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Maass KL, Halter E, Huschka TR, Sir MY, Nordland MR, Pasupathy KS. A discrete event simulation to evaluate impact of radiology process changes on emergency department computed tomography access. J Eval Clin Pract 2022; 28:120-128. [PMID: 34309137 DOI: 10.1111/jep.13606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/31/2021] [Accepted: 07/07/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hospitals face the challenge of managing demand for limited computed tomography (CT) resources from multiple patient types while ensuring timely access. METHODS A discrete event simulation model was created to evaluate CT access time for emergency department (ED) patients at a large academic medical center with six unique CT machines that serve unscheduled emergency, semi-scheduled inpatient, and scheduled outpatient demand. Three operational interventions were tested: adding additional patient transporters, using an alternative creatinine lab, and adding a registered nurse dedicated to monitoring CT patients in the ED. RESULTS All interventions improved access times. Adding one or two transporters improved ED access times by up to 9.8 minutes (Mann-Whitney (MW) CI: [-11.0,-8.7]) and 10.3 minutes (MW CI [-11.5, -9.2]). The alternative creatinine and RN interventions provided 3-minute (MW CI: [-4.0, -2.0]) and 8.5-minute (MW CI: [-9.7, -8.3]) improvements. CONCLUSIONS Adding one transporter provided the greatest combination of reduced delay and ability to implement. The projected simulation improvements have been realized in practice.
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Affiliation(s)
- Kayse Lee Maass
- Mechanical and Industrial Engineering Department, Northeastern University, Boston, Massachusetts, USA.,Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Halter
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.,Industrial and Systems Engineering Department, Washington University, St. Louis, Missouri, USA
| | - Todd R Huschka
- Mayo Clinic Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mustafa Y Sir
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kalyan S Pasupathy
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
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Applying Discrete Event Simulation to Reduce Patient Wait Times and Crowding: The Case of a Specialist Outpatient Clinic with Dual Practice System. Healthcare (Basel) 2022; 10:healthcare10020189. [PMID: 35206804 PMCID: PMC8871892 DOI: 10.3390/healthcare10020189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 11/17/2022] Open
Abstract
Long wait times and crowding are major issues affecting outpatient service delivery, but it is unclear how these affect patients in dual practice settings. This study aims to evaluate the effects of changing consultation start time and patient arrival on wait times and crowding in an outpatient clinic with a dual practice system. A discrete event simulation (DES) model was developed based on real-world data from an Obstetrics and Gynaecology (O&G) clinic in a public hospital. Data on patient flow, resource availability, and time taken for registration and clinic processes for public and private patients were sourced from stakeholder discussion and time-motion study (TMS), while arrival times were sourced from the hospital’s information system database. Probability distributions were used to fit these input data in the model. Scenario analyses involved configurations on consultation start time/staggered patient arrival. The median registration and clinic turnaround times (TT) were significantly different between public and private patients (p < 0.01). Public patients have longer wait times than private patients in this study’s dual practice setting. Scenario analyses showed that early consultation start time that matches patient arrival time and staggered arrival could reduce the overall TT for public and private patients by 40% and 21%, respectively. Similarly, the number of patients waiting at the clinic per hour could be reduced by 10–21% during clinic peak hours. Matching consultation start time with staggered patient arrival can potentially reduce wait times and crowding, especially for public patients, without incurring additional resource needs and help narrow the wait time gap between public and private patients. Healthcare managers and policymakers can consider simulation approaches for the monitoring and improvement of healthcare operational efficiency to meet rising healthcare demand and costs.
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Models for Assessing Strategies for Improving Hospital Capacity for Handling Patients during a Pandemic. Disaster Med Public Health Prep 2022; 17:e110. [PMID: 35000643 DOI: 10.1017/dmp.2022.12] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the performance of key hospital units associated with emergency care of both routine emergency and pandemic (COVID-19) patients under capacity enhancing strategies. METHODS This investigation was conducted using whole-hospital, resource-constrained, patient-based, stochastic, discrete-event, simulation models of a generic 200-bed urban U.S. tertiary hospital serving routine emergency and COVID-19 patients. Systematically designed numerical experiments were conducted to provide generalizable insights into how hospital functionality may be affected by the care of COVID-19 pandemic patients along specially designated care paths, under changing pandemic situations, from getting ready to turning all of its resources to pandemic care. RESULTS Several insights are presented. For example, each day of reduction in average ICU length of stay increases intensive care unit patient throughput by up to 24% for high COVID-19 daily patient arrival levels. The potential of 5 specific interventions and 2 critical shifts in care strategies to significantly increase hospital capacity is also described. CONCLUSIONS These estimates enable hospitals to repurpose space, modify operations, implement crisis standards of care, collaborate with other health care facilities, or request external support, thereby increasing the likelihood that arriving patients will find an open staffed bed when 1 is needed.
