Measuring and optimizing accessibility to emergency medical services

Emergency medical services (EMSs) undertake the responsibility of providing rapid medical care to patients suffering from unexpected illnesses or injuries and transferring them to definitive care facilities. This research concerns several research gaps that are associated with different EMS trips, real-time traffic conditions, improving EMS efficiency and equalities. This research aims to develop GIS-based spatial optimization methods to improve service efficiency and equality in EMS systems. Specifically, the research intends to achieve the following goals: (1) to measure spatiotemporal accessibility to EMS; (2) to improve EMS efficiency and provision through spatial optimization approaches; (3) to reduce urban-rural inequalities in EMS accessibility and coverage using spatial optimization approaches. The proposed approaches are applied in three empirical studies in Wuhan, China. To achieve the first objective, the proximity and the enhanced two-step floating catchment method (E-2SFCA) are adopted to evaluate spatiotemporal accessibility. First, the EMS travel time is estimated for the two related trips as an overall EMS journey: one is from the nearest EMS station to the scene (Trip 1), and the other is from the scene to the nearest emergency hospital (Trip 2). Then, the E-2SFCA method is employed to calculate the accessibility score that integrates both geographic accessibility and availability of EMS. Travel time is estimated by using both static road network with standard speed limits and online map service considering real-time traffic. To achieve the second objective, two facility location models are proposed to improve EMS service coverages for two-related trips (Trips 1 and 2). The first model maximizes the amount of demand covered by both ambulance coverage (EMS station – demand) and hospital coverage (demand – hospital). The second model maximizes the amount of demand that can be served by both ambulance coverage and overall coverage (EMS station – demand – hospital). To achieve the third objective, two bi-objective optimization models are developed. The two models have the same primary objective to maximize the total covered demand by ambulance. The second objective is to minimize one of the two inequality measures: one focuses on accessibility of uncovered rural people, and the other concerns the urban-rural inequality in service coverage. For the first empirical study with respect to spatiotemporal access to EMS, different spatial patterns are found for the three trips (two partial trips and the overall trip). Good accessibility to one trip cannot guarantee good accessibility to another trip. In addition, urban-rural inequalities in EMS accessibility and coverage are observed. Finally, it is observed that real-time traffic conditions greatly affect EMS accessibility, particularly in urban districts. Specifically, the accessibility of EMS becomes poor during the morning (7-9 am) and evening peak periods (5-7 pm). For the second empirical study in relation to EMS optimization involving two related trips, the results find that the first proposed model can guarantee that more demand to be covered by both ambulance and hospital coverages than the Maximum Coverage Location Problem (MCLP). The second proposed model can ensure that as many people as possible to be served by both ambulance and overall coverage than the work by ReVelle et al. (1976). For the third empirical study attempting to reduce urban-rural inequality in EMS, the results show that the first bi-objective model can improve EMS accessibility of uncovered rural demand, and the second model can reduce EMS service coverages between urban and rural areas. However, the improvement EMS inequalities between urban and rural areas leads to a cost of a decrease in the total covered population, especially in urban areas. Regarding policy implications, this research suggests that different EMS trips and traffic conditions should be considered when measuring spatial accessibility to EMS. Spatial optimization research can help improving service efficiency and reduce regional equalities in EMS systems. The work presented in this thesis can aid the planning practice of public services like EMS and provide decision support for policymakers

An Optimization Approach to Improve Equitable Access to Local Parks

Local parks are public resources that promote human and environmental welfare. Unfortunately, park inequities are commonplace as historically marginalized groups may have insufficient access. Platforms exist to identify the geographical areas that would benefit from future park improvements. However, these platforms do not include budget, infrastructure, and environmental considerations that are relevant to park location decisions. To support recreational and government agencies in addressing inequities in the distribution and quality of parks, we propose a mixed-integer program that minimizes insufficient access, defined as weighted deviations across multiple categories. We consider an equity-focused min-max objective and an overall objective to minimize total weighted deviations. We apply the model to a case study of Asheville, North Carolina. We conduct extensive data collection to parameterize the model. In policy analyses, we consider the effects of available budget, planning horizons, strategic demographic priorities, and thresholds of access. The model reflects user-defined criteria and goals, and the results suggest that the framework may be generalizable to other cities. This study serves as the first step in the development and incorporation of mathematical modeling to achieve social goals within the recreational setting

Models and algorithms for trauma network design.

