The Incremental Cooperative Design of Preventive Healthcare Networks

This document is the Accepted Manuscript version of the following article: Soheil Davari, 'The incremental cooperative design of preventive healthcare networks', Annals of Operations Research, first published online 27 June 2017. Under embargo. Embargo end date: 27 June 2018. The final publication is available at Springer via http://dx.doi.org/10.1007/s10479-017-2569-1.In the Preventive Healthcare Network Design Problem (PHNDP), one seeks to locate facilities in a way that the uptake of services is maximised given certain constraints such as congestion considerations. We introduce the incremental and cooperative version of the problem, IC-PHNDP for short, in which facilities are added incrementally to the network (one at a time), contributing to the service levels. We first develop a general non-linear model of this problem and then present a method to make it linear. As the problem is of a combinatorial nature, an efficient Variable Neighbourhood Search (VNS) algorithm is proposed to solve it. In order to gain insight into the problem, the computational studies were performed with randomly generated instances of different settings. Results clearly show that VNS performs well in solving IC-PHNDP with errors not more than 1.54%.Peer reviewe

Health care operations management

Health care operations management has become a major topic for health care service providers and society. Operations research already has and further will make considerable contributions for the effective and efficient delivery of health care services. This special issue collects seven carefully selected papers dealing with optimization and decision analysis problems in the field of health care operations management

A heuristic approach to solve the preventive health care problem with budget and congestion constraints

This document is the Accepted Manuscript version of the following article: Soheil Davari, Kemal Kilic, and Siamak Naderi, ‘A heuristic approach to solve the preventive health care problem with budget and congestion constraints’, Applied Mathematics and Computation, Vol. 276, pp. 442-453, March 2016, doi: https://doi.org/10.1016/j.amc.2015.11.073. This manuscript version is made available under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License CC BY NC-ND 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.Preventive health care is of utmost importance to governments since they can make massive savings on health care expenditure and promote the well-being of the society. Preventive care includes many services such as cancer screenings, vaccinations, hepatitis screenings, and smoking cessation programs. Despite the benefits of these services, their uptake is not satisfactory in many countries in the world. This can be attributed to financial barriers, social issues., and other factors. One of the most important barriers for preventive care is accessibility to proper services, which is a function of various qualitative and quantitative factors such as the distance to travel, waiting time, vicinity of facilities to other attractive facilities (such as shopping malls), and even the cleanliness of the facilities. Statistics show that even a small improvement in people’s participation can save massive amounts of money for any government and improve the well-being of the people in a society. This paper addresses the problem of designing a preventive health care network considering impatient clients, and budget constraints. The objective is to maximize the accessibility of services to people. We model the problem as a mixed-integer programming problem with budget constraints, and congestion considerations. An efficient variable neighborhood search procedure is proposed and computational experiments are performed on a large set of instances.Peer reviewedFinal Accepted Versio

Mobilizing medicine: a design response to the accessibility and cost issues in health care

textNationally, there is increasing concern over the accessibility, cost, and quality of the American health care system. While the quality of the care given is generally out of the control of designers, it has received increased attention in recent years, as is evidenced in the trends of healing gardens, private patient rooms, and improved social settings. As beneficial as these trends are to the patients they serve, they often have a negative effect on overall accessibility and cost of care due to the constant construction and renovations needed and their largely urban presence. While quality health care is very important and should not suffer as a result, how can designers address nonenvironmental sustainability issues of cost and access in the American healthcare system? Due to the trend in increasing cases of chronic illness, as opposed to more pathogenic ailments of the past, the necessity for all healthcare settings to be highly controlled and sterile environments should be reevaluated. While less popular and not as fully developed as the typical facilities most Americans are familiar with, an increase in mobilized health care units could be a solution to the lack of economic and social access and sustainability in the current healthcare model while still providing safe, quality care. By examining current instances of mobile clinics, I will explore the design requirements necessary to make mobile clinics accessible and cost effective. In addition, I will look for facilitators and barriers to these systems, such as improvements in mobile communication technologies and lack of stakeholder support.Architectur

