Health Care Management Science (Health Care Manag Sci)

Publications in this journal

• Article: Prioritization strategies for patient evacuations.

  Ashley Kay Childers, Maria E Mayorga, Kevin M Taaffe
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  ABSTRACT: Evacuation from a health care facility is considered last resort, and in the event of a complete evacuation, a standard planning assumption is that all patients will be evacuated. A literature review of the suggested prioritization strategies for evacuation planning-as well as the transportation priorities used in actual facility evacuations-shows a lack of consensus about whether critical or non-critical care patients should be transferred first. In addition, it is implied that these policies are "greedy" in that one patient group is given priority, and patients from that group are chosen to be completely evacuated before any patients are evacuated from the other group. The purpose of this paper is to present a dynamic programming model for emergency patient evacuations and show that a greedy, "all-or-nothing" policy is not always optimal as well as discuss insights of the resulting optimal prioritization strategies for unit- or floor-level evacuations.
  Health Care Management Science 05/2013;
• Article: An IP-based healthcare provider shift design approach to minimize patient handoffs.

  Pooyan Kazemian, Yue Dong, Thomas R Rohleder, Jonathan E Helm, Mark P Van Oyen
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  ABSTRACT: The new Accreditation Council for Graduate Medical Education (ACGME) duty-hour standards for residents and fellows went into effect in 2011. These regulations were designed to reduce fatigue-related medical errors and improve patient safety. The new shift restrictions, however, have led to more frequent transitions in patient care (handoffs), resulting in greater opportunity for communication breakdowns between caregivers, which correlate with medical errors and adverse events. Recent research has focused on improving the quality of these transitions through standardization of the handoff protocols; however, no attention has been given to reducing the number of transitions in patient care. This research leverages integer programming methods to design a work shift schedule for trainees that minimizes patient handoffs while complying with all ACGME duty-hour standards, providing required coverage, and maintaining physician quality of life. In a case study of redesigning the trainees' schedule for a Mayo Clinic Medical Intensive Care Unit (MICU), we show that the number of patient handoffs can be reduced by 23 % and still meet all required and most desired scheduling constraints. Furthermore, a 48 % reduction in handoffs could be achieved if only the minimum required rules are satisfied.
  Health Care Management Science 04/2013;
• Article: A system model of work flow in the patient room of hospital emergency department.

  Junwen Wang, Jingshan Li, Patricia K Howard
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  ABSTRACT: Modeling and analysis of patient flow in hospital emergency department (ED) is of significant importance. In a hospital ED, the patients spend most of their time in the patient room and most of the care delivery services are carried out during this time period. In this paper, we propose a system model to study patient (or work) flow in the patient room of an ED when the resources are partially available. A closed and re-entrant process model is developed to characterize the care service activities in the patient room with limited resources of doctors, nurses, and diagnosis tests. Analytical calculation of patient's length of stay in the patient room is derived, and monotonic properties with respect to care service parameters are investigated.
  Health Care Management Science 04/2013;
• Article: Treatment speed and high load in the Emergency Department-does staff quality matter?

  Ludwig Kuntz, Sandra Sülz
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  ABSTRACT: Research in the field of operations management and medicine analyzed how workload affects productivity and patient outcomes. However, staff quality has largely been neglected, and if staffing information has indeed been included, then it takes the form of quantitative measures like staff-to-patient ratios. We therefore seek to analyze how education and experience are directly associated with effort. How do responses to workload differ with respect to education and experience? By analyzing a single hospital unit, we are able to establish a link between staff quality and patient outcomes, allowing us to demonstrate empirically that knowledge and experience are highly relevant in staff members' responses to increasing system load. The systematic aligning of staffing with expected system load should therefore consider not only staffing quantity but also staffing quality. Provided with a reliable prediction of system load, this knowledge would allow managers to generate savings since they can assign high-quality staff more effectively.
  Health Care Management Science 04/2013;
• Article: Stochastic online appointment scheduling of multi-step sequential procedures in nuclear medicine.

