The performance of a generalized Bailey–Welch rule for outpatient appointment scheduling under inpatient and emergency demand

We are considering the problem of scheduling a given number of outpatients to a medical service facility with two resources servicing outpatients, inpatients, and emergency patients. Each of the three patient classes has associated class-specific arrival processes and cost-figures. The objective is to maximize the total expected reward which is made of revenues for served patients, costs for letting patients wait, and costs for denial of service. For this problem we propose a generalization of the well-known Bailey–Welch rule as well as a neighborhood search heuristic. We analyze the impact of different problem parameters on the total reward and the structure of the derived appointment schedules and address the question of the number of outpatients to be scheduled. The results show that the generalized Bailey–Welch rule performs astonishingly well over a wide range of problem parameters.     

Dynamic optimization of chemotherapy outpatient scheduling with uncertainty

Chemotherapy outpatient scheduling is a complex, dynamic, uncertain problem. Chemotherapy centres are facing increasing demands and they need to increase their efficiency; however there are very few studies looking at using optimization technology on the chemotherapy scheduling problem. We address dynamic uncertainty that arises from requests for appointments that arrive in real time and uncertainty due to last minute scheduling changes. We propose dynamic template scheduling, a novel technique that combines proactive and online optimization and we apply it to the chemotherapy outpatient scheduling problem. We create a proactive template of an expected day in the chemotherapy centre using a deterministic optimization model and a sample of appointments. As requests for appointments arrive, we use the template to schedule them. When a request arrives that does not fit the template, we update the template online using the optimization model and a revised set of appointments. To accommodate last minute additions and cancellations to the schedule, we propose a shuffling algorithm that moves appointment start times within a predefined time limit. We test the use of dynamic template scheduling against the optimal offline solution and the actual performance of the cancer centre. We find improvements in makespan of up to 20 % when using dynamic template scheduling compared to current practice.     

Case mix and charges for inpatient and outpatient chemotherapy.

Case mix and charges for chemotherapy treatment were examined by an analysis of the inpatient discharges for DRG 410 (chemotherapy) from eight teaching hospitals and of outpatient visits from two teaching hospitals. Discharges for ovarian cancer were the most common and the least expensive, costing $1,600 or half as much as the most costly, less common conditions (leukemia and testicle cancer). Diagnosis explained 13 percent of the inpatient charge variation; metastasis explained less than 1 percent. Outpatient chemotherapy overlapped with inpatient among only 3 of the 10 most common diagnoses. The implication is that the two settings are complementary with regard to chemotherapy administration.     

Transitioning from inpatient to outpatient therapy in patients with in-hospital hyperglycemia

Transition from inpatient to outpatient care for patients with type 2 diabetes mellitus is an important aspect of patient management for which there is no guidance. Intensive glucose lowering with insulin is generally favored for seriously ill hospitalized patients, but after discharge, patients often resume their prior regimens, which may include an array of oral or injected glucose-lowering agents. Factors that should be considered in this transition include goals of care/life expectancy, glycated hemoglobin at hospital admission, home medications for other illnesses and their potential for interactions with antidiabetes treatment, comorbidities, nutritional status, physical disabilities, ability to carry out self-monitoring of blood glucose, risk for hypoglycemia, contraindications to oral medications, health literacy, and financial and other resources. Traditional oral therapies that may be used after the patient leaves the hospital include sulfonylureas, α-glucosidase inhibitors, thiazolidinediones, and metformin. α-Glucosidase inhibitors are limited by gastrointestinal adverse events, and thiazolidinediones by fluid retention and increased risk for heart failure. Thiazolidinediones also require a long period of administration for onset glucose lowering and are not suitable for transitioning hospitalized patients who have been receiving insulin to outpatient care. Metformin is contraindicated in patients with renal, cardiac, or pulmonary insufficiency. Incretin-based therapies, glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors, have limited use in hospitals, but may be suitable for the transition to outpatient treatment. The most common adverse events with glucagon-like peptide-1 inhibitors involve the gastrointestinal system. More formal studies of treatment regimens for patients with hyperglycemia leaving the hospital are needed to guide care for this group.     