Planning a Better Future for Dual Eligible Elderly in Montgomery County

Older adults who are dual eligible (who qualify for both Medicare and Medicaid) face a daunting gauntlet of challenges in healthcare. Despite comprehensive coverage through Medicare and Medicaid, the lack of coordination between the two systems creates often insurmountable problems of access and delivery. Federally-funded Medicare lacks coordination and integration with federal-state funded Medicaid. Ironically, it is these dual eligible individuals who so desperately need healthcare since they have a higher incidence of cognitive impairment (including Alzheimer's Disease), mental disorders, diabetes, pulmonary disease and strokes. Further, they are more vulnerable and frail, have lower incomes, and are more isolated than are non-dual eligible elderly. These problems, in turn, contribute to significant challenges with housing, food and transportation. The challenges with access to care are tragic, expensive and avoidable.The high care needs of dual eligible individuals and the associated costs have driven states and the federalgovernment to seek ways to better integrate and coordinate their care. The Affordable Care Act (2010) is teemingwith initiatives, demonstrations, and new opportunities premised on finding a way to better meet dual eligibleindividuals' healthcare needs at a cost-effective rate. While little has yet been done at the state level, localproviders are starting to test innovative approaches to delivering better care to dual eligible individuals.This report summarizes state and federal initiatives and opportunities for delivering better care to dual eligible elderly. It also presents the efforts underway at the County level and by local providers. Following the informational section of the report, the Workgroup presents nine systems change recommendations to better improve the care provided to Montgomery County's dual eligible elderly. The recommendations may stand alone, each reflecting their own systems change, or may be combined in a more encompassing effort at service delivery system overhaul.There are numerous federal opportunities for delivering better care to frail populations. Some of them are specifically targeted towards the dual eligible population and others are targeted towards other populations, but include a considerable number of dual eligible individuals. In the report, we describe five different types ofapproaches and describe examples of each

Feasibility and Coverage of Implementing Intermittent Preventive Treatment of Malaria in Pregnant women Contacting Private or Public Clinics in Tanzania: Experience-based Viewpoints of Health Managers in Mkuranga and Mufindi districts.

Evidence on healthcare managers' experience on operational feasibility of malaria intermittent preventive treatment for malaria during pregnancy (IPTp) using sulphadoxine-pyrimethamine (SP) in Africa is systematically inadequate. This paper elucidates the perspectives of District Council Health Management Team (CHMT)s regarding the feasibility of IPTp with SP strategy, including its acceptability and ability of district health care systems to cope with the contemporary and potential challenges. The study was conducted in Mkuranga and Mufindi districts. Data were collected between November 2005 and December 2007, involving focus group discussion (FGD) with Mufindi CHMT and in-depth interviews were conducted with few CHMT members in Mkuranga where it was difficult to summon all members for FGD. Participants in both districts acknowledged the IPTp strategy, considering the seriousness of malaria in pregnancy problem; government allocation of funds to support healthcare staff training programmes in focused antenatal care (fANC) issues, procuring essential drugs distributed to districts, staff remuneration, distribution of fANC guidelines, and administrative activities performed by CHMTs. The identified weaknesses include late arrival of funds from central level weakening CHMT's performance in health supervision, organising outreach clinics, distributing essential supplies, and delivery of IPTp services. Participants anticipated the public losing confidence in SP for IPTp after government announced artemither-lumefantrine (ALu) as the new first-line drug for uncomplicated malaria replacing SP. Role of private healthcare staff in IPTp services was acknowledged cautiously because CHMTs rarely supplied private clinics with SP for free delivery in fear that clients would be required to pay for the SP contrary to government policy. In Mufindi, the District Council showed a strong political support by supplementing ANC clinics with bottled water; in Mkuranga such support was not experienced. A combination of health facility understaffing, water scarcity and staff non-adherence to directly observed therapy instructions forced healthcare staff to allow clients to take SP at home. Need for investigating in improving adherence to IPTp administration was emphasised. High acceptability of the IPTp strategy at district level is meaningless unless necessary support is assured in terms of number, skills and motivation of caregivers and availability of essential supplies

Effect of Preventive Primary Care Outreach on Health Related Quality of Life Among Older Adults at Risk of Functional Decline: Randomised Controlled Trial

