A systematic literature review of operational research methods for modelling patient flow and outcomes within community healthcare and other settings

An ambition of healthcare policy has been to move more acute services into community settings. This systematic literature review presents analysis of published operational research methods for modelling patient flow within community healthcare, and for modelling the combination of patient flow and outcomes in all settings. Assessed for inclusion at three levels – with the references from included papers also assessed – 25 “Patient flow within community care”, 23 “Patient flow and outcomes” papers and 5 papers within the intersection are included for review. Comparisons are made between each paper’s setting, definition of states, factors considered to influence flow, output measures and implementation of results. Common complexities and characteristics of community service models are discussed with directions for future work suggested. We found that in developing patient flow models for community services that use outcomes, transplant waiting list may have transferable benefits

Assessing the number of users who are excluded by domestic heating controls

This is the pre-print version of the Article. This Article is also referred to as: "Assessing the 'Design Exclusion' of Heating Controls at a Low-Cost, Low-Carbon Housing Development". - Copyright @ 2011 Taylor & FrancisSpace heating accounts for almost 60% of the energy delivered to housing which in turn accounts for nearly 27% of the total UK's carbon emissions. This study was conducted to investigate the influence of heating control design on the degree of ‘user exclusion’. This was calculated using the Design Exclusion Calculator, developed by the Engineering Design Centre at the University of Cambridge. To elucidate the capability requirements of the system, a detailed hierarchical task analysis was produced, due to the complexity of the overall task. The Exclusion Calculation found that the current design placed excessive demands upon the capabilities of at least 9.5% of the UK population over 16 years old, particularly in terms of ‘vision’, ‘thinking’ and ‘dexterity’ requirements. This increased to 20.7% for users over 60 years old. The method does not account for the level of numeracy and literacy and so the true exclusion may be higher. Usability testing was conducted to help validate the results which indicated that 66% of users at a low-carbon housing development could not programme their controls as desired. Therefore, more detailed analysis of the cognitive demands placed upon the users is required to understand where problems within the programming process occur. Further research focusing on this cognitive interaction will work towards a solution that may allow users to behave easily in a more sustainable manner

Death and Emergency Readmission of Infants Discharged After Interventions for Congenital Heart Disease: A National Study of 7643 Infants to Inform Service Improvement.

Improvements in hospital-based care have reduced early mortality in congenital heart disease. Later adverse outcomes may be reducible by focusing on care at or after discharge. We aimed to identify risk factors for such events within 1 year of discharge after intervention in infancy and, separately, to identify subgroups that might benefit from different forms of intervention.Cardiac procedures performed in infants between 2005 and 2010 in England and Wales from the UK National Congenital Heart Disease Audit were linked to intensive care records. Among 7976 infants, 333 (4.2%) died before discharge. Of 7643 infants discharged alive, 246 (3.2%) died outside the hospital or after an unplanned readmission to intensive care (risk factors were age, weight-for-age, cardiac procedure, cardiac diagnosis, congenital anomaly, preprocedural clinical deterioration, prematurity, ethnicity, and duration of initial admission; c-statistic 0.78 [0.75-0.82]). Of the 7643, 514 (6.7%) died outside the hospital or had an unplanned intensive care readmission (same risk factors but with neurodevelopmental condition and acquired cardiac diagnosis and without preprocedural deterioration; c-statistic 0.78 [0.75-0.80]). Classification and regression tree analysis were used to identify 6 subgroups stratified by the level (3-24%) and nature of risk for death outside the hospital or unplanned intensive care readmission based on neurodevelopmental condition, cardiac diagnosis, congenital anomaly, and duration of initial admission. An additional 115 patients died after planned intensive care admission (typically following elective surgery).Adverse outcomes in the year after discharge are of similar magnitude to in-hospital mortality, warrant service improvements, and are not confined to diagnostic groups currently targeted with enhanced monitoring

Identifying improvements to complex pathways: evidence synthesis and stakeholder engagement in infant congenital heart disease

OBJECTIVES: Many infants die in the year following discharge from hospital after surgical or catheter intervention for congenital heart disease (3–5% of discharged infants). There is considerable variability in the provision of care and support in this period, and some families experience barriers to care. We aimed to identify ways to improve discharge and postdischarge care for this patient group. DESIGN: A systematic evidence synthesis aligned with a process of eliciting the perspectives of families and professionals from community, primary, secondary and tertiary care. SETTING: UK. RESULTS: A set of evidence-informed recommendations for improving the discharge and postdischarge care of infants following intervention for congenital heart disease was produced. These address known challenges with current care processes and, recognising current resource constraints, are targeted at patient groups based on the number of patients affected and the level and nature of their risk of adverse 1-year outcome. The recommendations include: structured discharge documentation, discharging certain high-risk patients via their local hospital, enhanced surveillance for patients with certain (high-risk) cardiac diagnoses and an early warning tool for parents and community health professionals. CONCLUSIONS: Our recommendations set out a comprehensive, system-wide approach for improving discharge and postdischarge services. This approach could be used to address challenges in delivering care for other patient populations that can fall through gaps between sectors and organisations

