A Markovian queueing model for ambulance offload delays

Ambulance offload delays are a growing concern for health care providers in many countries. Offload delays occur when ambulance paramedics arriving at a hospital Emergency Department (ED) cannot transfer patient care to staff in the ED immediately. This is typically caused by overcrowding in the ED. Using queueing theory, we model the interface between a regional Emergency Medical Services (EMS) provider and multiple EDs that serve both ambulance and walk-in patients. We introduce Markov chain models for the system and solve for the steady state probability distributions of queue lengths and waiting times using matrix-analytic methods. We develop several algorithms for computing performance measures for the system, particularly the offload delays for ambulance patients. Using these algorithms, we analyze several three-hospital systems and assess the impact of system resources on offload delays. In addition, simulation is used to validate model assumptions.     

Using self‐dissimilarity to quantify complexity

For many systems characterized as “complex” the patterns exhibited on different scales differ markedly from one another. For example, the biomass distribution in a human body “looks very different” depending on the scale at which one examines it. Conversely, the patterns at different scales in “simple” systems (e.g., gases, mountains, crystals) vary little from one scale to another. Accordingly, the degrees of self‐dissimilarity between the patterns of a system at various scales constitute a complexity “signature” of that system. Here we present a novel quantification of self‐dissimilarity. This signature can, if desired, incorporate a novel information‐theoretic measure of the distance between probability distributions that we derive here. Whatever distance measure is chosen, our quantification of self‐dissimilarity can be measured for many kinds of real‐world data. This allows comparisons of the complexity signatures of wholly different kinds of systems (e.g., systems involving information density in a digital computer vs. species densities in a rain forest vs. capital density in an economy, etc.). Moreover, in contrast to many other suggested complexity measures, evaluating the self‐dissimilarity of a system does not require one to already have a model of the system. These facts may allow self‐dissimilarity signatures to be used as the underlying observational variables of an eventual overarching theory relating all complex systems. To illustrate self‐dissimilarity, we present several numerical experiments. In particular, we show that the underlying structure of the logistic map is picked out by the self‐dissimilarity signature of time series produced by that map. © 2007 Wiley Periodicals, Inc. Complexity 12: 77–85, 2007     

Dynamic overbooking scheduling system to improve patient access

Patient no-show has long been a recognized problem in modern outpatient health-care delivery systems. The common impacts are reduced clinic efficiency and provider productivity, wasted medical resources, increased health-care cost and limited patient access to care. The main goal of this research is to develop an effective dynamic overbooking policy into any scheduling system that accounts for the predictive probability of no-shows for any given patient. This policy increases the quality of patient care in terms of wait time and access to care while minimizing the clinic's costs. This proposed model is also illustrated to be more cost-effective than overbooking patients evenly throughout a clinic session. This paper also suggests that overbooking should be performed at better patient flow and higher no-show rate so that the costs are minimized. Consequently, this research improves the outpatient experience for both patients and medical providers.     

A stochastic model for a visit to the doctor’s office

This paper presents a stochastic model of an individual patient’s experience during a visit to a doctor’s office. The stochastic model is based on tracking the visit of patients at a local family practice clinic. A rigorous, iterative procedure for model development allows the stochastic model to be constructed, evaluated, and validated to establish consistency with both the theoretical stochastic assumptions and the clinic’s actual operating environment. This model extends the use of stochastic models in health care in two important respects. First, the stochastic model represents an application of semi-Markov processes in outpatient health care settings. Second, through the use of the infinitesimal generator associated with the transition probability matrices governing patient flow, numerical predictions for first passage times are easily obtained.     

A hybrid data mining/simulation approach for modelling outpatient no-shows in clinic scheduling

This paper considers the outpatient no-show problem faced by a rural free clinic located in the south-eastern United States. Using data mining and simulation techniques, we develop sequencing schemes for patients, in order to optimize a combination of performance measures used at the clinic. We utilize association rule mining (ARM) to build a model for predicting patient no-shows; and then use a set covering optimization method to derive three manageable sets of rules for patient sequencing. Simulation is used to determine the optimal number of patients and to evaluate the models. The ARM technique presented here results in significant improvements over models that do not employ rules, supporting the conjecture that, when dealing with noisy data such as in an outpatient clinic, extracting partial patterns, as is done by ARM, can be of significant value for simulation modelling.     

Application of discrete-event simulation in health care clinics: A survey

In recent decades, health care costs have dramatically increased, while health care organisations have been under severe pressure to provide improved quality health care for their patients. Several health care administrators have used discrete-event simulation as an effective tool for allocating scarce resources to improve patient flow, while minimising health care delivery costs and increasing patient satisfaction. The rapid growth in simulation software technology has created numerous new application opportunities, including more sophisticated implementations, as well as combining optimisation and simulation for complex integrated facilities. This paper surveys the application of discrete-event simulation modeling to health care clinics and systems of clinics (for example, hospitals, outpatient clinics, emergency departments, and pharmacies). Future directions of research and applications are also discussed.     