Objective: To evaluate the impact of a provider initiated primary care outreach intervention compared with usual care among older adults at risk of functional decline. Design: Randomised controlled trial. Setting: Patients enrolled with 35 family physicians in five primary care networks in Hamilton, Ontario, Canada. Participants: Patients were eligible if they were 75 years of age or older and were not receiving home care services. Of 3166 potentially eligible patients, 2662 (84%) completed the validated postal questionnaire used to determine risk of functional decline. Of 1724 patients who met the risk criteria, 769 (45%) agreed to participate and 719 were randomised. Intervention: The 12 month intervention, provided by experienced home care nurses in 2004-6, consisted of a comprehensive initial assessment using the resident assessment instrument for home care; collaborative care planning with patients, their families, and family physicians; health promotion; and referral to community health and social support services. Main outcome measures: Quality adjusted life years (QALYs), use and costs of health and social services, functional status, self rated health, and mortality. Results: The mean difference in QALYs between intervention and control patients during the study period was not statistically significant (0.017, 95% confidence interval ?0.022 to 0.056; P=0.388). The mean difference in overall cost of prescription drugs and services between the intervention and control groups was not statistically significant, (-$C165 (£107; 118;$162), 95% confidence interval -$C16 545 to$$16 214; P=0.984). Changes over 12 months in functional status and self rated health were not significantly different between the intervention and control groups. Ten patients died in each group. Conclusions: The results of this study do not support adoption of this preventive primary care intervention for this target population of high risk older adults

Improve primary care performance through operations management: An application to emergency care and preventive care

El propósito principal de esta tesis es aplicar el método de gestión de operaciones para mejorar el rendimiento de los responsables de proporcionar atención sanitaria en relación con dos componentes principales de la atención primaria: atención de urgencia y atención primaria. Durante muchos años, en la atención sanitaria se han aplicado los sistemas de gestión de operaciones (OM) y de investigación de operaciones (OR) con la finalidad de mejorar la eficiencia en la prestación de los servicios sanitarios. El núcleo del sistema de atención médica es la atención sanitaria, cuyas funciones principales incluyen el suministro de un punto de entrada, la prestación de atención médica y preventiva fundamental y ayudar a los pacientes a coordinar y a integrar la atención, aspectos que son fundamentales de cara a mejorar no solo el resultado sanitario de los pacientes, sino también el rendimiento en términos de coste de todo el sistema sanitario (Starfield 1998). En un estudio sobre el rendimiento de la atención primaria y del sistema de salud (Schoen et al., 2004), en EE. UU. se registró un índice de utilización del departamento de urgencias (ED) muy superior al de otros tres países, el cual venía acompañado de un menor porcentaje de adultos que dispusieran de un doctor, un lugar o una clínica habitual donde acudir al caer enfermos. Por este motivo, el capítulo 2 de esta disertación aborda la mejora del departamento de salas de urgencia a través del rediseño del proceso. Otro hallazgo fundamental de la encuesta es que Canadá cuenta con el menor índice de chequeos en términos de prueba de Papanicolaou y mamografías. Debido a la importancia de la atención preventiva para salvar vidas y reducir costes, el capítulo 3 de esta disertación analiza cómo mejorar el programa de atención preventiva financiado por el gobierno a través del diseño de la red. El capítulo 2 establece el contexto de un departamento de urgencias (ED) en un hospital terciario con un censo anual de 55 000 pacientes, y analiza la forma en la que el proceso de rediseño de una prueba sanguínea específica tiene un determinado impacto sobre la congestión del ED. De forma más específica, analizamos en cambio en tres magnitudes de rendimiento después de que el análisis de la muestra de sangre del paciente para determinar los niveles de troponina fuera trasladada del laboratorio central del laboratorio al interior del ED. Mediante la teoría de la asignación de colas de prioridad, generamos hipótesis sobre las siguientes medidas de rendimiento: tiempo de espera (definido como la diferencia de tiempo entre el registro de entrada del paciente y la asignación de cama), tiempo de servicio (definido como la diferencia de tiempo entre la asignación de cama y la distribución, el metabolismo y la eliminación de un fármaco) y calidad del servicio (definido como el índice de revisión de los pacientes tras 72 horas). Mediante un modelo de diferencias en diferencias, determinamos que el rediseño del proceso está asociado con unas mejoras estadísticamente significativas en casi todas las mediciones de rendimiento operativo. Concretamente, encontramos que la adopción de POCT está asociada a una reducción del 21,6 % en el tiempo de servicio entre los pacientes objeto de la prueba durante las horas punta, y en una reducción de entre el 5,9 % y el 35,5 % en el tiempo de espera en función de la categoría de prioridad del paciente durante esas mismas horas punta. Además, encontramos que la adopción de un POCT estaba asociada con una mejora de la calidad del servicio, puesto que la probabilidad de recaída pronosticada se redujo en un 0,64 % durante su uso. También descubrimos importantes efectos indirectos a través de todo el sistema en pacientes que no habían sido objeto de un POCT (pacientes que no son objeto de prueba). En otras palabras, la adopción de un POCT está asociada con una reducción del tiempo de espera entre estos pacientes que no son objeto de prueba de un 4,73 % y a una reducción del 11,6 % en el tiempo de espera en función de la categoría de prioridad de los pacientes durante las horas punta. Al examinar el impacto del POCT entre ambas poblaciones de pacientes, tanto los que fueron sometidos a la prueba como los que no, se pudo determinar que esta investigación es única a la hora de identificar los grandes beneficios en el sistema que pueden lograrse a través del rediseño del proceso asociado al ED. El tercer capítulo de esta tesis emplea un modelo de elección de preferencias para analizar las prioridades del cliente en la atención preventiva desde la perspectiva de la configuración del servicio. Aplicamos el modelo en el contexto de un programa de chequeos asociados con el cáncer de mama financiado por el gobierno en Montreal (Canadá), con el fin de identificar las contrapartidas que reciben los participantes del programa a la hora de acceder a un conjunto de instalaciones con diferentes configuraciones de servicio basadas en sus auténticas preferencias. De forma más concreta, analizamos estas preferencias en relación con el tiempo de espera para obtener cita, el tiempo de desplazamiento a la clínica en la que se vaya a practicar el chequeo, la disponibilidad del aparcamiento de la clínica, el horario de apertura de la clínica, el tiempo de espera dentro de la clínica el día del chequeo, la preparación del personal de enfermería, el proceso de chequeo y el tiempo de espera para recibir el resultado. Pudimos comprobar que la preparación del personal de enfermería (es decir, si son capaces de responder preguntas relacionadas con el chequeo o con el cáncer de mama) y el tiempo de espera para obtener una cita eran los factores más determinantes a la hora de elegir una clínica, seguidos de cerca por la disponibilidad de aparcamiento. Mediante el análisis de clases latentes también podemos confirmar que, al contrario de lo apuntado por otras investigaciones, no existe una heterogeneidad clara entre los participantes del programa. Nuestro modelo Arena de simulación muestra que tener en cuenta las preferencias del cliente en el diseño de las configuraciones del servicio mejorará notablemente tanto el nivel de congestión como el índice de participación en las nuevas pruebas. Como conclusión de ambos capítulos, esta tesis trata de generar implicaciones en términos de gestión en lo que respecta a la configuración de la atención sanitaria que puedan ayudar a mejorar la calidad del servicio mediante el uso de un enfoque de metodología empírica. Vemos que pueden acometerse importantes mejoras en los servicios existentes a través del rediseño del proceso de servicio y de la comprensión de las preferencias del cliente, sin necesidad de revisar todo el sistema de atención sanitaria

