Long term evaluation of operating theater planning policies

This paper addresses Operating Room (OR) planning policies in elective surgery. In particular, we investigate long-term policies for determining the Master Surgical Schedule (MSS) throughout the year, analyzing the tradeoff between organizational simplicity, favored by an MSS that does not change completely every week, and quality of the service offered to the patients, favored by an MSS that dynamically adapts to the current state of waiting lists, the latter objective being related to a lean approach to hospital management. Surgical cases are selected from the waiting lists according to several parameters, including surgery duration, waiting time and priority class of the operations. We apply the proposed models to the operating theater of a public, medium-size hospital in Empoli, Italy, using Integer Linear Programming formulations, and analyze the scalability of the approach on larger hospitals. The simulations point out that introducing a very limited degree of variability in MSS in terms of OR sessions assignment can largely pay off in terms of resource efficiency and due date performance

Simulation analysis of the consequences of shifting the balance of health care: a system dynamics approach

Objectives: The shift in the balance of health care, bringing services 'closer to home', is a well-established trend. This study sought to provide insight into the consequences of this trend, in particular the stimulation of demand, by exploring the underlying feedback structure. Methods: We constructed a simulation model using the system dynamics method, which is specifically designed for the analysis of feedback structure. The model was calibrated to two cases of the shift in cardiac catheterization services in the UK. Data sources included archival data, observations and interviews with senior health care professionals. Key model outputs were the basic trends displayed by waiting lists, average waiting times, cumulative patient referrals, cumulative patient activity and cumulative overall costs. Results: Demand was stimulated in both cases via several different mechanisms. We revealed the roles for clinical guidelines and capacity changes, and the typical responses to imbalances between supply and demand. Our analysis also demonstrated the potential benefits of changing the goals that drive activity by seeking a waiting list goal rather than a waiting time goal. Conclusions: Appreciating the wider consequences of shifting the balance of care is essential if services are to be improved overall. The underlying feedback mechanisms of both intended and unintended effects need to be understood. Using a systemic approach, more effective policies may be designed through coordinated programmes rather than isolated initiatives, which may have only a limited impact

The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World

Critics of the U.S. health care system frequently point to other countries as models for reform. They point out that many countries spend far less on health care than the United States yet seem to enjoy better health outcomes. The United States should follow the lead of those countries, the critics say, and adopt a government- run, national health care system. However, a closer look shows that nearly all health care systems worldwide are wrestling with problems of rising costs and lack of access to care. There is no single international model for national health care, of course. Countries vary dramatically in the degree of central control, regulation, and cost sharing they impose, and in the role of private insurance. Still, overall trends from national health care systems around the world suggest the following: Health insurance does not mean universal access to health care. In practice, many countries promise universal coverage but ration care or have long waiting lists for treatment. Rising health care costs are not a uniquely American phenomenon. Although other countries spend considerably less than the United States on health care, both as a percentage of GDP and per capita, costs are rising almost everywhere, leading to budget deficits, tax increases, and benefit reductions. In countries weighted heavily toward government control, people are most likely to face waiting lists, rationing, restrictions on physician choice, and other obstacles to care. Countries with more effective national health care systems are successful to the degree that they incorporate market mechanisms such as competition, cost sharing, market prices, and consumer choice, and eschew centralized government control. Although no country with a national health care system is contemplating abandoning universal coverage, the broad and growing trend is to move away from centralized government control and to introduce more market-oriented features. The answer then to America's health care problems lies not in heading down the road to national health care but in learning from the experiences of other countries, which demonstrate the failure of centralized command and control and the benefits of increasing consumer incentives and choice

Waiting lists, waiting times and admissions: an empirical analysis at hospital and general practice level