A cost-effective urgent care policy to improve patient access in a dynamic scheduled clinic setting

Patient no-show in outpatient clinics has been a long recognized issue, which negatively impacts clinic operational efficiency in terms of costs and patient access to care. One way to reduce these negative impacts is to allow urgent walk-ins during a clinic day. Some clinics allow random walk-ins and some purposely leave open time slots to accommodate them. The objective of this paper is to develop a cost-effective urgent care policy that is added on top of a full schedule and takes into account scheduled patients’ no-show rates to improve patient access to care in a dynamic clinic environment. The findings indicate that the proposed approach outperforms the current random and urgent slot approaches. This paper demonstrates a dynamic approach for accommodating urgent patients into a patient scheduling system, based on the prediction of an individual patient's no-show probability and the maximum number of urgent patients allowed.     

Information theoretic measures of UHG graphs with low computational complexity

We introduce a novel graph class we call universal hierarchical graphs (UHG) whose topology can be found numerously in problems representing, e.g., temporal, spacial or general process structures of systems. For this graph class we show, that we can naturally assign two probability distributions, for nodes and for edges, which lead us directly to the definition of the entropy and joint entropy and, hence, mutual information establishing an information theory for this graph class. Furthermore, we provide some results under which conditions these constraint probability distributions maximize the corresponding entropy. Also, we demonstrate that these entropic measures can be computed efficiently which is a prerequisite for every large scale practical application and show some numerical examples.     

An inventory control model with stochastic review interval and special sale offer

Periodic review inventory models are widely used in practice, especially for inventory systems in which many different items are purchased from the same supplier. However, most of periodic review models have assumed a fixed length of the review periods. In practice, it is possible that the review periods are of a random (stochastic) length. This paper presents an inventory control model in the case of random review intervals and special sale offer from the supplier. The replenishment interval is assumed to obey from two different distributions, namely, exponential and uniform distributions. Also, shortages are allowed in the term of partial backordering. For this model, its convexity condition is discussed and closed form solutions are proposed.     

Combining discrete-event simulation and system dynamics in a healthcare setting: A composite model for Chlamydia infection

This paper presents a composite model in which two simulation approaches, discrete-event simulation (DES) and system dynamics (SD), are used together to address a major healthcare problem, the sexually transmitted infection Chlamydia. The paper continues an on-going discussion in the literature about the potential benefits of linking DES and SD. Previous researchers have argued that DES and SD are complementary approaches and many real-world problems would benefit from combining both methods. In this paper, a DES model of the hospital outpatient clinic which treats Chlamydia patients is combined with an SD model of the infection process in the community. These two models were developed in commercial software and linked in an automated fashion via an Excel interface. To our knowledge this is the first time such a composite model has been used in a healthcare setting. The model shows how the prevalence of Chlamydia at a community level affects (and is affected by) operational level decisions made in the hospital outpatient department. We discuss the additional benefits provided by the composite model over and above the benefits gained from the two individual models.     

A simulation study of scheduling clinic appointments in surgical care: individual surgeon <Emphasis Type="Italic">versus</Emphasis> pooled lists

The purpose of this paper is to compare two methods of scheduling outpatient clinic appointments in the setting where the availability of surgeons for appointments depends on other clinical activities. We used discrete-event simulation to evaluate the likely impact of the scheduling methods on the number of patients waiting for appointments, and the times to appointment and to surgery. The progression of individual patients in a surgical service was modelled as a series of updates in patient records in reaction to events generated by care delivery processes in an asynchronous fashion. We used the Statecharts visual formalism to define states and transitions within each care delivery process, based on detailed functional and behavioural specifications. Our results suggest that pooling referrals, so that clinic appointments are scheduled with the first available surgeon, has a differential impact on different segments of patient flow and across surgical priority groups.     

随机补货间隔且需求依赖库存水平的库存控制模型

定期补货库存模型在实践中被广泛使用,尤其是在单一供应商中购买多种不同产品的库存系统中更为常见.然而,大多数定期补货库存模型都假设补货的时间间隔是恒定不变的.但在实践中,补货的时间间隔也可能是一个随机的时间长度.提出了一个随机补货时间间隔和需求依赖于当前展示库存水平的库存控制模型,且补货间隔服从指数分布和均匀分布,同时允许短缺发生并且短缺量部分延期供给,并研究了模型最优解的存在性与唯一性.最后,给出了数值算例来说明模型在实际中的应用.     

The Balance of Care Project: Modelling the Allocation of Health and Personal Social Services

The Balance of Care model was designed to predict from aggregate health and personal social service plans the care which will be received by different types of potential client. Planners can use the model to assess the implications of various competing strategies and hence choose the one which will yield a pattern of care closest to that desired. In order to predict the pattern of care inherent in a service strategy it is necessary to establish the priorities governing the allocation of services to clients. This paper concentrates on the structure of the model and the techniques developed to deduce priorities from the past behaviour of the health and personal social service system. Applications of the model are described more fully elsewhere.     

