考虑空间随机需求的急救站点选址规划

随着人民生活水平的提高和人口老龄化加剧，公众对急救医疗服务的要求越来越高。为保证急救需求的响应及时性，急救站点的选址规划问题受到广泛关注。急救站点选址的依据是需求的分布，然而现有研究未能充分考虑急救需求在空间分布上的随机性影响，通常将其空间分布简化为若干个集中需求点，或将规划空间划分为若干矩形网格，然而这种需求刻画过于粗略，导致需求覆盖水平的计算不够准确，影响配置方案的有效性。针对该问题，本研究应用高斯混合模型解决了急救需求的空间分布刻画问题，创新性地提出基于高斯混合聚类的站点选址规划方法，考虑急救需求时空随机性，建立了相应的机会约束规划模型。实际数据的验证分析表明，该选址方法能够显著减少服务延误时间和次数，保证急救服务的响应及时性。     

A Lean transportation approach for improving emergency medical operations

Abstract

This paper extends the approach of Lean transportation to improve the performance of emergency medical processes (EMP) by adapting its main concepts into the main characteristics of the EMP environment. The paper is based on an inductive theory-building process initiated from a case study in the field of emergency medical services. The development of the suggested performance improvement approach triggered from an exhaustive analysis of a process involved and an exploratory review of the existing improvement approaches available. The process of concern can be described as a specialized transportation process, where human lives are at risk. Its characteristics led to a natural application of Lean transportation. The results include, a novel approach for improving the agility and efficient EMS processes. This is validated with an application for improving ambulance response times and turnaround times of the Red Cross operations located in Monterrey, Mexico. The approach proved to be an integrated scheme for identifying waste opportunities at a systems level. This characteristic is important to let operations management prioritize improvement efforts in a limited budget situation. This work suggests the application of the emerging Lean transportation approach for increasing the agility performance of EMS processes.     

Analysis and optimization of an ambulance offload delay and allocation problem

Ambulance offload delays have recently become one of the most significant operational challenges for Emergency Medical Services (EMS) providers. Offload delays occur when an ambulance arriving at a hospital Emergency Department (ED) is blocked until a bed becomes available for the patient. To formally investigate the effect of patient routing decisions on EMS offload delays, we introduce a stylized queueing network model with blocking. Following a decomposition approach, we develop an approximation scheme to find explicit solutions that can be used to find proper patient allocation policies to multiple hospitals in a region. We introduce a Markov chain representation for a single ED network and solve for its exact steady state distribution. A comprehensive numerical study is carried out to validate the approximation approaches and to gain insight into ambulance offload delays. By keeping the total offload delays at minimal levels, we observe that it is better to load larger EDs more heavily than smaller ones due to resource pooling.     

震后多目标动态应急医疗设施选址-伤员转运问题研究

地震等灾害的突发性和破坏性常导致部分伤员无法得到快速有效的救治，同时会给伤员造成一定的负面心理，影响救援效率。本文综合考虑救护车辆（救护车、直升机）和医疗设施容量的动态变化、各类伤员生存概率随时间动态变化以及伤员心理状况变化，构建了最大化伤员生存数量和最小化心理成本的震后伤员二级后送模式的医疗设施选址-伤员转运双目标动态规划模型。运用epsilon约束法有效处理双目标模型，以玉树地震后伤员后送问题为例，采用CPLEX对模型进行求解，通过分析医疗资源数量对伤员转运数量的影响，表明在伤员后送过程中，增加临时医院数量或容量与救护车数量比增加后方医院数量或容量与直升机数量更有效；考虑伤员的心理成本，为了提高伤员存活率，在灾害前期，可以通过增加救护车数量，转运更多的重伤员，而中后期提高临时医院容量，尽量优先转运轻伤员。     

A nested-compliance table policy for emergency medical service systems under relocation

The goal of Emergency Medical Service (EMS) systems is to provide rapid response to emergency calls in order to save lives. This paper proposes a relocation strategy to improve the performance of EMS systems. In practice, EMS systems often use a compliance table to relocate ambulances. A compliance table specifies ambulance base stations as a function of the state of the system. We consider a nested-compliance table, which restricts the number of relocations that can occur simultaneously. We formulate the nested-compliance table model as an integer programming model in order to maximize expected coverage. We determine an optimal nested-compliance table policy using steady state probabilities of a Markov chain model with relocation as input parameters. These parameter approximations are independent of the exact compliance table used. We assume that there is a single type of medical unit, single call priority, and no patient queue. We validate the model by applying the nested-compliance table policies in a simulated system using real-world data. The numerical results show the benefit of our model over a static policy based on the adjusted maximum expected covering location problem (AMEXCLP).     