We report an empirical analysis of the responses of the supply and demand for secondary care to waiting list size and waiting times. Whereas previous empirical analyses have used data aggregated to area level, our analysis is novel in that it focuses on the supply responses of a single hospital and the demand responses of the GP practices it serves, and distinguishes between outpatient visits, inpatient admissions, daycase treatment and emergency admissions. The results are plausible and in line with the theoretical model. For example: the demand from practices for outpatient visits is negatively affected by waiting times and distance to the hospital. Increases in waiting times and waiting lists lead to increases in supply; the supply of elective inpatient admissions is affected negatively by current emergency admissions and positively by lagged waiting list and waiting time. We use the empirical results to investigate the dynamic responses to one off policy measures to reduce waiting times and lists by increasing supply

Modelling the Dynamics of a Public Health Care System: Evidence from Time-Series Data

The English National Health Service was established in 1948, and has therefore yielded some long time series data on health system performance. Waiting times for inpatient care have been a persistent cause of policy concern since the creation of the NHS. This paper develops a theoretical model of the dynamic interaction between key indicators of health system performance. It then investigates empirically the relationship between hospital activity, waiting times and population characteristics using aggregate time-series data for the NHS over the period 1952-2005. Structural Vector Auto-Regression suggests that in the long run: a) higher activity is associated with lower waiting times (elasticity = -0.9%); b) a higher proportion of old population is associated with higher waiting times (elasticity = 1.6%). In the short run, higher lagged waiting time leads to higher activity (elasticity = 0.2%). We also find that shocks in waiting times are countered by higher activity, so the effect is only temporary, while shocks in activity have a permanent effect. We conclude that policies to reduce waiting times should focus on initiatives that increase hospital activity.Waiting times, Dynamics, Vector Auto-Regression.

Equitable allocation of extrarenal organs: With special reference to the liver

A national plan is proposed for the equitable allocation of extrarenal organs, with particular reference to the liver. The principles of the plan include preferential use of the organs in the local and regional area of procurement, with national listing of the organs left over after the original cut. At each of the local, regional, and national levels, the allocation is based on total points awarded for medical urgency, time waiting, blood group conformity, and physical location of both donor and recipient. The plan, which should be applicable as well for allocation of hearts, is compatible with international sharing with nearby countries such as Canada

Modelling the Dynamics of a Public Health Care System: Evidence from Time-Series Data

The English National Health Service was established in 1948, and has therefore yielded some long time series data on health system performance. Waiting times for inpatient care have been a persistent cause of policy concern since the creation of the NHS. This paper develops a theoretical model of the dynamic interaction between key indicators of health system performance. It then investigates empirically the relationship between hospital activity, waiting times and population characteristics using aggregate time-series data for the NHS over the period 1952— 2005. Structural Vector Auto-Regression suggests that in the long run: a) higher activity is associated with lower waiting times (elasticity = -0.9%); b) a higher proportion of old population is associated with higher waiting times (elasticity = 1.6%). In the short run, higher lagged waiting time leads to higher activity (elasticity = 0.2%). We also find that shocks in waiting times are countered by higher activity, so the effect is only temporary, while shocks in activity have a permanent effect. We conclude that policies to reduce waiting times should focus on initiatives that increase hospital activity.Waiting Times, Dynamics, Vector Auto-Regression

Modelling the feedback effects of reconfiguring health services

The shift in the balance of health care, bringing services ‘closer to home’, is a well-established trend, which has been motivated by the desire to improve the provision of services. However, these efforts may be undermined by the improvements in access stimulating demand. Existing analyses of this trend have been limited to isolated parts of the system with calls to control demand with stricter clinical guidelines or to meet demand with capacity increases. By failing to appreciate the underlying feedback mechanisms, these interventions may only have a limited effect. We demonstrate the contribution offered by system dynamics modelling by presenting a study of two cases of the shift in cardiac catheterization services in the UK. We hypothesize the effects of the shifts in services and produce model output that is not inconsistent with real world data. Our model encompasses several mechanisms by which demand is stimulated. We use the model to clarify the roles for stricter clinical guidelines and capacity increases, and to demonstrate the potential benefits of changing the goals that drive activity