Trauma continues to be the leading cause of death and disability in the US for people aged 44 and under, making it a major public health problem. The geographical maldistribution of Trauma Centers (TCs), and the resulting higher access time to the nearest TC, has been shown to impact trauma patient safety and increase disability or mortality. State governments often design a trauma network to provide prompt and definitive care to their citizens. However, this process is mainly manual and experience-based and often leads to a suboptimal network in terms of patient safety and resource utilization. This dissertation fills important voids in this domain and adds much-needed realism to develop insights that trauma decision-makers can use to design their trauma network. In this dissertation, we develop multiple optimization-based trauma network design approaches focusing minimizing mistriages and, in some cases, ensuring equity in care among regions. To mimic trauma care in practice, several realistic features are considered in our approach, which include the consideration of: (i) both severely and non-severely injured trauma patients and associated mistriages, (ii) intermediate trauma centers (ITCs) along with major trauma centers (MTCs), (iii) three dominant criteria for destination determination, and (iv) mistriages in on-scene clinical assessment of injuries. Our first contribution (Chapter 2) proposes the Trauma Center Location Problem (TCLP) that determines the optimal number and location of major trauma centers (MTCs) to improve patient safety. The bi-objective optimization model for TCLP explicitly considers both types of patients (severe and non-severe) and associated mistriages (specifically, system-related under- and over-triages) as a surrogate for patient safety. These mistriages are estimated using our proposed notional tasking algorithm that attempts to mimic the EMS on-scene decision of destination hospital and transportation mode. We develop a heuristic based on Particle Swarm Optimization framework to efficiently solve realistic problem sizes. We illustrate our approach using 2012 data from the state of OH and show that an optimized network for the state could achieve 31.5% improvement in patient safety compared to the 2012 network with the addition of just one MTC; redistribution of the 21 MTCs in the 2012 network led to a 30.4% improvement. Our second contribution (Chapter 3) introduces a Nested Trauma Network Design Problem (NTNDP), which is a nested multi-level, multi-customer, multi-transportation, multi-criteria, capacitated model. The NTNDP model has a bi-objective of maximizing the weighted sum of equity and effectiveness in patient safety. The proposed model includes intermediate trauma centers (TCs) that have been established in many US states to serve as feeder centers to major TCs. The model also incorporates three criteria used by EMS for destination determination; i.e., patient/family choice, closest facility, and protocol. Our proposed ‘3-phase’ approach efficiently solves the resulting MIP model by first solving a relaxed version of the model, then a Constraint Satisfaction Problem, and a modified version of the original optimization problem (if needed). A comprehensive experimental study is conducted to determine the sensitivity of the solutions to various system parameters. A case study is presented using 2019 data from the state of OH that shows more than 30% improvement in the patient safety objective. In our third contribution (Chapter 4), we introduce Trauma Network Design Problem considering Assessment-related Mistriages (TNDP-AM), where we explicitly consider mistriages in on-scene assessment of patient injuries by the EMS. The TNDP-AM model determines the number and location of major trauma centers to maximize patient safety. We model assessment-related mistriages using the Bernoulli random variable and propose a Simheuristic approach that integrates Monte Carlo Simulation with a genetic algorithm (GA) to solve the problem efficiently. Our findings indicate that the trauma network is susceptible to assessment-related mistriages; specifically, higher mistriages in assessing severe patients may lead to a 799% decrease in patient safety and potential clustering of MTCs near high trauma incidence rates. There are several implications of our findings to practice. State trauma decision-makers can use our approaches to not only better manage limited financial resources, but also understand the impact of changes in operational parameters on network performance. The design of training programs for EMS providers to build standardization in decision-making is another advantage