Semantic Metrics for Analysis of Software

A recently conceived suite of object-oriented software metrics focus is on semantic aspects of software, in contradistinction to traditional software metrics, which focus on syntactic aspects of software. Semantic metrics represent a more human-oriented view of software than do syntactic metrics. The semantic metrics of a given computer program are calculated by use of the output of a knowledge-based analysis of the program, and are substantially more representative of software quality and more readily comprehensible from a human perspective than are the syntactic metrics

Definition of important early morbidities related to paediatric cardiac surgery

BACKGROUND: Morbidity is defined as a state of being unhealthy or of experiencing an aspect of health that is "generally bad for you", and postoperative morbidity linked to paediatric cardiac surgery encompasses a range of conditions that may impact the patient and are potential targets for quality assurance. METHODS: As part of a wider study, a multi-disciplinary group of professionals aimed to define a list of morbidities linked to paediatric cardiac surgery that was prioritised by a panel reflecting the views of both professionals from a range of disciplines and settings as well as parents and patients. RESULTS: We present a set of definitions of morbidity for use in routine audit after paediatric cardiac surgery. These morbidities are ranked in priority order as acute neurological event, unplanned re-operation, feeding problems, the need for renal support, major adverse cardiac events or never events, extracorporeal life support, necrotising enterocolitis, surgical site of blood stream infection, and prolonged pleural effusion or chylothorax. It is recognised that more than one such morbidity may arise in the same patient and these are referred to as multiple morbidities, except in the case of extracorporeal life support, which is a stand-alone constellation of morbidity. CONCLUSIONS: It is feasible to define a range of paediatric cardiac surgical morbidities for use in routine audit that reflects the priorities of both professionals and parents. The impact of these morbidities on the patient and family will be explored prospectively as part of a wider ongoing, multi-centre study

Understanding patient flow within community healthcare - a novel mapping of sequences and patterns of referral

Background: Community healthcare is a diverse sector consisting a wide range of different services, where patients commonly use a range of services to treat any number of co-morbidities. With a policy focus towards increased care for patients with multiple long term illnesses and increased community provision, the management and planning of these services is a key priority. In this project we worked alongside the North East London Foundation Trust (NELFT) to better understand referrals and patient use within community services for elderly patients, based in Havering. Of interest was how patients concurrently used services, whether common patterns of referrals existed and how sequences of referrals occurred over time. To this end we developed a range of novel maps in collaboration with NELFT clinicians to aid in the design and implementation of a single point of access (SPA) for referrals into community services. / Methods: Using operational research methods, we attempt to better understand the structure of NELFT's community provision. From a non-identifiable patient level dataset we constructed a series of maps exploring patient referrals. We first created a network depiction of referrals where nodes represented services and edges represented a referral between them. In support of this, we plotted the time distribution of concurrent patient referrals at a population level – looking at how long patients remained in one, two, three, four, five and six or greater referrals at the same time as time progressed. Developing further, we analysed common sequences and patterns of referrals. We found common mixtures and orders of services first used by patients, looking at sequences of three, four, five and six referrals. Finally, using a timeline plot, we analysed how subsequent referrals develop after a first referral to a given service. / Results: The network map highlights the intensity and frequency of patient activity within the system as well as its complexity and vastness. The time distribution of patient discharges shows how the number of patients requiring multiple treatments evolves over time and how subsequent referrals overlap. Insight into groups of services with high activity and correlation of referrals is gained by finding common sequences and patterns of referrals, whilst the timeline of subsequent referrals shows how these sequences develop over time. Implications In applying these methods to NELFT services we helped to inform the design of their SPA using a "what if" analysis. This analysis provided information about how referrals may be streamlined to improve access, particularly in light of both areas of high activity formed of multiple services, and the large volume of low use referral paths. These methods highlighted important dynamics of patient flow and referrals within community care to be considered in planning services, and visually depicted them to communicate valuable insight into NELFT community referrals

Modelling patient flow and outcomes in community healthcare − a fluid approximation of a stochastic queueing system

An ambition of UK healthcare policy in recent decades has been to deliver more care in the community. However, questions remain over the impact of shifting services from acute settings closer to patient homes. This is complicated by a lack of comparable measures, nationally and locally, for evaluating quality across differing community services. In this project we develop a novel patient flow model to aid the evaluation of community services which incorporates patient outcomes. The model includes patient flow dynamics common to community care such as the use of multiple services and possible re-use of services. We represent outcomes as groups which patients may move between during a course of care, which are used to model differentiated service. The model provides insight into the performance of an interrelated healthcare services. We extend a first order fluid approximation of a stochastic queueing system with service reuse to include multiple patient groups. In considering differentiated service, we implement a novel method for dynamically allocating servers across parallel queues, overcoming problems of server inactivity. Furthermore, we develop a new measure of “the flow of outcomes” to evaluate how individual services contribute to the output of outcomes from a system of care over time