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Healthcare Engineering:
Quantitative Decision Support
Models for the Healthcare Industry
Michael W. Carter
Centre for Research in Healthcare Operations
Mechanical and Industrial Engineering
University of Toronto
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Outline
• Brief Overview of the Health Care Industry
• Why do we need engineers?
• Some application examples
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o
o
o
The Importance of Health Care
Health care is North America’s
largest single industry.
Estimated total spending in
Canada was $183 billion (CN)
in 2009. ($2.5 trillion in the US)
In Canada, in 2009, $5,452
per person was spent on
health care compared to
$8,047 in US
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International Trends
Health Spending as a % of GDP
20
US
Canada
France
Germany
% GDP
15
UK
Netherland
s
Japan
10
Mexico
OECD web site: www.oecd.org Oct 2007
'06
'04
'02
'00
98
96
94
92
90
88
86
84
82
80
5
Belgium
Unfair Comparison:
More $ doesn’t = better health?
Life Expectancy 2003
Japan
Sweden
Switzerland
Australia
Canada
New Zealand
United Kingdom
Netherlands
France
Germany
United States
65.0
70.0
75.0
Women
80.0
Men
85.0
90.0
Infant Mortality per 1,000 live births 2003
United States
New Zealand
Canada
United Kingdom
Netherlands
Australia
Switzerland
Germany
France
Sweden
Japan
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
Health Care Delivery
(% Public Payor in 2007)
Public
Payor
Private
Payor
Public
Provider
UK (82),
Japan (81)
Private
Provider
Canada (70%), United States
Germany (77) (45)
France (79)
Mix
** Most OECD states
allow wealthy to opt
out. of public system
**
Mix
Sweden (82)
Holland (75)
Commonwealth Fund
Overall Ranking 2007
Country Rankings
1.0-2.66
2.67-4.33
4.34-6.0
AUST.
CAN.
GER
N.Z.
U.K.
U.S.
3.5
5
2
3.5
1
6
4
6
2.5
2.5
1
5
Right Care
5
6
3
4
2
1
Safe Care
4
5
1
3
2
6
Coordinated Care
3
6
4
2
1
5
Patient-Centered Care
3
6
2
1
4
5
Access
3
5
1
2
4
6
Efficiency
4
5
3
2
1
6
Equity
2
5
4
3
1
6
Long, Healthy, and Productive
Lives
1
3
2
4.5
4.5
6
$2,876*
$3,165
$3,005*
$2,083
$2,546
$6,102
OVERALL RANKING (2007)
Quality Care
Health Expenditures per
Capita, 2004
* 2003 data
Source: Calculated by Commonwealth Fund based on the Commonwealth Fund 2004 International Health Policy Survey, the Commonwealth Fund 2005 International
Health Policy Survey of Sicker Adults, the 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, and the Commonwealth Fund
Commission on a High Performance Health System National Scorecard.
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Systemic Hospital Issues:
The Four Faces of Health Care*
Containment
Coalition
 Health care is a
business, but...
Multiple decision makers.
Conflicting goals,
incentives.
Social “good”.
No market, no manager.
*Glouberman & Mintzberg, 2001
Trustees
Community
Managers
Control
Insider
Coalition
Status
Coalition
Doctors
Nursing
Cure
Care
Clinical
Coalition
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The Four Faces of Health Care*
 The same divisions apply
to the overall social health
system!
Elected
Officials
Community
Involvement
Acute
Hospital
Acute Cure
Health
Authorities
Insurance
Public
Control
LTC, Primary
Community
Care
*Glouberman & Mintzberg, 2001
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Some success stories
• Ontario Waitlist Forecast
• System Dynamics: Cardiac Surgeons
• Ministry of Health and Long Term Care and the
Local Health Integration Networks (LHINs)
• Cancer Care Ontario: Chemo Therapy Centres
• Surgical Planning: Orthopaedic
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Ontario Waitlist Initiative
•
Target to reduce wait times to
benchmarks for five priority areas:
Cardiac, Cataract, Cancer, Hip & Knee
Replacement, MRI/CT
• Problem: How many (cataracts) do we
need to do to meet bench mark (90% wait
less than 26 weeks) by March 2007?
