A Decision-Support System to Schedule Rotations for Trainees.

Background: Each training program has its own internal policies and restrictions, which must be considered while developing trainee schedules. Designing these schedules is complex and time consuming, and the final schedules often contain undesirable aspects for trainees. Objective: We developed a decision-support system (DSS) to optimally schedule daily assignments and monthly rotations for trainees. The proposed DSS aims to 1) reduce the schedule development time, 2) maximize trainee preferences for desired rotations and vacation times, and 3) ensure adaptability of the DSS across multiple graduate medical programs through a flexible design and intuitive graphical user interface. Methods: Using mixed-integer linear programming, we developed a scheduling model that 1) maximized trainees' preferences on specific rotations and vacation times and 2) ensured fairness by assigning equal numbers of vacation days and a balanced schedule of difficult versus easy rotations among trainees. The model was successfully implemented in the Mayo Clinic Division of Pulmonary and Critical Care for the academic year 2018-2019. Results: Using the DSS, it took only a few minutes to produce a schedule versus several days of preparation time required by the manual process. Compared with the manually developed schedule, the DSS schedule satisfied 11% more rotation preferences and improved fairness by 19%. All trainees met duty hours in the DSS schedule compared with 83% in the manually developed schedule. Conclusion: The proposed DSS can dramatically reduce the schedule preparation time, accommodate more of trainees' preferences, and improve fairness in assigning rotations.

Non-invasive Hemoglobin Measurement Predictive Analytics with Missing Data and Accuracy Improvement Using Gaussian Process and Functional Regression Model.

Recent use of noninvasive and continuous hemoglobin (SpHb) concentration monitor has emerged as an alternative to invasive laboratory-based hematological analysis. Unlike delayed laboratory based measures of hemoglobin (HgB), SpHb monitors can provide real-time information about the HgB levels. Real-time SpHb measurements will offer healthcare providers with warnings and early detections of abnormal health status, e.g., hemorrhagic shock, anemia, and thus support therapeutic decision-making, as well as help save lives. However, the finger-worn CO-Oximeter sensors used in SpHb monitors often get detached or have to be removed, which causes missing data in the continuous SpHb measurements. Missing data among SpHb measurements reduce the trust in the accuracy of the device, influence the effectiveness of hemorrhage interventions and future HgB predictions. A model with imputation and prediction method is investigated to deal with missing values and improve prediction accuracy. The Gaussian process and functional regression methods are proposed to impute missing SpHb data and make predictions on laboratory-based HgB measurements. Within the proposed method, multiple choices of sub-models are considered. The proposed method shows a significant improvement in accuracy based on a real-data study. Proposed method shows superior performance with the real data, within the proposed framework, different choices of sub-models are discussed and the usage recommendation is provided accordingly. The modeling framework can be extended to other application scenarios with missing values.

Predicting Risk of Surgery in Patients With Small Bowel Crohn's Disease Strictures Using Computed Tomography and Magnetic Resonance Enterography.

BACKGROUND: We aimed to determine if patient symptoms and computed tomography enterography (CTE) and magnetic resonance enterography (MRE) imaging findings can be used to predict near-term risk of surgery in patients with small bowel Crohn's disease (CD). METHODS: CD patients with small bowel strictures undergoing serial CTE or MRE were retrospectively identified. Strictures were defined by luminal narrowing, bowel wall thickening, and unequivocal proximal small bowel dilation. Harvey-Bradshaw index (HBI) was recorded. Stricture observations and measurements were performed on baseline CTE or MRE and compared to with prior and subsequent scans. Patients were divided into those who underwent surgery within 2 years and those who did not. LASSO (least absolute shrinkage and selection operator) regression models were trained and validated using 5-fold cross-validation. RESULTS: Eighty-five patients (43.7 ± 15.3 years of age at baseline scan, majority male [57.6%]) had 137 small bowel strictures. Surgery was performed in 26 patients within 2 years from baseline CTE or MRE. In univariate analysis of patients with prior exams, development of stricture on the baseline exam was associated with near-term surgery (P = .006). A mathematical model using baseline features predicting surgery within 2 years included an HBI of 5 to 7 (odds ratio [OR], 1.7 × 105; P = .057), an HBI of 8 to 16 (OR, 3.1 × 105; P = .054), anastomotic stricture (OR, 0.002; P = .091), bowel wall thickness (OR, 4.7; P = .064), penetrating behavior (OR, 3.1 × 103; P = .096), and newly developed stricture (OR: 7.2 × 107; P = .062). This model demonstrated sensitivity of 67% and specificity of 73% (area under the curve, 0.62). CONCLUSIONS: CTE or MRE imaging findings in combination with HBI can potentially predict which patients will require surgery within 2 years.

