Healthcare Engineering: Quantitative Decision Support Models for the Healthcare Industry

1. 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

2. Outline • Brief Overview of the Health Care Industry • Why do we need engineers? • Some application examples

3. 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 personwas spent on health care compared to $8,047 in US

4. International Trends OECD web site: www.oecd.org Oct 2007

6. Unfair Comparison:More $ doesn’t = better health?

8. Health Care Delivery (% Public Payor in 2007)

9. Commonwealth Fund Overall Ranking 2007 * 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.

10. 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. Trustees Community Managers Control Insider Coalition Status Coalition Doctors Cure Nursing Care Clinical Coalition *Glouberman & Mintzberg, 2001

11. The Four Faces of Health Care* • The same divisions apply to the overall social health system! Health Authorities Insurance Public Control Elected Officials Community Involvement Acute Hospital Acute Cure LTC, Primary Community Care *Glouberman & Mintzberg, 2001

12. 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

13. 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?

14. 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

15. Observed Waitlist Approximation Cutoff Point

18. 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

19. Health Human Resources Modelling

20. 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

21. In Canada only 5 out of 11 slots were filled in 2009 match I

22. But . . . Retiring Surgeon Population Demand patterns … CABG Non-CABG

23. Population is aging …

24. 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

25. Causal Loop (Influence) Diagram

26. Scenario Testing

27. 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 Operations Research & Patient Flow

29. Local Health Integration Networks (LHINs) Planning Tools for “Aging at Home” GIS models of Supply & Demand Ali Esensoy, Agnita Pal & Mike Carter

30. Demand Estimation

31. Estimated Adult Day Program Demand in TC LHIN

32. Adult Day Program Supply in TC LHIN

33. Cluster Analysis of ADP Gap in TC LHIN

34. Cancer Care Ontario How many medical oncologists do we need in Ontario? Graham Woodward, Adriane Castellino, Matt Nelson & Mike Carter

35. 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

37. 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?”

38. Integer Programming Models Given current volume and mix of patients, determine “ideal” provider configuration. Given current set of providers, how many patients can be treated? (% of current volume) How many providers are needed under different models of care? How do sites compare to each other in terms of resource use? (Best Practice.)

39. Surgical Planning & Scheduling Sherry Weaver, Daphne Sniekers, Dionne Aleman, Solmaz Azari-Rad, Carolyn Busby & Mike Carter

40. 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

41. 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

42. 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