A multi-period ambulance location and allocation problem in the disaster

To achieve quick response in the disaster, this paper addresses the issue of ambulance location and allocation, as well as the location problem of temporary medical centers. Considering budget and capacity limitations, a multi-period mixed integer programming model is proposed and two hybrid heuristic algorithms are designed to solve this complex problem. The proposed model and algorithm are further verified in a real case study, and the numerical experiments demonstrate the effectiveness of our proposed model. Specifically, we obtain several findings based on the computational results: (1) The best locations of ambulance stations should change in each period because the demand rate changes over time. (2) Involving temporary medical centers is necessary to reduce the average waiting time of injured people. (3) It may not be optimal to allocate ambulances from the nearest ambulance stations because of potentially limited station capacity.

     

Modeling Rabbit Responses to Single and Multiple Aerosol Exposures of Bacillus anthracis Spores

Survival models are developed to predict response and time‐to‐response for mortality in rabbits following exposures to single or multiple aerosol doses of Bacillus anthracis spores. Hazard function models were developed for a multiple‐dose data set to predict the probability of death through specifying functions of dose response and the time between exposure and the time‐to‐death (TTD). Among the models developed, the best‐fitting survival model (baseline model) is an exponential dose–response model with a Weibull TTD distribution. Alternative models assessed use different underlying dose–response functions and use the assumption that, in a multiple‐dose scenario, earlier doses affect the hazard functions of each subsequent dose. In addition, published mechanistic models are analyzed and compared with models developed in this article. None of the alternative models that were assessed provided a statistically significant improvement in fit over the baseline model. The general approach utilizes simple empirical data analysis to develop parsimonious models with limited reliance on mechanistic assumptions. The baseline model predicts TTDs consistent with reported results from three independent high‐dose rabbit data sets. More accurate survival models depend upon future development of dose–response data sets specifically designed to assess potential multiple‐dose effects on response and time‐to‐response. The process used in this article to develop the best‐fitting survival model for exposure of rabbits to multiple aerosol doses of B. anthracis spores should have broad applicability to other host–pathogen systems and dosing schedules because the empirical modeling approach is based upon pathogen‐specific empirically‐derived parameters.     

Reducing Hospital Readmissions by Integrating Empirical Prediction with Resource Optimization

Hospital readmissions present an increasingly important challenge for health‐care organizations. Readmissions are expensive and often unnecessary, putting patients at risk and costing $15 billion annually in the United States alone. Currently, 17% of Medicare patients are readmitted to a hospital within 30 days of initial discharge with readmissions typically being more expensive than the original visit to the hospital. Recent legislation penalizes organizations with a high readmission rate. The medical literature conjectures that many readmissions can be avoided or mitigated by post‐discharge monitoring. To develop a good monitoring plan it is critical to anticipate the timing of a potential readmission and to effectively monitor the patient for readmission causing conditions based on that knowledge. This research develops new methods to empirically generate an individualized estimate of the time to readmission density function and then uses this density to optimize a post‐discharge monitoring schedule and staffing plan to support monitoring needs. Our approach integrates classical prediction models with machine learning and transfer learning to develop an empirical density that is personalized to each patient. We then transform an intractable monitoring plan optimization with stochastic discharges and health state evolution based on delay‐time models into a weakly coupled network flow model with tractable subproblems after applying a new pruning method that leverages the problem structure. Using this multi‐methodologic approach on two large inpatient datasets, we show that optimal readmission prediction and monitoring plans can identify and mitigate 40–70% of readmissions before they generate an emergency readmission.     

A memetic algorithm for the patient transportation problem

This paper addresses a real-life public patient transportation problem derived from the Hong Kong Hospital Authority (HKHA), which provides ambulance transportation services for disabled and elderly patients from one location to another. We model the problem as a multi-trip dial-a-ride problem (MTDARP), which requires designing several routes for each ambulance. A route is a sequence of locations, starting and terminating at the depot (hospital), according to which the ambulance picks up clients at the origins and delivers them to the destinations. A route is feasible only if it satisfies a series of side constraints, such as the pair and precedence constraints, capacity limit, ride time, route duration limit and time windows. Owing to the route duration limit, in particular, every ambulance is scheduled to operate several routes during the working period. To prevent the spread of disease, the interior of the ambulances needs to be disinfected at the depot between two consecutive trips. The primary aim of the problem investigated herein is to service more requests with the given resources, and to minimize the total travel cost for the same number of requests. In this paper, we provide a mathematical formulation for the problem and develop a memetic algorithm with a customized recombination operator. Moreover, the segment-based evaluation method is adapted to examine the moves quickly. The performance of the proposed algorithm is assessed using the real-world data from 2009 and compared with results obtained by solving the mathematical model. In addition, the proposed algorithm is adapted to solve the classic DARP instances, and found to perform well on medium-scale instances.     