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Data Requirements for Prediction
•
•
•
•
•
•
Current Patient Arrival Rate
Projected Future Arrival Rate
Current Waitlist
Distribution of Patients on Waitlist (Priority)
Surgical Volumes (Service Rates)
Future Funded Surgical Volumes
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Observed Waitlist Approximation
Cataract Wait Times
450
Cutoff Point
400
350
300
250
200
150
Mean
90th Percentile
Median
100
50
0
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Ratio of 90th Percentile to the Mean
3
2.5
2
1.5
1
0.5
0
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Cataract Surgery
Arrivals
Corrected Arrivals
Total Surgeries
14000
13000
12000
11000
10000
9000
8000
7000
6000
5000
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Recent Ontario Performance
• Oct./Nov./Dec. 2009 (all priorities)
– Hips – 23 weeks (Ont. target 90% in 26 weeks)
– Knees – 26 weeks (target 26)
– Cataracts – 16 weeks (target 26)
– Breast cancer – 5 weeks (target 12)
– Colorectal cancer – 6 weeks (target 12)
– Cardiac Bypass – 8 weeks (target 26)
– MRI – 16.6 weeks (target 4)
– CT – 7 weeks (target 4)
www.health.gov.on.ca
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Health Human Resources
Modelling
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Modeling the Future of Canadian
Cardiac Surgery Workforce Using
System Dynamics
Michael Carter1,Chris Feindel2,Timothy Latham2 & Sonia Vanderby1
1Centre
for Research in Healthcare Engineering, University of Toronto
2Canadian Society of Cardiac Surgeons
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I
In Canada only 5 out of 11 slots were filled in 2009 match
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But . . .
Retiring Surgeon Population
Demand patterns …
Cardiac Surgery Rates
Current Cardiac Surgeons by Age
45 to 49
16%
50 to 54
18%
40 to 44
23%
> 50
55 to 59
12%
60 to 68
13%
35 to 39
14%
Per-Capita Surgical Rate
0.45%
0.40%
0.35%
0.30%
0.25%
0.20%
0.15%
0.10%
0.05%
Male
0.00%
<15
30 to 34
4%
20-39
40-64
65-74
Female
> 75+
Age Cohort
CABG
Non-CABG
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Population is aging …
Canadian Population Projections by Age
12000
Population ( 000s)
10000
40 to 60
20 to 40
8000
Under 20
6000
60 to 80
4000
2000
0
2006
Over 80
2011
Under 20
2016
20 to 40
2021
40 to 60
60 to 80
2026
Over 80
2031
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Study Motivation
• Will there be a future shortage of surgeons?
• Specialty selection decisions being made
based on current situation
– Current oversupply; unemployed grads
– Education Process > 10 years
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Causal Loop (Influence) Diagram
IMG Module
International
Medical Graduates
Student Population Module
Surgeon Population Module
Practicing Surgeon
Population
Total Surgical
Capacity
Student
Population
Demand Module
General
Population
Surgical Demand
per capita
Clinical Productivity Module
Total Surgical
Demand
Demand-Supply
Gap
Average Clinical
Productivity per
surgeon
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Scenario Testing
R-1 Entry responds to Unemployment
Persons
15
10
5
0
2008
grads
2012
2016
unemployed grads
2020
2024
Net Surgeon Shortage
2028
R-1 Entry
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Other System Dynamics Projects
• Alberta Health & Wellness
– Model for demand for GPs for next ten years
• Ontario MOHLTC
– Model impact of “Aging at Home” strategy
– Model of mental health strategies
May 20, 2009
Operations Research & Patient Flow
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national/regional
economic strength
eligibility
requirements of
tuition supports
ODSP eligibility
requirements OW eligibility
requirements
acessibility of
financial supports
ability to afford
education &
training
eligibility for and
amount of ODSP
received
productivity
availability
of jobs
eligibility for and
wage/salary
amount of OW received
work related
medical
benefits
costs of care?
+
willingness to ability to pay for
find job
care
awareness of financial
support options
education/
training
level
life skills &
abilities
ability to attend
school & work
+
Income level
ability to keep
job
ability to find a
job
+
Level of care
required
likelihood of
"sticking with" care
delays
+
obtaining care+-
likelihood of seeking
level of
sense of
disability
+ school/community community/school financial supports
+
attachment
involvement
+
nutrition & healthy
homelessness
opportunities for
lifestyle
school/community
transportation
rurality
?