  Eduardo Pérez, Lewis Ntaimo, César O Malavé, Carla Bailey, Peter McCormack
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  ABSTRACT: The increased demand for medical diagnosis procedures has been recognized as one of the contributors to the rise of health care costs in the U.S. in the last few years. Nuclear medicine is a subspecialty of radiology that uses advanced technology and radiopharmaceuticals for the diagnosis and treatment of medical conditions. Procedures in nuclear medicine require the use of radiopharmaceuticals, are multi-step, and have to be performed under strict time window constraints. These characteristics make the scheduling of patients and resources in nuclear medicine challenging. In this work, we derive a stochastic online scheduling algorithm for patient and resource scheduling in nuclear medicine departments which take into account the time constraints imposed by the decay of the radiopharmaceuticals and the stochastic nature of the system when scheduling patients. We report on a computational study of the new methodology applied to a real clinic. We use both patient and clinic performance measures in our study. The results show that the new method schedules about 600 more patients per year on average than a scheduling policy that was used in practice by improving the way limited resources are managed at the clinic. The new methodology finds the best start time and resources to be used for each appointment. Furthermore, the new method decreases patient waiting time for an appointment by about two days on average.
  Health Care Management Science 03/2013;
• Article: Comparing health outcomes among hospitals: the experience of the Lombardy Region.

  Paolo Berta, Chiara Seghieri, Giorgio Vittadini
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  ABSTRACT: In recent years, governments and other stakeholders have increasingly used administrative data for measuring healthcare outcomes and building rankings of health care providers. However, the accuracy of such data sources has often been questioned. Starting in 2002, the Lombardy (Italy) regional administration began monitoring hospital care effectiveness on administrative databases using seven outcome measures related to mortality and readmissions. The present study describes the use of benchmarking results of risk-standardized mortality from Lombardy regional hospitals. The data usage is part of a general program of continuous improvement directed to health care service and organizational learning, rather than at penalizing or rewarding hospitals. In particular, hierarchical regression analyses - taking into account mortality variation across hospitals - were conducted separately for each of the most relevant clinical disciplines. Overall mortality was used as the outcome variable and the mix of the hospitals' output was taken into account by means of Diagnosis Related Group data, while also adjusting for both patient and hospital characteristics. Yearly adjusted mortality rates for each hospital were translated into a reporting tool that indicates to healthcare managers at a glance, in a user-friendly and non-threatening format, underachieving and over-performing hospitals. Even considering that benchmarking on risk-adjusted outcomes tend to elicit contrasting public opinions and diverging policymaking, we show that repeated outcome measurements and the development and dissemination of organizational best practices have promoted in Lombardy region implementation of outcome measures in healthcare management and stimulated interest and involvement of healthcare stakeholders.
  Health Care Management Science 03/2013;
• Article: Using discrete-event simulation in strategic capacity planning for an outpatient physical therapy service.

  Chi-Lun Rau, Pei-Fang Jennifer Tsai, Sheau-Farn Max Liang, Jhih-Cian Tan, Hong-Cheng Syu, Yue-Ling Jheng, Ting-Syuan Ciou, Fu-Shan Jaw
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  ABSTRACT: This study uses a simulation model as a tool for strategic capacity planning for an outpatient physical therapy clinic in Taipei, Taiwan. The clinic provides a wide range of physical treatments, with 6 full-time therapists in each session. We constructed a discrete-event simulation model to study the dynamics of patient mixes with realistic treatment plans, and to estimate the practical capacity of the physical therapy room. The changes in time-related and space-related performance measurements were used to evaluate the impact of various strategies on the capacity of the clinic. The simulation results confirmed that the clinic is extremely patient-oriented, with a bottleneck occurring at the traction units for Intermittent Pelvic Traction (IPT), with usage at 58.9 %. Sensitivity analysis showed that attending to more patients would significantly increase the number of patients staying for overtime sessions. We found that pooling the therapists produced beneficial results. The average waiting time per patient could be reduced by 45 % when we pooled 2 therapists. We found that treating up to 12 new patients per session had no significantly negative impact on returning patients. Moreover, we found that the average waiting time for new patients decreased if they were given priority over returning patients when called by the therapists.
  Health Care Management Science 03/2013;
• Article: Do caesarean section rates 'catch-up'? Evidence from 14 European countries.

  Wen-Yi Chen
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  ABSTRACT: This study investigated the catch up effect of Caesarean Section (CS) birth rates across 14 European countries during 1980-2009 for the first time. The panel stationary test incorporating multiple structural breaks and cross-sectional dependence was used to provide reliable evidence for the existence of the catch up effect of CS birth rates. Our results suggested that the CS birth rates in 14 European countries have mostly exhibited signs of convergence through a steady upward trend from 1980 to 2009. Policymakers in low CS birth rate countries should be cautioned concerning the negative impact of the increase of CS births.
  Health Care Management Science 03/2013;
• Article: Using optimization models to demonstrate the need for structural changes in training programs for surgical medical residents.