A Markov decision model for determining optimal outpatient scheduling

Managing an efficient outpatient clinic can often be complicated by significant no-show rates and escalating appointment lead times. One method that has been proposed for avoiding the wasted capacity due to no-shows is called open or advanced access. The essence of open access is “do today’s demand today”. We develop a Markov Decision Process (MDP) model that demonstrates that a short booking window does significantly better than open access. We analyze a number of scenarios that explore the trade-off between patient-related measures (lead times) and physician- or system-related measures (revenue, overtime and idle time). Through simulation, we demonstrate that, over a wide variety of potential scenarios and clinics, the MDP policy does as well or better than open access in terms of minimizing costs (or maximizing profits) as well as providing more consistent throughput.     

A mathematical programming approach for scheduling physicians in the emergency room

Preparing a schedule for physicians in the emergency room is a complex task, which requires taking into account a large number of (often conflicting) rules, related to various aspects: limits on the number of consecutive shifts or weekly hours, special rules for night shifts and weekends, seniority rules, vacation periods, individual preferences, ... In this paper, we present a mathematical programming approach to facilitate this task. The approach models the situation in a major hospital of the Montréal region (approximately 20 physicians are members of the working staff). We show that the approach can significantly reduce the time and the effort required to construct a six-month schedule. A human expert, member of the working staff, typically requires a whole dedicated week to perform this task, with the help of a spreadsheet. With our approach, a schedule can be completed in less than one day. Our approach also generates better schedules than those produced by the expert, because it can take into account simultaneously more rules than any human expert can do. This revised version was published online in August 2006 with corrections to the Cover Date.     

低肺栓塞严重程度指数急性肺栓塞患者住院及非住院治疗的疗效及安全性比较

目的 评估对低肺栓塞严重程度指数(PESI)急性肺栓塞(APE)患者进行院外自我抗凝管理的疗效及安全性.方法 将PESI分级Ⅰ～Ⅱ级的68例APE患者按随机数字表法分为院外治疗组和住院治疗组,每组34例.所有患者均给予低分子量肝素联合口服抗凝药物治疗,院外治疗组进行自我抗凝管理.观察两组患者治疗后2周及3个月时的疗效,包括静脉血栓栓塞(VTE)的复发情况、国际标准化比值(INR)达标时间、VTE相关的急救次数、出血事件的发生及总体病死率.结果 治疗期间住院治疗组2例(5.9％,2/34)VTE复发,院外治疗组仅1例(2.9％,1/34) VTE复发,差异无统计学意义(P＞0.05).住院治疗组INR达标时间(8.5±2.9)d,明显短于院外治疗组的(16.1±4.4)d,差异有统计学意义(P＜0.01).两组患者VTE相关的急救次数比较差异无统计学意义(P＞0.05).68例患者中仅院外治疗组发生1例严重出血、1例死亡.结论 对于PESI分级Ⅰ～Ⅱ级的APE患者早期进行院外自我抗凝管理,安全有效,可大大缩短住院时间,减轻患者的物质及精神负担.     

The substitutability of outpatient primary care in rural community health centers for inpatient hospital care.

To determine whether outpatient medical care obtained at federally funded rural community health centers (CHCs) in Maine acts primarily as a substitute or as a complement to inpatient care, a study of 36 communities served by CHCs was conducted. The hospital use of CHC users (age- and sex-adjusted admissions, days, and length of stay) was compared with that of nonusers from the same communities in 1980. Statistically lower rates of hospital admissions and days were observed for all CHC patients and for selected groups based on their age, sex, and insurance status (specifically Medicaid or Medicare). Hospital use of CHC community populations was then compared with that of 24 comparison communities without access to CHCs, using multiple linear regression in a pre/post design. The model tested, which included rates of health center use, insurance penetration, poverty, and hospital availability, among other factors, did not detect any differences in hospital use between CHC community and comparison populations. These results and additional data presented on selected hospital diagnoses and insurance coverage suggest that treatment, and hospitalization incentives, of CHC providers may reduce hospitalization. Clinic providers lack the economic, professional, and institutional incentives to hospitalize. Additional study to determine the actual substitutability effect is indicated.     