Computed tomography and magnetic resonance enterography imaging measurements and observations, in combination with patient symptoms, can potentially predict which patients will require surgery within 2 years with modest degree of accuracy.

A discrete event simulation to evaluate impact of radiology process changes on emergency department computed tomography access.

BACKGROUND: Hospitals face the challenge of managing demand for limited computed tomography (CT) resources from multiple patient types while ensuring timely access. METHODS: A discrete event simulation model was created to evaluate CT access time for emergency department (ED) patients at a large academic medical center with six unique CT machines that serve unscheduled emergency, semi-scheduled inpatient, and scheduled outpatient demand. Three operational interventions were tested: adding additional patient transporters, using an alternative creatinine lab, and adding a registered nurse dedicated to monitoring CT patients in the ED. RESULTS: All interventions improved access times. Adding one or two transporters improved ED access times by up to 9.8 minutes (Mann-Whitney (MW) CI: [-11.0,-8.7]) and 10.3 minutes (MW CI [-11.5, -9.2]). The alternative creatinine and RN interventions provided 3-minute (MW CI: [-4.0, -2.0]) and 8.5-minute (MW CI: [-9.7, -8.3]) improvements. CONCLUSIONS: Adding one transporter provided the greatest combination of reduced delay and ability to implement. The projected simulation improvements have been realized in practice.

Mapping of critical events in disease progression through binary classification: Application to amyotrophic lateral sclerosis.

BACKGROUND: The progression of many degenerative diseases is tracked periodically using scales evaluating functionality in daily activities. Although estimating the timing of critical events (i.e., disease tollgates) during degenerative disease progression is desirable, the necessary data may not be readily available in scale records. Further, analysis of disease progression poses data challenges, such as censoring and misclassification errors, which need to be addressed to provide meaningful research findings and inform patients. METHODS: We developed a novel binary classification approach to map scale scores into disease tollgates to describe disease progression leveraging standard/modified Kaplan-Meier analyses. The approach is demonstrated by estimating progression pathways in amyotrophic lateral sclerosis (ALS). Tollgate-based ALS Staging System (TASS) specifies the critical events (i.e., tollgates) in ALS progression. We first developed a binary classification predicting whether each TASS tollgate was passed given the itemized ALSFRS-R scores using 514 ALS patients' data from Mayo Clinic-Rochester. Then, we utilized the binary classification to translate/map the ALSFRS-R data of 3,264 patients from the PRO-ACT database into TASS. We derived the time trajectories of ALS progression through tollgates from the augmented PRO-ACT data using Kaplan-Meier analyses. The effects of misclassification errors, condition-dependent dropouts, and censored data in trajectory estimations were evaluated with Interval Censored Kaplan Meier Analysis and Multistate Model for Panel Data. RESULTS: The approach using Mayo Clinic data accurately estimated tollgate-passed states of patients given their itemized ALSFRS-R scores (AUCs > 0.90). The tollgate time trajectories derived from the augmented PRO-ACT dataset provide valuable insights; we predicted that the majority of the ALS patients would have modified arm function (67%) and require assistive devices for walking (53%) by the second year after ALS onset. By the third year, most (74%) ALS patients would occasionally use a wheelchair, while 48% of the ALS patients would be wheelchair-dependent by the fourth year. Assistive speech devices and feeding tubes were needed in 49% and 30% of the patients by the third year after ALS onset, respectively. The onset body region alters some tollgate passage time estimations by 1-2 years. CONCLUSIONS: The estimated tollgate-based time trajectories inform patients and clinicians about prospective assistive device needs and life changes. More research is needed to personalize these estimations according to prognostic factors. Further, the approach can be leveraged in the progression of other diseases.