  Jonathan Turner, Kibaek Kim, Sanjay Mehrotra, Debra A Darosa, Mark S Daskin, Heron E Rodriguez
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  ABSTRACT: The primary goal of a residency program is to prepare trainees for unsupervised care. Duty hour restrictions imposed throughout the prior decade require that residents work significantly fewer hours. Moreover, various stakeholders (e.g. the hospital, mentors, other residents, educators, and patients) require them to prioritize very different activities, often conflicting with their learning goals. Surgical residents' learning goals include providing continuity throughout a patient's pre-, peri-, and post-operative care as well as achieving sufficient surgical experience levels in various procedure types and participating in various formal educational activities, among other things. To complicate matters, senior residents often compete with other residents for surgical experience. This paper features experiments using an optimization model and a real dataset. The experiments test the viability of achieving the above goals at a major academic center using existing models of delivering medical education and training to surgical residents. It develops a detailed multi-objective, two-stage stochastic optimization model with anticipatory capabilities solved over a rolling time horizon. A novel feature of the models is the incorporation of learning curve theory in the objection function. Using a deterministic version of the model, we identify bounds on the achievement of learning goals under existing training paradigms. The computational results highlight the structural problems in the current surgical resident educational system. These results further corroborate earlier findings and suggest an educational system redesign is necessary for surgical medical residents.
  Health Care Management Science 03/2013;
• Article: Developing an adaptive policy for long-term care capacity planning.

  Yue Zhang, Martin L Puterman
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  ABSTRACT: This paper describes a refined methodology for determining long-term care (LTC) capacity levels over a multi-year planning horizon based on a previous study. The problem is to find a capacity level in each year during the planning horizon to meet a wait time service level criterion. Instead of a static policy for capacity planning, we proposal an adaptive policy, where the capacity level required in this year depends on the achieved service level in the last year as the state of the LTC system. We aggregate service levels into a few groups for tractability. Our methodology integrates a discrete event simulation for describing the LTC system and an optimization algorithm to find required capacity levels. We illustrate this methodology through a case study. The results show that the refined methodology overcomes the problems observed in the previous study. It also improves resource utilization greatly. To execute this adaptive policy in practice requires availability of surge or temporary capacity.
  Health Care Management Science 03/2013;
• Article: Recovery bed planning in cardiovascular surgery: a simulation case study.

  Yariv N Marmor, Thomas R Rohleder, David J Cook, Todd R Huschka, Jeffrey E Thompson
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  ABSTRACT: Recovery beds for cardiovascular surgical patients in the intensive care unit (ICU) and progressive care unit (PCU) are costly hospital resources that require effective management. This case study reports on the development and use of a discrete-event simulation model used to predict minimum bed needs to achieve the high patient service level demanded at Mayo Clinic. In addition to bed predictions that incorporate surgery growth and new recovery protocols, the model was used to explore the effects of smoothing surgery schedules and transferring long-stay patients from the ICU. The model projected bed needs that were 30 % lower than the traditional bed-planning approach and the options explored by the practice could substantially reduce the number of beds required.
  Health Care Management Science 03/2013;
• Article: A two-phase approach to scheduling multi-category outpatient appointments - A case study of a women's clinic.

  Xiuli Qu, Yidong Peng, Nan Kong, Jing Shi
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  ABSTRACT: In this paper, we propose a two-phase approach for designing a weekly scheduling template for outpatient clinics providing multiple types of services. In many outpatient clinics, various service types are categorized to address the operational challenge of substantial changeover time between certain pairs of services. In the first phase of our approach, a mixed-integer program is formulated to assign service categories to clinic sessions during a week and determine the optimal number of appointments reserved for each service type in each clinic session. The objective in the first phase is to balance the workload of the providers among clinic sessions. In the second phase, a stochastic mixed-integer program is formulated for each clinic session to assign each contained appointment with a starting time based on several time-based performance measures. To solve the formulated stochastic program, we develop a Monte Carlo sampling based genetic algorithm. The two-phase approach is tested numerically with cases derived from a real women's clinic. Our results demonstrate that the two-phase approach can efficiently find promising weekly appointment scheduling templates for outpatient clinics. In addition, our results suggest that the best suboptimal scheduling templates found become more sensitive to the weighting coefficients of the time-based measures as the provider workload increases.
  Health Care Management Science 03/2013;
• Article: Measuring the efficiencies of visiting nurse service agencies using data envelopment analysis.