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Gao L, Bivard A, Parsons M, Spratt NJ, Levi C, Butcher K, Kleinig T, Yan B, Dong Q, Cheng X, Lou M, Yin C, Chen C, Wang P, Lin L, Choi P, Miteff F, Moodie M. Real-World Cost-Effectiveness of Late Time Window Thrombectomy for Patients With Ischemic Stroke. Front Neurol 2022; 12:780894. [PMID: 34970213 PMCID: PMC8712752 DOI: 10.3389/fneur.2021.780894] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To compare the cost-effectiveness of providing endovascular thrombectomy (EVT) for patients with ischemic stroke in the >4.5 h time window between patient groups who met and did not meet the perfusion imaging trial criteria. Methods: A discrete event simulation (DES) model was developed to simulate the long-term outcome post EVT in patients meeting or not meeting the extended time window clinical trial perfusion imaging criteria at presentation, vs. medical treatment alone (including intravenous thrombolysis). The effectiveness of thrombectomy in patients meeting the landmark trial criteria (DEFUSE 3 and DAWN) was derived from a prospective cohort study of Australian patients who received EVT for ischemic stroke, between 2015 and 2019, in the extended time window (>4.5 h). Results: Endovascular thrombectomy was shown to be a cost-effective treatment for patients satisfying the clinical trial criteria in our prospective cohort [incremental cost-effectiveness ratio (ICER) of $11,608/quality-adjusted life year (QALY) for DEFUSE 3-postive or $34,416/QALY for DAWN-positive]. However, offering EVT to patients outside of clinical trial criteria was associated with reduced benefit (−1.02 QALY for DEFUSE 3; −1.43 QALY for DAWN) and higher long-term patient costs ($8,955 for DEFUSE 3; $9,271 for DAWN), thereby making it unlikely to be cost-effective in Australia. Conclusions: Treating patients not meeting the DAWN or DEFUSE 3 clinical trial criteria in the extended time window for EVT was associated with less gain in QALYs and higher cost. Caution should be exercised when considering this procedure for patients not satisfying the trial perfusion imaging criteria for EVT.
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Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Andrew Bivard
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Mark Parsons
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia.,Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia.,Department of Neurology, UNSW South Western Clinical School, Liverpool Hospital, University of New South Wales, Kensington, NSW, Australia
| | - Neil J Spratt
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Christopher Levi
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Kenneth Butcher
- Department of Neurology, Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Min Lou
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Congguo Yin
- Department of Neurology, Hangzhou First Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chushuang Chen
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Peng Wang
- Zhejiang Provincial People's Hospital, Zhejiang, China
| | - Longting Lin
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia
| | - Ferdinand Miteff
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
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Chen CH, Tsai YT, Chou CA, Weng SJ, Lee WC, Hsiao LW, Derek N, Ko CP. Evaluating Different Strategies on the Blood Collection Counter Settings to Improve Patient Waiting Time in Outpatient Units. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2022; 59:469580221095797. [PMID: 35505594 PMCID: PMC9073117 DOI: 10.1177/00469580221095797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Long patient waiting time is one of the major problems in the healthcare system and it would decrease patient satisfaction. Previous studies usually investigated how to improve the treatment flow in order to reduce patient waiting time or length of stay. The studies on blood collection counters have received less attention. Therefore, the objective of this study is to reduce the patient waiting time at outpatient clinics for metabolism and nephrology outpatients. A discrete-event simulation is used to analyze the four different strategies for blood collection counter resource allocation. Through analyzing four different strategic settings, the experimental results revealed that the maximum number of patients waiting before the outpatient clinics was reduced from 41 to 33 (20%); the maximum patient waiti-ng time at the outpatient clinics was decreased from 201.6 minutes to 83 minutes (59%). In this study, we found that adjusting the settings of blood collection counters would be beneficial. Assigning one exclusive blood collection counter from 8 to 10 am is the most suitable option with the least impact on the operational process for hospital staff. The results provide managerial insight regarding the cost-effective strategy selection for the hospital operational strategy.