Extended Patient Alone Time in Emergency Department Leads to Increased Risk of 30-Day Hospitalization.

OBJECTIVES: This study was conducted to describe patients at risk for prolonged time alone in the emergency department (ED) and to determine the relationship between clinical outcomes, specifically 30-day hospitalization, and patient alone time (PAT) in the ED. METHODS: An observational cohort design was used to evaluate PAT and patient characteristics in the ED. The study was conducted in a tertiary academic ED that has both adult and pediatric ED facilities and of patients placed in an acute care room for treatment between May 1 and July 31, 2016, excluding behavioral health patients. Simple linear regression and t tests were used to evaluate the relationship between patient characteristics and PAT. Logistic regression was used to evaluate the relationship between 30-day hospitalization and PAT. RESULTS: Pediatric patients had the shortest total PAT compared with all older age groups (86.4 minutes versus 131 minutes, P < 0.001). Relationships were seen between PAT and patient characteristics, including age, geographic region, and the severity and complexity of the health condition. Controlling for Charlson comorbidity index and other potentially confounding variables, a logistic regression model showed that patients are more likely to be hospitalized within 30 days after their ED visit, with an odds ratio (95% confidence interval) of 1.056 (1.017-1.097) for each additional hour of PAT. CONCLUSIONS: Patient alone time is not equal among all patient groups. Study results indicate that PAT is significantly associated with 30-day hospitalization. This conclusion indicates that PAT may affect patient outcomes and warrants further investigation.

Using operative features to identify surgical complexity: a case in breast surgery practice.

Increasing workload is one of the main problems that surgical practices face. This increase is not only due to the increasing demand volume but also due to increasing case complexity. This raises the question on how to measure and predict the complexity to address this issue. Predicting surgical duration is critical to parametrize surgical complexity, improve surgeon satisfaction by avoiding unexpected overtime, and improve operation room utilization. Our objective is to utilize the historical data on surgical operations to obtain complexity groups and use this groups to improve practice.Our study first leverages expert opinion on the surgical complexity to identify surgical groups. Then, we use a tree-based method on a large retrospective dataset to identify similar complexity groups by utilizing the surgical features and using surgical duration as a response variable. After obtaining the surgical groups by using two methods, we statistically compare expert-based grouping with the data-based grouping. This comparison shows that a tree-based method can provide complexity groups similar to the ones generated by an expert by using features that are available at the time of surgical listing. These results suggest that one can take advantage of available data to provide surgical duration predictions that are data-driven, evidence-based, and practically relevant.

Unnecessary wait hours: a novel ED system-level metric.

BACKGROUND: Emergency department (ED) operations leaders are under increasing pressure to make care delivery more efficient. Publicly reported ED efficiency metrics are traditionally patient centred and do not show situational or facility-based improvement opportunities. We propose the consideration of a novel metric, the 'Number of Unnecessary Waits (NUW)' and the corresponding 'Unnecessary Wait Hours (UWH)', to measure space efficiency, and we describe how we used NUW to evaluate operational changes in our ED. METHODS: UWH summarises the relationship between the number of available rooms and the number of patients waiting by returning a value equal to the number of unnecessary patient waits. We used this metric to evaluate reassigning a clinical technician assistant (CTA) to the new role of flow CTA. RESULTS: We retrospectively analysed 3.5 months of data from before and after creation of the flow CTA. NUW metric analysis suggested that the flow CTA decreased the amount of unnecessary wait hours, while higher patient volumes had the opposite effect. CONCLUSIONS: Situational system-level metrics may provide a new dimension to evaluating ED operational efficiencies. Studies focussed on system-level metrics to evaluate an ED practice are needed to understand the role these metrics play in evaluation of a department's operations.