  Yuki Kuwahara, Satoko Nagata, Atsuko Taguchi, Takashi Naruse, Hiroyuki Kawaguchi, Sachiyo Murashima
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  ABSTRACT: This study develops a measure of the efficiency of visiting nurse (VN) agencies in Japan, examining the issues related to the measurement of efficiency, and identifying the characteristics that influence efficiency. We have employed a data envelopment analysis to measure the efficiency of 108 VN agencies, using the numbers of 5 types of staff as the input variables and the numbers of 3 types of visits as the output variables. The median efficiency scores of the VN agencies were found to be 0.80 and 1.00 according to the constant returns to scale (CRS) and variable returns to scale (VRS) models, respectively, and the median scale efficiency score was 0.95. This study supports using both the CRS and VRS models to measure the scale efficiency of VN service agencies. We also found that relatively efficient VN agencies filled at least 30 % of staff positions with experienced workers, and so concluded that this characteristic has a direct influence on the length of visits.
  Health Care Management Science 03/2013;
• Article: Analyzing the nursing organizational structure and process from a scheduling perspective.

  Broos Maenhout, Mario Vanhoucke
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  ABSTRACT: The efficient and effective management of nursing personnel is of critical importance in a hospital's environment comprising approximately 25 % of the hospital's operational costs. The nurse organizational structure and the organizational processes highly affect the nurses' working conditions and the provided quality of care. In this paper, we investigate the impact of different nurse organization structures and different organizational processes for a real-life situation in a Belgian university hospital. In order to make accurate nurse staffing decisions, the employed solution methodology incorporates shift scheduling characteristics in order to overcome the deficiencies of the many phase-specific methodologies that are proposed in the academic literature.
  Health Care Management Science 03/2013;
• Article: What is the value of 'me-too' drugs?

  Stephane Régnier
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  ABSTRACT: The objective of this article is to estimate the value of 'follow-on' or 'me-too' drugs from the payer, industry and societal perspectives. Since me-too drugs do not bring additional clinical benefits, they are only valuable to payers if they save costs. An empirical model was constructed to identify the factors affecting whether a me-too drug results in cost savings to the pharmaceutical budgets of payers. These factors included the intensity of promotional spending, price discount and time to entry. Twenty-seven second-entrant products with limited differentiation were identified; their launch dates ranged from 1988 to 2009. On average, me-too drugs launch 2.5 years after the first entrant, with 20 % more promotional investment, and capture 38 % of market share within 4 years. Peak market share is significantly affected by share of voice (p < 0.001) but not price discount (p = 0.77). Launch delay was significant in terms of reducing both market share (p < 0.001) and price (p < 0.05). With a launch price 15 % below the incumbent, cumulative savings from use of a me-too drug peak at over $1000 million, but decrease rapidly after the first entrant becomes generic and only amount to $450 million over the me-too drug's lifecycle. With a price discount less than 10 %, cumulative savings are negative over the life of the me-too drug. Therefore, me-too drugs may be cost saving in the short term, but can represent a cost in the longer term. From a societal perspective, me-too drugs always decrease the economic surplus if they do not grow the market. If me-too drugs grow the market by 20 %, they augment, on average, the economic surplus only if the variable costs (including promotional investment) do not increase by more than $300 million per year.
  Health Care Management Science 02/2013;
• Article: Female labour supply and nursing home prices.

  Thomas K Bauer, Magdalena A Stroka
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  ABSTRACT: Long term care in Germany is provided in nursing homes, by professional ambulatory services and by the patient's relatives at home, with the latter being predominantly provided by women. Given an increasing labour market participation of women, long term care at home by female relatives might become less frequent in the future which in turn may result in rising demand for and hence rising prices for long term care services. This paper builds upon the existing literature on the determinants of nursing home prices and investigates whether the labour market participation and the education level of women are correlated with the prices of nursing homes. To the best of our knowledge, this is the first study using panel data approaches in this field of research. Based on a full sample of nursing homes in Germany for the years 2001, 2003, 2005 and 2007, our empirical results suggest that a high share of full-time employed women aged 50-65 at the district level is not associated with higher prices of nursing homes. Furthermore, we find only weak evidence for a positive correlation of prices with the local average of women's educational level and a negative correlation with part-time employment indicating that price levels are lower in regions with higher shares of part-time employed women.
  Health Care Management Science 02/2013;
• Article: Balancing operating theatre and bed capacity in a cardiothoracic centre.