Approximate Dynamic Programming: Health Care Applications

This dissertation considers different approximate solutions to Markov decision problems formulated within the dynamic programming framework in two health care applications. Dynamic formulations are appropriate for problems which require optimization over time and a variety of settings for different scenarios and policies. This is similar to the situation in a lot of health care applications for which because of the curses of dimensionality, exact solutions do not always exist. Thus, approximate analysis to find near optimal solutions are motivated. To check the quality of approximation, additional evidence such as boundaries, consistency analysis, or asymptotic behavior evaluation are required. Emergency vehicle management and dose-finding clinical trials are the two heath care applications considered here in order to investigate dynamic formulations, approximate solutions, and solution quality assessments. The dynamic programming formulation for real-time ambulance dispatching and relocation policies, response-adaptive dose-finding clinical trial, and optimal stopping of adaptive clinical trials is presented. Approximate solutions are derived by multiple methods such as basis function regression, one-step look-ahead policy, simulation-based gridding algorithm, and diffusion approximation. Finally, some boundaries to assess the optimality gap and a proof of consistency for approximate solutions are presented to ensure the quality of approximation

An Optimisation-based Framework for Complex Business Process: Healthcare Application

The Irish healthcare system is currently facing major pressures due to rising demand, caused by population growth, ageing and high expectations of service quality. This pressure on the Irish healthcare system creates a need for support from research institutions in dealing with decision areas such as resource allocation and performance measurement. While approaches such as modelling, simulation, multi-criteria decision analysis, performance management, and optimisation can – when applied skilfully – improve healthcare performance, they represent just one part of the solution. Accordingly, to achieve significant and sustainable performance, this research aims to develop a practical, yet effective, optimisation-based framework for managing complex processes in the healthcare domain. Through an extensive review of the literature on the aforementioned solution techniques, limitations of using each technique on its own are identified in order to define a practical integrated approach toward developing the proposed framework. During the framework validation phase, real-time strategies have to be optimised to solve Emergency Department performance issues in a major hospital. Results show a potential of significant reduction in patients average length of stay (i.e. 48% of average patient throughput time) whilst reducing the over-reliance on overstretched nursing resources, that resulted in an increase of staff utilisation between 7% and 10%. Given the high uncertainty in healthcare service demand, using the integrated framework allows decision makers to find optimal staff schedules that improve emergency department performance. The proposed optimum staff schedule reduces the average waiting time of patients by 57% and also contributes to reduce number of patients left without treatment to 8% instead of 17%. The developed framework has been implemented by the hospital partner with a high level of success

Park Equity Modeling: A Case Study of Asheville, North Carolina

Parks and greenspaces are publicly available entities that serve the vital purpose of promoting multiple aspects of human welfare. Unfortunately, the existence of park disparities is commonplace within the park setting. Specifically, marginalized individuals encounter limited park access, insufficient amenity provision, and poor maintenance. To remedy these disparities, we propose a process in which we select candidate park facilities and utilize facility location models to determine the optimal primary parks from both existing and candidate sites. We note that platforms currently exist to identify the geographical areas where residents lack sufficient access to parks. However, these platforms do not yet integrate the variety of demographic, infrastructural, dimensional, monetary, and environmental factors to guide decisions of future park locations. Further, these tools do not have the ability to recommend multiple park sites by considering how simultaneous park selection affects overall access. To support park and government agencies in their aims to improve the distribution and quality of greenspaces, we present a case study of park selection optimization modeling in Asheville, North Carolina. We propose mixed-integer programs that maximize park access across different dimensions of equity. The developed facility location models serve as intuitive preliminary tools to support proactive park and greenspace planning initiatives. Our research process includes developing an understanding of current park and greenspace inequities. We determine the key indicators of park goodness in order to formulate and analyze facility location models that promote park and greenspace equity. We begin this study with an introduction to park and greenspace benefits and disparities and discuss current park distribution and equity initiatives within Asheville, North Carolina. We explore literature concerning park requirements and facility location modeling. We represent the components of park goodness and equity in the formulation of two facility location models and include the data collection, analysis, and visualization of Asheville to depict model elements. Finally, we present and discuss the results of multiple analyses to recommend new park locations in Asheville and to determine the effectiveness of our models as a tool to guide strategic park location decisions based upon user-defined criteria and goals. This study serves as an initial step in the further development and incorporation of mathematical modeling to achieve social goals within the recreational setting