+ +
involvement
barriers/physical
situational stress
divorce/b
isolation
+
ability
to
obtain
&
afford
reak-ups
ability to afford &
insurance (auto & home)
availability of
+ stigma +
maintain appropriate
? in MH&A
settlement support
change
+demands of chronic disease
language +
housing
- physical health
- barriers
+
++
home life
+ +
+
manageability of
+
+
culture
sense of
MHA
isolation/community
age
# of single
parent
coordination &
families
?
trauma
effectiveness of
major life +
discrimination
community planning
+
+
transitions
+
genetics/family
involvement in use of alcohol, tobacco,
abuse
- of MH&A2
-history
gambling
sexual
+
other substances
quality of
orientation
+
+
suicide rate
availability of
+relationships
availability of
healthy
gambling
substances
environment
availability of
parenting
+ classes/daycare/ECE
out-of-pocket
medical costs
duration, continuity
& comprehensiven
ess of care
+
+
+
- accessibility of
care/support
+
+
+
ED arrivals
+
personal
+
- likelihood of +
seeking care
reliance on
informal/family care
providers
+
+
education &
skills of
providers
Likelihood &
influence of family
support/intervention
+
contacts with
justice system
+
+demand for legal
demand for law
assistance
enforcement
-+ +
?
appropriateness of
referrals
+ care eligibility
Demand for
support/care
+
?
use of evidence
based care
availability
of MHA
treatment in EDs
prestige/r
eputation
+
awareness of care &
support options
+
+
use of common
assessment & intake
procedures
requirements
adverse
selection
?
+
ED staff ?
turnover
provider ?
incentives
+
provider attitude
+
+
funding regime &
duration
collaboration &
coordination of
care
?
?
+
effectiveness of care
+
+
+
likelihood of being eligible for care
+
symptom
+
+ identification
+
+
involvement in care
workload /
provider
+
availability of
care/support
public education
of MHA
+
+
outcome monitoring
& reporting
+
+
research &
development of care
standards
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Local Health Integration
Networks (LHINs)
Planning Tools for “Aging at Home”
GIS models of Supply & Demand
Ali Esensoy, Agnita Pal & Mike Carter
Demand Estimation
Estimated Adult Day Program Demand in TC LHIN
Adult Day Program Supply in TC LHIN
Cluster Analysis of ADP Gap in TC LHIN
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Cancer Care Ontario
How many medical oncologists do
we need in Ontario?
Graham Woodward, Adriane Castellino,
Matt Nelson & Mike Carter
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HHR Model
 How are teams of providers configured in chemo
clinics?
 How are responsibilities/tasks distributed among
providers? (i.e., Who does what?)
 Focus on functions that could be performed by
more than one type of provider
 Are there differences among sites? Best practice
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Systemic Treatment Visits by Provider
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Systemic treatment
Onc
Further
treatment?
Yes
Re-stage cancer
No
End-of-life care
Onc
Palliative Palliative
Care
MD
No
APN
Pharm
Onc
Biopsy
Staging
tests
Suspicion of
cancer and
diagnosis
Consult
Onc
Onc
Pharm GPO
Check in with med
onc
Chemo treatment
GPO
APN
APN
Onc
Cancer in remission?
Onc
Follow up with
oncologist
Pharm
Urgent care &
symptom
management
Yes
GPO
Well-follow-up
APN
Onc
Palliative
Care
Can refer to a Medical Oncologist or a
Hematology Oncologist
Oncologist must be present
Oncologist may or not be present
May or may not be necessary
Usually performed by family doctor
and/or surgeon
APN
Onc
Pharm GPO
Onc
Onc
Discharge back to
family practitioner
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Data Collection
• Each centre has different people doing the tasks.
• Need rough estimate of time required for each
task by type of patient (expert opinion)
• Only trying to get a high level sense of who does
what to answer questions like:
– “How many Medical Oncologists do we need at this
centre?”
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Integer Programming Models
1. Given current volume and mix of patients,
determine “ideal” provider configuration.
2. Given current set of providers, how many patients
can be treated? (% of current volume)
3. How many providers are needed under different
models of care?
4. How do sites compare to each other in terms of
resource use? (Best Practice.)
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Surgical Planning & Scheduling
Sherry Weaver, Daphne Sniekers,
Dionne Aleman, Solmaz Azari-Rad,
Carolyn Busby & Mike Carter
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Several current projects
• Western Canada Wait List: Orthopaedic surgery
– Alberta Bone & Joint Health Institute: Calgary,
Edmonton, Winnipeg
– Bone & Joint Canada
• General Perioperative Simulation
– Hamilton, UHN, St. Mike’s, Mt. Sinai, William Osler
(Brampton Civic & Etobicoke General)
• Sunnybrook Health Sciences
– Urgent Ortho & Smoothing Resource Use
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Conclusions
• Health Care is major industry
• The current system is not sustainable
• Quantitative methods (Operational Research)
can help
• The health care industry is beginning to
recognize the value of systems thinking
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Opportunities for Operations Research?
Watch your newspaper:
• Patient flow → Supply Chain
• ED Wait times → Queueing/Simulation
• Surgical Wait Lists → Better scheduling
• Infectious Diseases → Logistics, Modelling
• Health Human Resources → Forecasting
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