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Affiliation(s)
- Chih-Hao Chen
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
| | - Yao-Te Tsai
- Department of International Business, Feng Chia University, Taichung, Taiwan
| | - Chun-An Chou
- Department of Mechanical and Industrial Engineering, Northeastern University, Boston, MA, USA
| | - Shao-Jen Weng
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
| | - Wen-Chin Lee
- Division of Nephrology, Department of Internal Medicine, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Li-Wei Hsiao
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Natan Derek
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
| | - Chang-Pu Ko
- Department of Industrial Engineering and Systems Management, Feng Chia University, Taichung, Taiwan
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Soper BC, Cadena J, Nguyen S, Chan KHR, Kiszka P, Womack L, Work M, Duggan JM, Haller ST, Hanrahan JA, Kennedy DJ, Mukundan D, Ray P. OUP accepted manuscript. J Am Med Inform Assoc 2022; 29:864-872. [PMID: 35137149 PMCID: PMC8903413 DOI: 10.1093/jamia/ocac012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/15/2021] [Accepted: 01/28/2022] [Indexed: 11/12/2022] Open
Abstract
Objective The study sought to investigate the disease state–dependent risk profiles of patient demographics and medical comorbidities associated with adverse outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Materials and Methods A covariate-dependent, continuous-time hidden Markov model with 4 states (moderate, severe, discharged, and deceased) was used to model the dynamic progression of COVID-19 during the course of hospitalization. All model parameters were estimated using the electronic health records of 1362 patients from ProMedica Health System admitted between March 20, 2020 and December 29, 2020 with a positive nasopharyngeal PCR test for SARS-CoV-2. Demographic characteristics, comorbidities, vital signs, and laboratory test results were retrospectively evaluated to infer a patient’s clinical progression. Results The association between patient-level covariates and risk of progression was found to be disease state dependent. Specifically, while being male, being Black or having a medical comorbidity were all associated with an increased risk of progressing from the moderate disease state to the severe disease state, these same factors were associated with a decreased risk of progressing from the severe disease state to the deceased state. Discussion Recent studies have not included analyses of the temporal progression of COVID-19, making the current study a unique modeling-based approach to understand the dynamics of COVID-19 in hospitalized patients. Conclusion Dynamic risk stratification models have the potential to improve clinical outcomes not only in COVID-19, but also in a myriad of other acute and chronic diseases that, to date, have largely been assessed only by static modeling techniques.
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Affiliation(s)
- Braden C Soper
- Corresponding Author: Braden C. Soper, PhD, Computing Directorate, Lawrence Livermore National Laboratory, 7000 East Ave, Livermore, CA 94550, USA;
| | - Jose Cadena
- Engineering Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - Sam Nguyen
- Engineering Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - Kwan Ho Ryan Chan
- Engineering Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - Paul Kiszka
- Information Technology Services, ProMedica Health System, Inc, Toledo, Ohio, USA
| | - Lucas Womack
- Information Technology Services, ProMedica Health System, Inc, Toledo, Ohio, USA
| | - Mark Work
- Information Technology Services, ProMedica Health System, Inc, Toledo, Ohio, USA
| | - Joan M Duggan
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | - Steven T Haller
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | - Jennifer A Hanrahan
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | - David J Kennedy
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | - Deepa Mukundan
- Department of Pediatrics, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | - Priyadip Ray
- Engineering Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
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Ghiyasinasab M, Lahrichi N, Lehoux N. A simulation model to analyse automation scenarios in decontamination centers. Health Syst (Basingstoke) 2021; 12:181-197. [PMID: 37234464 PMCID: PMC10208212 DOI: 10.1080/20476965.2021.2004933] [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: 02/20/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022] Open
Abstract
Decontamination centres provide sterilisation services (sort, disinfect, package, and sterilise) for reusable surgical instruments that have a vital impact on patient safety. The market trend is to increase the level of automation in the decontamination process, to increase productivity, and reduce the risk of human error and musculoskeletal injuries. The goal of this research is to study the use of automated guided vehicles (AGVs) in sterilisation departments, to improve safety and efficiency. A generic simulation model is created based on data gathering of various decontamination centres and is validated for a specific centre to analyse various aspects of applying AGVs to automate the internal transfer. Centre's potential to increase capacity through AGV application is analysed and a Design of Experiments is conducted to identify the most promising implementation scenarios. Results show reductions in treatment time and work in process, while ,maintaining the accessibility of medical instruments, and ensuring worker safety.