  John Bowers
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  ABSTRACT: Cardiothoracic surgery requires many expensive resources. This paper examines the balance between operating theatres and beds in a specialist facility providing elective heart and lung surgery. Without both operating theatre time and an Intensive Care bed a patient's surgery has to be postponed. While admissions can be managed, there are significant stochastic features, notably the cancellation of theatre procedures and patients' length of stay on the Intensive Care Unit. A simulation was developed, with clinical and management staff, to explore the interdependencies of resource availabilities and the daily demand. The model was used to examine options for expanding the capacity of the whole facility. Ideally the bed and theatre capacity should be well balanced but unmatched increases in either resource can still be beneficial. The study provides an example of a capacity planning problem in which there is uncertainty in the demand for two symbiotic resources.
  Health Care Management Science 02/2013;
• Article: Predicting 30-day all-cause hospital readmissions.

  Mollie Shulan, Kelly Gao, Crystal Dea Moore
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  ABSTRACT: Hospital readmission rate has been broadly accepted as a quality measure and cost driver. However, success in reducing readmissions has been elusive. In the US, almost 20 % of Medicare inpatients are rehospitalized within 30 days, which amounts to a cost of $17 billion. Given the skyrocketing healthcare cost, policymakers, researchers and payers are focusing more than ever on readmission reduction. Both hospital comparison of readmissions as a quality measure and identification of high-risk patients for post-discharge interventions require accurate predictive modeling. However, most predictive models for readmissions perform poorly. In this study, we endeavored to explore the full potentials of predictive models for readmissions and to assess the predictive power of different independent variables. Our model reached the highest predicting ability (c-statistic =0.80) among all published studies that used administrative data. Our analyses reveal that demographics, socioeconomic variables, prior utilization and Diagnosis-related Group (DRG) all have limited predictive power; more sophisticated patient stratification algorithm or risk adjuster is desired for more accurate readmission predictions.
  Health Care Management Science 01/2013;
• Article: Tactical resource allocation and elective patient admission planning in care processes.

  Peter J H Hulshof, Richard J Boucherie, Erwin W Hans, Johann L Hurink
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  ABSTRACT: Tactical planning of resources in hospitals concerns elective patient admission planning and the intermediate term allocation of resource capacities. Its main objectives are to achieve equitable access for patients, to meet production targets/to serve the strategically agreed number of patients, and to use resources efficiently. This paper proposes a method to develop a tactical resource allocation and elective patient admission plan. These tactical plans allocate available resources to various care processes and determine the selection of patients to be served that are at a particular stage of their care process. Our method is developed in a Mixed Integer Linear Programming (MILP) framework and copes with multiple resources, multiple time periods and multiple patient groups with various uncertain treatment paths through the hospital, thereby integrating decision making for a chain of hospital resources. Computational results indicate that our method leads to a more equitable distribution of resources and provides control of patient access times, the number of patients served and the fraction of allocated resource capacity. Our approach is generic, as the base MILP and the solution approach allow for including various extensions to both the objective criteria and the constraints. Consequently, the proposed method is applicable in various settings of tactical hospital management.
  Health Care Management Science 01/2013;
• Article: Physicians in leadership: the association between medical director involvement and staff-to-patient ratios.

  Ludwig Kuntz, Stefan Scholtes
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  ABSTRACT: In a hospital environment that demands a careful balance between commercial and clinical interests, the extent to which physicians are involved in hospital leadership varies greatly. This paper assesses the influence of the extent of this involvement on staff-to-patient ratios. Using data gathered from 604 hospitals across Germany, this study evidences the positive relationship between a full-time medical director (MD) or heavily involved part-time MD and a higher staff-to-patient ratio. The data allows us to control for a range of confounding variables, such as size, rural/urban location, ownership structure, and case-mix. The results contribute to the sparse body of empirical research on the effect of clinical leadership on organizational outcomes.
  Health Care Management Science 11/2012;