Block appointment systems for outpatient clinics with multiple doctors

Studies of appointment systems have to some extent led to a wide acceptance of individual or block appointment schemes in private practice and outpatient clinics. Most of the studies assume there is one punctual doctor in a clinic, which is often not the case in reality. Motivated by observations of actual clinic operations, we develop a block appointment system for clinic operations with multiple random arriving doctors. Through extensive simulation studies, we identify properties shared by the best appointment schedules. With these properties we can design a scheme based on simulation search that provides the optimal schedule for a given scheduling environment in an acceptable computation time. A simple (suboptimal) appointment rule is also proposed.     

Analysis of a Fork/Join Synchronization Station with Inputs from Coxian Servers in a Closed Queuing Network

Fork/join stations are commonly used to model the synchronization constraints in queuing models of computer networks, fabrication/assembly systems and material control strategies for manufacturing systems. This paper presents an exact analysis of a fork/join station in a closed queuing network with inputs from servers with two-phase Coxian service distributions, which models a wide range of variability in the input processes. The underlying queue length and departure processes are analyzed to determine performance measures such as throughput, distributions of the queue length and inter-departure times from the fork/join station. The results show that, for certain parameter settings, variability in the arrival processes has a significant impact on system performance. The model is also used to study the sensitivity of performance measures such as throughput, mean queue lengths, and variability of inter-departure times for a wide range of input parameters and network populations.     

Modelling hospital costs to produce evidence for policies that promote equity and efficiency

Third party payers for health care, when introducing policies to promote equity, through formulas for resource allocation by capitation, and efficiency, through prospective payment by case-mix, have sought to make adjustments for “unavoidable” hospital costs, which are caused by structural characteristics and are beyond the scope of local hospital management. To date, however, most published studies of such estimates have been inadequate. This paper reports the development of a generalisable model that aims to produce sound estimates of “unavoidable” hospital costs and shows how this stochastic multilevel model can be used to estimate unavoidable costs per unit of measurable output, identify sources of allocative inefficiency, and capture systematic variations in costs between different types of hospitals, through prospective payment by case-mix or formulas for resource allocation by capitation The application of the model to Portuguese hospitals has identified various causes of allocative inefficiencies: centrally-determined distributions of beds and doctors, a lack of local flexibility, systems with perverse incentives, and the existence of diseconomies of scale.     

Bounds for the quasi-stationary distribution of some specialized Markov chains

The quasi-stationary distributions of Markov chains have been investigated by many papers and are known to have considerable practical importance in, e.g., biological, chemical and applied probability models. However, computation of the quasi-stationary distributions is often nontrivial, which has limited its use in practice despite the usefulness of its own, except for some simple cases. This paper develops some bounds, which are relatively easy to calculate, for the quasi-stationary distribution of some specialized Markov chains.     

What belongs where? Variable selection for zero-inflated count models with an application to the demand for health care

This paper develops a Bayesian spike and slab model for zero-inflated count models which are commonly used in health economics. We account for model uncertainty and allow for model averaging in situations with many potential regressors. The proposed techniques are applied to a German data set analyzing the demand for health care. An accompanying package for the free statistical software environment R is provided.     

Simulation based analysis of patient arrival to health care systems and evaluation of an operations improvement scheme

Various demands of different patients over both medical resource and time domains in health care systems raise requests of strategies for balanced system capacity from an operations perspective. In this paper, a quantitative modeling technique with both patient arrival and associated treatment process integrated are used to characterize health care system performance and evaluate system efficiency. The patient arrival process is described as a dynamic random Poisson process and patient treatments are characterized as consumption processes of various health care resources over time with a view of the “product line” used. The waiting time of patients and usage of health care resources are proposed as system performance measures based on their means, variances, and confidence intervals. A simulation considering patients with several various diseases is given to find a mechanism of conflicting factors in decisions of balanced system capacity, and an operation scheme of “evenly balanced load for bottlenecks” is obtained based on analysis of simulation outputs. Simul8 provides the software environment for the simulation.     

Reverse-engineering of polynomial dynamical systems

Multivariate polynomial dynamical systems over finite fields have been studied in several contexts, including engineering and mathematical biology. An important problem is to construct models of such systems from a partial specification of dynamic properties, e.g., from a collection of state transition measurements. Here, we consider static models, which are directed graphs that represent the causal relationships between system variables, so-called wiring diagrams. This paper contains an algorithm which computes all possible minimal wiring diagrams for a given set of state transition measurements. The paper also contains several statistical measures for model selection. The algorithm uses primary decomposition of monomial ideals as the principal tool. An application to the reverse-engineering of a gene regulatory network is included. The algorithm and the statistical measures are implemented in Macaulay 2, and are available from the authors.