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Affiliation(s)
- Marzieh Ghiyasinasab
- Department of mathematics and industrial engineering, Polytechnique Montréal, Montréal, Canada
| | - Nadia Lahrichi
- Department of mathematics and industrial engineering, Polytechnique Montréal, Montréal, Canada
| | - Nadia Lehoux
- Department of mechanical engineering, Laval University, Québec, Canada
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Gowda NR, Khare A, Vikas H, Singh AR, Sharma DK, Poulose R, John DC. More from less: Study on increasing throughput of COVID-19 screening and testing facility at an apex tertiary care hospital in New Delhi using discrete-event simulation software. Digit Health 2021; 7:20552076211040987. [PMID: 34868613 PMCID: PMC8642042 DOI: 10.1177/20552076211040987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/05/2021] [Accepted: 08/03/2021] [Indexed: 11/24/2022] Open
Abstract
Background One of the challenges has been coping with an increasing need for COVID-19
testing. A COVID-19 screening and testing facility was created. There was a
need for increasing throughput of the facility within the existing space and
limited resources. Discrete event simulation was used to address this
challenge. Methodology A cross-sectional interventional study was done from September 2020 to
October 2020. Detailed process mapping with all micro-processes was done.
Patient arrival patterns and time taken at each step were measured by two
independent observers at random intervals over two weeks. The existing
system was simulated and a bottleneck was identified. Two possible
alternatives to the problem were simulated and evaluated. Results Scenario 1 showed a maximum throughput of 316. The average milestone times of
all the processes after the step of “Preparation of sampling kits” jumped
62%; from 82 to 133 min. Staff state times also showed that staff at this
step was stretched and medical lab technicians were underutilized. Scenario
2 simulated the alternative with lesser time spent on sampling kit
preparation with a 22.4% increase in throughput, but could have led to
impaired quality check. Scenario 3 simulated with increased manpower at the
stage of bottleneck with 26.5% increase in throughput and was implemented
on-ground. Conclusion Discrete event simulation helped to identify the bottleneck, simulate
possible alternative solutions without disturbing the ongoing work, and
finally choose the most suitable intervention to increase throughput,
without the need for additional space allocation. It therefore helped to
optimally utilize resources and get “more from less.”
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Affiliation(s)
- Naveen R Gowda
- Department of Hospital Administration, All India Institute of Medical Sciences (AIIMS), India
| | - Amitesh Khare
- Department of Hospital Administration, All India Institute of Medical Sciences (AIIMS), India
| | - H Vikas
- Department of Hospital Administration, All India Institute of Medical Sciences (AIIMS), India
| | - Angel R Singh
- Department of Hospital Administration, All India Institute of Medical Sciences (AIIMS), India
| | - D K Sharma
- All India Institute of Medical Sciences (AIIMS), India
| | - Ramya Poulose
- All India Institute of Medical Sciences (AIIMS), India
| | - Dhayal C John
- All India Institute of Medical Sciences (AIIMS), India
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Vázquez-Serrano JI, Peimbert-García RE, Cárdenas-Barrón LE. Discrete-Event Simulation Modeling in Healthcare: A Comprehensive Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:12262. [PMID: 34832016 PMCID: PMC8625660 DOI: 10.3390/ijerph182212262] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 11/26/2022]
Abstract
Discrete-event simulation (DES) is a stochastic modeling approach widely used to address dynamic and complex systems, such as healthcare. In this review, academic databases were systematically searched to identify 231 papers focused on DES modeling in healthcare. These studies were sorted by year, approach, healthcare setting, outcome, provenance, and software use. Among the surveys, conceptual/theoretical studies, reviews, and case studies, it was found that almost two-thirds of the theoretical articles discuss models that include DES along with other analytical techniques, such as optimization and lean/six sigma, and one-third of the applications were carried out in more than one healthcare setting, with emergency departments being the most popular. Moreover, half of the applications seek to improve time- and efficiency-related metrics, and one-third of all papers use hybrid models. Finally, the most popular DES software is Arena and Simul8. Overall, there is an increasing trend towards using DES in healthcare to address issues at an operational level, yet less than 10% of DES applications present actual implementations following the modeling stage. Thus, future research should focus on the implementation of the models to assess their impact on healthcare processes, patients, and, possibly, their clinical value. Other areas are DES studies that emphasize their methodological formulation, as well as the development of frameworks for hybrid models.