Residual barriers for utilization of maternal and child health services: community perceptions from rural Pakistan.

Low utilization of maternal and child care services in rural areas has constrained Pakistan from meeting targets of Millennium Development Goals (MDGs) 4 and 5. This study explores community barriers in accessing Maternal and Child Health (MCH) services in ten remote rural districts of Pakistan. It further presents how the barriers differ across a range of MCH services, and also whether the presence of Community Health Workers (CHWs) reduces client barriers. Qualitative methods were used involving altogether sixty focus group discussions with mothers, their spouses and community health workers. Low awareness, formidable distances, expense, and poorly functional services were the main barriers reported, while cultural and religious restrictions were lesser reported. For preventive services including antenatal care (ANC), facility deliveries, postnatal care (PNC), childhood immunization and family planning, the main barrier was low awareness. Conversely, formidable distances and poorly functional services were the main reported constraints in the event of maternal complications and acute child illnesses. The study also found that clients residing in areas served by CHWs had better awareness only of ANC and family planning, while other MCH services were overlooked by the health worker program. The paper highlights that traditional policy emphasis on health facility infrastructure expansion is not likely to address poor utilization rates in remote rural areas. Preventive MCH services require concerted attention to building community awareness, task shifting from facility to community for services provision, and re-energization of CHW program. For maternal and child emergencies there is strong community demand to utilize health facilities, but this will require catalytic support for transport networks and functional health care centers