Substituting inpatient for outpatient care: what is the impact on hospital costs and efficiency?

Substitution of inpatient for outpatient care is seen as a means to increase patient throughput and control costs. The purpose of this study was to assess the impact of increased outpatient care on hospital costs and efficiency using Finnish specialty-level data from years 2003–2006 to which we applied stochastic frontier analysis. The results reveal that outpatient services have a smaller impact on total costs than inpatient services. At the same time, increased outpatient activity appears to have an adverse effect on estimated cost efficiency. This counterintuitive finding is probably due to the low weight given to outpatient activities by the Diagnosis Related Groups (DRG) system. A common weighting for inpatient and outpatient services is required in order to assess accurately the impact of outpatient care on efficiency.     

Bone turnover during inpatient nutritional therapy and outpatient follow-up in patients with anorexia nervosa compared with that in healthy control subjects

BACKGROUND: Osteopenia and osteoporosis are among the most frequent and severe complications in adolescents with anorexia nervosa. OBJECTIVE: The aim of this study was to assess the influence of nutritional therapy on bone metabolism during adolescent anorexia nervosa. DESIGN: We studied 19 anorectic patients aged 14.1 +/- 1.4 y (x +/- SD) with a body mass index (BMI; in kg/m(2)) of 14.2 +/- 1.4 and 19 age-matched control subjects aged 15.1 +/- 2.3 y with a BMI of 20.8 +/- 1.9 for 1 y. Blood samples were taken for the measurement of bone markers, insulin-like growth factor I (IGF-I), and leptin. RESULTS: BMI rose significantly from 14.2 +/- 1.4 at baseline to 17.4 +/- 0.6 (P < 0.0001) at week 15. Compared with concentrations in the control subjects, concentrations of the bone formation markers procollagen type I propeptide (PICP) and bone alkaline phosphatase (bAP) in the anorectic patients were lower at baseline (PICP: P = 0.0071; bAP: P = 0.0012), increased with nutritional therapy (PICP: P = 0.0060, bAP: P = 0.0147), and were no longer significantly different (P > 0.05) during the follow-up period. Concentrations of IGF-I and leptin were significantly lower (P < 0.0001 for both) in the anorectic patients than in the control subjects at baseline. IGF-I increased with nutritional therapy but was still significantly lower (P = 0.0036) than that in the control group and decreased again during the follow-up period (P = 0.0126). In contrast, serum C-telopeptide decreased with nutritional therapy (P = 0.0446). CONCLUSION: Nutritional therapy improves concentrations of bone formation markers in adolescent patients with anorexia nervosa.     

Effects of establishing a financing scheme for outpatient care on inpatient services: empirical evidence from a quasi-experiment in China

The European Journal of Health Economics - The relationship between outpatient and inpatient care is central to the current healthcare reform debate especially in developing countries. Despite the...     

Employer, worker with AIDS settle claim for job accommodation

An out-of-court settlement was reached between an employee with AIDS and his Philadelphia-based employer. The Equal Employment Opportunity Commission (EEOC) filed suit on behalf of Robert A. Pinard, who was denied permission for a flexible work schedule to accommodate side effects from experimental AIDS treatment. Since Pinard accomplished the bulk of his work at a computer terminal, he contended that he could perform his job from home using a personal computer and modem. The Spectacor Management Company denied that request and tried to force him to take family leave or go on disability. The EEOC suit charged that the Spectacor violated the Americans with Disabilities (ADA) Act by refusing to allow the employee reasonable accommodation. A confidential settlement was reached in June of 1995.     

Exploring the association of dual use of the VHA and Medicare with mortality: separating the contributions of inpatient and outpatient services

Background  

Older veterans may use both the Veterans Health Administration (VHA) and Medicare, but the association of dual use with health outcomes is unclear. We examined the association of indirect measures of dual use with mortality.