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Affiliation(s)
- Jesús Isaac Vázquez-Serrano
- School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey 64849, Northeast Nuevo Leon, Mexico; (J.I.V.-S.); (L.E.C.-B.)
| | - Rodrigo E. Peimbert-García
- School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey 64849, Northeast Nuevo Leon, Mexico; (J.I.V.-S.); (L.E.C.-B.)
- School of Engineering, Macquarie University, Sydney, NSW 2109, Australia
| | - Leopoldo Eduardo Cárdenas-Barrón
- School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey 64849, Northeast Nuevo Leon, Mexico; (J.I.V.-S.); (L.E.C.-B.)
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Sheldrick RC, Cruden G, Schaefer AJ, Mackie TI. Rapid-cycle systems modeling to support evidence-informed decision-making during system-wide implementation. Implement Sci Commun 2021; 2:116. [PMID: 34627399 PMCID: PMC8502394 DOI: 10.1186/s43058-021-00218-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background To “model and simulate change” is an accepted strategy to support implementation at scale. Much like a power analysis can inform decisions about study design, simulation models offer an analytic strategy to synthesize evidence that informs decisions regarding implementation of evidence-based interventions. However, simulation modeling is under-utilized in implementation science. To realize the potential of simulation modeling as an implementation strategy, additional methods are required to assist stakeholders to use models to examine underlying assumptions, consider alternative strategies, and anticipate downstream consequences of implementation. To this end, we propose Rapid-cycle Systems Modeling (RCSM)—a form of group modeling designed to promote engagement with evidence to support implementation. To demonstrate its utility, we provide an illustrative case study with mid-level administrators developing system-wide interventions that aim to identify and treat trauma among children entering foster care. Methods RCSM is an iterative method that includes three steps per cycle: (1) identify and prioritize stakeholder questions, (2) develop or refine a simulation model, and (3) engage in dialogue regarding model relevance, insights, and utility for implementation. For the case study, 31 key informants were engaged in step 1, a prior simulation model was adapted for step 2, and six member-checking group interviews (n = 16) were conducted for step 3. Results Step 1 engaged qualitative methods to identify and prioritize stakeholder questions, specifically identifying a set of inter-related decisions to promote implementing trauma-informed screening. In step 2, the research team created a presentation to communicate key findings from the simulation model that addressed decisions about programmatic reach, optimal screening thresholds to balance demand for treatment with supply, capacity to start-up and sustain screening, and availability of downstream capacity to provide treatment for those with indicated need. In step 3, member-checking group interviews with stakeholders documented the relevance of the model results to implementation decisions, insight regarding opportunities to improve system performance, and potential to inform conversations regarding anticipated implications of implementation choices. Conclusions By embedding simulation modeling in a process of stakeholder engagement, RCSM offers guidance to realize the potential of modeling not only as an analytic strategy, but also as an implementation strategy.