Power Outage Estimation for Tropical Cyclones: Improved Accuracy with Simpler Models

In this article, we discuss an outage‐forecasting model that we have developed. This model uses very few input variables to estimate hurricane‐induced outages prior to landfall with great predictive accuracy. We also show the results for a series of simpler models that use only publicly available data and can still estimate outages with reasonable accuracy. The intended users of these models are emergency response planners within power utilities and related government agencies. We developed our models based on the method of random forest, using data from a power distribution system serving two states in the Gulf Coast region of the United States. We also show that estimates of system reliability based on wind speed alone are not sufficient for adequately capturing the reliability of system components. We demonstrate that a multivariate approach can produce more accurate power outage predictions.     

Health economic modeling to support surgery management at a Swedish hospital

Elective surgery management typically deals with a queue of patients that have to be scheduled for surgery within a certain time frame, considering both medical and economic constraints. In order to prevent the patient queue and waiting times from growing, surgery management has to decide whether to temporarily increase patient throughput at the regional hospital or have some patients scheduled for surgery at another hospital. In Sweden, a newly passed law states that patients who decide to receive surgery should not have to wait more than 90 days before this surgery is carried out. Therefore, if a patient decides to apply the new law by requesting surgery within 90 days, the regional hospital is obliged to arrange and pay for either in-house surgery or surgery at another hospital. In this paper, we suggest an approach using simulation including optimization for modeling surgery management decisions. We study a case based on data from a General Surgery Department at a Swedish hospital and present our results as a health economic evaluation. The results indicate an increase in the mean waiting times for medium prioritized patients when the new law is applied.     

Modeling patient arrivals in community clinics

We develop improved methods for modeling and simulating the streams of patients arriving at a community clinic. In previous practice, random (unscheduled) patient arrivals were often assumed to follow an ordinary Poisson process (so the corresponding patient interarrival times were randomly sampled from an exponential distribution); and for scheduled arrivals, each patient's tardiness (i.e., the deviation from the scheduled appointment time) was often assumed to be randomly sampled from a normal distribution. A thorough analysis of patient arrival times, obtained from detailed workflow observations in nine community clinics, indicates these assumptions are not generally valid, and the tardiness data sets for this study are best modeled by unbounded Johnson distributions. We also propose a nonhomogeneous Poisson process to model the random patient arrivals; we review a nonparametric approach to estimating the associated mean-value function; and we describe an algorithm for generating random patient arrivals from the estimated model. The adequacy of this model of random patient arrivals can be assessed by standard goodness-of-fit tests. These findings are important since testable scheduling optimization strategies must be based upon accurate models for both random and scheduled patient arrivals. The impacts on modeling, as well as implications for practice management, are discussed.     

Shelf Space Management When Demand Depends on the Inventory Level

Two factors that their influence on the demand has been investigated in many papers are (i) the shelf space allocated to a product and to its complement or supplement products and (ii) the instantaneous inventory level seen by customers. Here we analyze the joint shelf space allocation and inventory decisions for multiple items with demand that depends on both factors. The traditional approach to solve inventory models with a state‐dependent demand rate uses a time domain approach. However, this approach often does not lead to closed‐form expressions for the profit rate with both dependencies. We analyze the problem in the inventory domain via level crossing theory. This approach leads to closed‐form expressions for a large set of demand rate functions exhibiting both dependencies. These closed‐form expressions substantially simplify the search for optimal solutions; thus we use them to solve the joint inventory control and shelf space allocation problem. We consider examples with two products to investigate the significance of capturing both demand dependencies. We show that in some settings it is important to capture both dependencies. We consider two heuristics, each one of them ignores one of the two dependencies. Using these heuristics it seems that ignoring the dependency on the shelf space might be less harmful than ignoring the dependency on the inventory level, which, based on computational results, can lead to profit losses of more than 6%. We demonstrate that retailers should use their operational control, e.g., reorder point, to promote higher demand products.     

Time-Dose-Response Models for Microbial Risk Assessment

While microbial risk assessment (MRA) has been used for over 25 years, traditional dose-response analysis has only predicted the overall risk of adverse consequences from exposure to a given dose. An important issue for consequence assessment from bioterrorist and other microbiological exposure is the distribution of cases over time due to the initial exposure. In this study, the classical exponential and beta-Poisson dose-response models were modified to include exponential-power dependency of time post inoculation (TPI) or its simplified form, exponential-reciprocal dependency of TPI, to quantify the time of onset of an effect presumably associated with the kinetics of in vivo bacterial growth. Using the maximum likelihood estimation approach, the resulting time-dose-response models were found capable of providing statistically acceptable fits to all tested pooled animal survival dose-response data. These new models can consequently describe the development of animal infectious response over time and represent observed responses fairly accurately. This is the first study showing that a time-dose-response model can be developed for describing infections initiated by various pathogens. It provides an advanced approach for future MRA frameworks.     