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Affiliation(s)
- R Christopher Sheldrick
- Department of Health Law, Policy and Management, School of Public Health, Boston University, One Silber Way, Boston, MA, USA.
| | - Gracelyn Cruden
- Oregon Social Learning Center, 10 Shelton McMurphey Blvd, Eugene, OR, USA
| | - Ana J Schaefer
- SUNY Downstate Health Sciences University, 450 Clarkson Ave, Brooklyn, NY, USA
| | - Thomas I Mackie
- SUNY Downstate Health Sciences University, 450 Clarkson Ave, Brooklyn, NY, USA
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Asgary A, Najafabadi MM, Wendel SK, Resnick-Ault D, Zane RD, Wu J. Optimizing planning and design of COVID-19 drive-through mass vaccination clinics by simulation. HEALTH AND TECHNOLOGY 2021; 11:1359-1368. [PMID: 34631358 PMCID: PMC8492036 DOI: 10.1007/s12553-021-00594-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/31/2021] [Indexed: 01/15/2023]
Abstract
Drive-through clinics have previously been utilized in vaccination efforts and are now being more widely adopted for COVID-19 vaccination in different parts of the world by offering many advantages including utilizing existing infrastructure, large daily throughput and enforcing social distancing by default. Successful, effective, and efficient drive-through facilities require a suitable site and keen focus on layout and process design. To demonstrate the role that high fidelity computer simulation can play in planning and design of drive-through mass vaccination clinics, we used multiple integrated discrete event simulation (DES) and agent-based modelling methods. This method using AnyLogic simulation software to aid in planning, design, and implementation of one of the largest and most successful early COVID-19 mass vaccination clinics operated by UCHealth in Denver, Colorado. Simulations proved to be helpful in aiding the optimization of UCHealth drive through mass vaccination clinic design and operations by exposing potential bottlenecks, overflows, and queueing, and clarifying the necessary number of supporting staff. Simulation results informed the target number of vaccinations and necessary processing times for different drive through station set ups and clinic formats. We found that modern simulation tools with advanced visual and analytical capabilities to be very useful for effective planning, design, and operations management of mass vaccination facilities.
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Affiliation(s)
- Ali Asgary
- Disaster & Emergency Management, York University, 4700 Keele Street, Toronto, ON M3J 1P3 Canada
| | - Mahdi M. Najafabadi
- Postdoc Research Associate, City University of New York’s Graduate School of Public Health, New York, NY USA
| | - Sarah K. Wendel
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO USA
| | - Daniel Resnick-Ault
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO USA
| | - Richard D. Zane
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO USA
| | - Jianhong Wu
- Department of Mathematics and Statistics, University Distinguished Research Professor, York University, Toronto, ON Canada
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Leeftink AG, Visser J, de Laat JM, van der Meij NTM, Vos JBH, Valk GD. Reducing failures in daily medical practice: Healthcare failure mode and effect analysis combined with computer simulation. ERGONOMICS 2021; 64:1322-1332. [PMID: 33829959 DOI: 10.1080/00140139.2021.1910734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/25/2021] [Indexed: 06/12/2023]
Abstract
This study proposes a risk analysis approach for complex healthcare processes that combines qualitative and quantitative methods to improve patient safety. We combine Healthcare Failure Mode and Effect Analysis with Computer Simulation (HFMEA-CS), to overcome widely recognised HFMEA drawbacks regarding the reproducibility and validity of the outcomes due to human interpretation, and show the application of this methodology in a complex healthcare setting. HFMEA-CS is applied to analyse drug adherence performance in the surgical admission to discharge process of pheochromocytoma patients. The multidisciplinary team identified and scored the failure modes, and the simulation model supported in prioritisation of failure modes, uncovered dependencies between failure modes, and predicted the impact of measures on system behaviour. The results show that drug adherence, defined as the percentage of required drugs received at the right time, can be significantly improved with 12%, to reach a drug adherence of 99%. We conclude that HFMEA-CS is both a viable and effective risk analysis approach, combining strengths of expert opinion and quantitative analysis, for analysing human-system interactions in socio-technical systems. Practitioner summary: We propose combining Healthcare Failure Mode and Effects Analysis with Computer Simulation (HFMEA-CS) for prospective risk analysis of complex and potentially harmful processes, to prevent critical incidents from occurring. HFMEA-CS combines expert opinions with quantitative analyses, such that the results are more reliable, reproducible, and fitting for complex healthcare settings.