The Impact of Estimation: A New Method for Clustering and Trajectory Estimation in Patient Flow Modeling

The ability to accurately forecast and control inpatient census, and thereby workloads, is a critical and long‐standing problem in hospital management. The majority of current literature focuses on optimal scheduling of inpatients, but largely ignores the process of accurate estimation of the trajectory of patients throughout the treatment and recovery process. The result is that current scheduling models are optimizing based on inaccurate input data. We developed a Clustering and Scheduling Integrated (CSI) approach to capture patient flows through a network of hospital services. CSI functions by clustering patients into groups based on similarity of trajectory using a novel semi‐Markov model (SMM)‐based clustering scheme, as opposed to clustering by patient attributes as in previous literature. Our methodology is validated by simulation and then applied to real patient data from a partner hospital where we demonstrate that it outperforms a suite of well‐established clustering methods. Furthermore, we demonstrate that extant optimization methods achieve significantly better results on key hospital performance measures under CSI, compared with traditional estimation approaches, increasing elective admissions by 97% and utilization by 22% compared to 30% and 8% using traditional estimation techniques. From a theoretical standpoint, the SMM‐clustering is a novel approach applicable to any temporal‐spatial stochastic data that is prevalent in many industries and application areas.     

Bayesian Stacked Parametric Survival with Frailty Components and Interval‐Censored Failure Times: An Application to Food Allergy Risk

To better understand the risk of exposure to food allergens, food challenge studies are designed to slowly increase the dose of an allergen delivered to allergic individuals until an objective reaction occurs. These dose‐to‐failure studies are used to determine acceptable intake levels and are analyzed using parametric failure time models. Though these models can provide estimates of the survival curve and risk, their parametric form may misrepresent the survival function for doses of interest. Different models that describe the data similarly may produce different dose‐to‐failure estimates. Motivated by predictive inference, we developed a Bayesian approach to combine survival estimates based on posterior predictive stacking, where the weights are formed to maximize posterior predictive accuracy. The approach defines a model space that is much larger than traditional parametric failure time modeling approaches. In our case, we use the approach to include random effects accounting for frailty components. The methodology is investigated in simulation, and is used to estimate allergic population eliciting doses for multiple food allergens.     

考虑交通时间与设备转换时间的跨区域就医调度优化问题

在资源共享时代背景下,跨区域就医可以很好地解决患者日益增长的就医需求与医疗资源紧张的矛盾。本论文以医疗联盟为研究对象,在关键医疗资源共享的前提下,通过患者跨区域就医实现就医诊断延误最小化,以满足患者就医需求。本研究同时考虑了患者跨区域交通时间与基于患者诊断类型的设备转换时间,以最小化患者就医总延迟为目标,分配患者就诊医院及优化患者就诊/检查顺序。针对该问题,论文首次提出以最早交货期原则（EDD rule）为基础,以患者再分配为主导的EDD-ReAss1和EDD-ReAss2启发式算法,结合局部搜索算法以进一步提高就医调度方案的质量,缩短患者诊断/检查等待时间。实验结果表明,新启发式算法EDD-ReAss1和EDD-ReAss2算法性能显著好于EDD,SPT和LPT等调度规则;在较短运算时间内Swap局部搜索算法性能最优。     

WARRANTY COST ESTIMATION: A GOAL PROGRAMMING APPROACH

This paper proposes a goal programming approach to the warranty cost estimation problem. Past research on this topic has mostly dealt with a single objective—the minimization of the warranty reserve cost or the maximization of profit. A more realistic approach to warranty cost problems could, however, involve several goals, some of which might be conflicting to others. In this paper, three goals are prioritized. The goals considered are minimization of warranty reserve cost per unit, offering a minimum level of warranty time based on an allowable proportion of failures within the warranty period, and capturing a minimum specified market share of the product. An example is illustrated using the proposed formulation, and goal achievements are discussed.     

APPLICATION OF AN EXPECTED COVERING MODEL TO EMERGENCY MEDICAL SERVICE SYSTEM DESIGN*

The Emergency Medical Service (EMS) Act specifies the fraction of all demands for service that must be reached in a given amount of time for urban and rural areas. The conditions have traditionally been interpreted to apply to the case in which all EMS vehicles are available to respond to demands. A model that considers the probability of a vehicle being busy is formulated and model properties are briefly discussed. The model is then applied to two problems: a 55-node test case and a 33-node census tract representation of Austin, Texas. The implications of the new model for EMS system design are discussed as are the limitations of the modeling approach.