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Affiliation(s)
- A G Leeftink
- Center for Healthcare Operations Improvement and Research, University of Twente, Enschede, The Netherlands
| | - J Visser
- Center for Healthcare Operations Improvement and Research, University of Twente, Enschede, The Netherlands
| | - J M de Laat
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N T M van der Meij
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J B H Vos
- Department of Quality and Safety; Division Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Santos RP, Pereira WCDA, Almeida RMVR. Discrete-event models for the simulation of computed tomography sectors according to hospital structural/organizational changes and expected patient arrival rates. Int J Health Plann Manage 2021; 37:536-542. [PMID: 34537982 DOI: 10.1002/hpm.3335] [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: 11/16/2020] [Revised: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To analyze the types of computed tomography (CT) scanners most suitable for different hospital sizes and 'scenarios' (exam rates and structural/organizational changes), using discrete-event simulation models. MATERIALS AND METHODS CT exams were divided into stages, measured during on-site surveys at CT services in small and average size private hospitals. Ten devices in nine health units, five cities and two states of Brazil were studied to this end, and the following data were collected: Time spent in each stage for each type of exam; average monthly number of exams performed and general characteristics of exams. Three arrival rates were defined (103, 154 and 206 patients/day), representing expected demand for the studied units. From these parameters, six scenarios were simulated, consisting of changes in personnel and hospital structure (e.g., 'adding a changing room') in a base scenario (one CT, one changing room, no nursing assistance, arrival rate 1). RESULTS It was possible to identify a scenario most useful for very large demands, such as large emergency hospitals in big cities, (a CT, nursing assistance and three changing rooms added to the base scenario). Another identified scenario was more adequate for small demands (adding a changing room to the base scenario). CONCLUSION Administrative/organizational measures are a very important factor in defining productivity in a hospital imaging sector. The focus of these measures should be on detecting bottlenecks and improving processes, regardless of the type of equipment used.
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Affiliation(s)
- Rogério Pires Santos
- Centro Federal de Educação Tecnológica Celso Suckow da Fonseca, Rio de Janeiro, RJ, Brazil.,Programa de Engenharia Biomédica, COPPE/Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Chen MS, Wu KC, Tsai YL, Jiang BC. Data analysis of ambient intelligence in a healthcare simulation system: a pilot study in high-end health screening process improvement. BMC Health Serv Res 2021; 21:936. [PMID: 34496839 PMCID: PMC8424928 DOI: 10.1186/s12913-021-06949-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 08/26/2021] [Indexed: 11/24/2022] Open
Abstract
Background This study aimed to reduce the total waiting time for high-end health screening processes. Method The subjects of this study were recruited from a health screening center in a tertiary hospital in northern Taiwan from September 2016 to February 2017, where a total of 2342 high-end customers participated. Three policies were adopted for the simulation. Results The first policy presented a predetermined proportion of customer types, in which the total waiting time was increased from 72.29 to 83.04 mins. The second policy was based on increased bottleneck resources, which provided significant improvement, decreasing the total waiting time from 72.29 to 28.39 mins. However, this policy also dramatically increased the cost while lowering the utilization of this health screening center. The third policy was adjusting customer arrival times, which significantly reduced the waiting time—with the total waiting time reduced from 72.29 to 55.02 mins. Although the waiting time of this policy was slightly longer than that of the second policy, the additional cost was much lower. Conclusions Scheduled arrival intervals could help reduce customer waiting time in the health screening department based on the “first in, first out” rule. The simulation model of this study could be utilized, and the parameters could be modified to comply with different health screening centers to improve processes and service quality.
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Affiliation(s)
- Ming-Shu Chen
- Department of Healthcare Administration, College of Management and Healthcare, Asia Eastern University of Science and Technology, No.58, Sec. 2, Sihchuan Rd., Pan-Chiao Dist., New Taipei, 22061, Taiwan, Republic of China.
| | - Kun-Chih Wu
- Department of Management Center, National Chung-Shan Institute of Science & Technology, Taoyuan City, 32546, Taiwan, Republic of China
| | - Yu-Ling Tsai
- Department of Industrial Management, National Taiwan University of Science and Technology, Taipei City, 10607, Taiwan, Republic of China
| | - Bernard C Jiang
- Department of Industrial Management, National Taiwan University of Science and Technology, Taipei City, 10607, Taiwan, Republic of China
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