PNaV: A tool for generating a high-dose-rate brachytherapy treatment plan by navigating the Pareto surface guided by the visualization of multidimensional trade-offs.

PURPOSE: A Pareto Navigation and Visualization (PNaV) tool is presented for interactively constructing a high-dose-rate (HDR) brachytherapy treatment plan by navigating and visualizing the multidimensional Pareto surface. PNaV aims to improve treatment planning time and quality and is generalizable to any number of dose-volume histogram (DVH) and convex dose metrics. METHODS AND MATERIALS: Pareto surface visualization and navigation were demonstrated for prostate, breast, and cervix HDR brachytherapy sites. A library of treatment plans was created to span the Pareto surfaces over a 30% range of doses in each of five DVH metrics. The PNaV method, which uses a nonnegative least-squares model to interpolate the library plans, was compared against pure optimization for 11,250 navigated plans using data envelopment analysis. The visualization of the metric trade-offs was accomplished using numerically estimated partial derivatives to plot the local curvature of the Pareto surface. PNaV enables the user to control both the magnitude and direction of the trade-off during navigation. RESULTS: Proof of principle of PNaV was demonstrated using a graphical user interface with visualization tools to enabled rapid plan selection and a quantitative review of metric trade-offs. PNaV produced deliverable plans with DVH metrics within < 0.4%, 0.6%, and 1.1% (95% confidence interval) of the Pareto surface using plan libraries with nominal plan spacing of 10%, 15%, and 30% in each metric dimension, respectively. The interpolation used for the navigation executed in 0.1 s. The fast interpolation allows for quick and efficient exploration of trade-off options by the physician, after an initial preprocessing step to generate the library. CONCLUSIONS: Generation, visualization, and navigation of the Pareto surface were validated for brachytherapy treatment planning. The PNaV method enables efficient and informed decision-making for radiotherapy.

Attitudes and Behavior of Health Care Workers Before, During, and After Implementation of Real-Time Location System Technology.

OBJECTIVE: To assess how staff attitudes before, during, and after implementation of a real-time location system (RTLS) that uses radio-frequency identification tags on staff and patient identification badges and on equipment affected staff's intention to use and actual use of an RTLS. PARTICIPANTS AND METHODS: A series of 3 online surveys were sent to staff at an emergency department with plans to implement an RTLS between June 1, 2015, and November 29, 2016. Each survey corresponded with a different phase of implementation: preimplementation, midimplementation, and postimplementation. Multiple logistic regression with backward elimination was used to assess the relationship between demographic variables, attitudes about RTLSs, and intention to use or actual use of an RTLS. RESULTS: Demographic variables were not associated with intention to use or actual use of the RTLS. Before implementation, poor perceptions about the technology's usefulness and lack of trust in how employers would use tracking data were associated with weaker intentions to use the RTLS. During and after implementation, attitudes about the technology's use, not issues related to autonomy and privacy, were associated with less use of the technology. CONCLUSION: Real-time location systems have the potential to assess patterns of health care delivery that could be modified to reduce costs and improve the quality of care. Successful implementation, however, may hinge on how staff weighs attitudes and concerns about their autonomy and personal privacy with organizational goals. With the large investments required for new technology, serious consideration should be given to address staff attitudes about privacy and technology in order to assure successful implementation.

A new optimization algorithm for HDR brachytherapy that improves DVH-based planning: Truncated Conditional Value-at-Risk (TCVaR).

Purpose:To introduce a new optimization algorithm that improves DVH results and is designed for the type of heterogeneous dose distributions that occur in brachytherapy.Methods:The new optimization algorithm is based on a prior mathematical approach that uses mean doses of the DVH metric tails. The prior mean dose approach is referred to as conditional value-at-risk (CVaR), and unfortunately produces noticeably worse DVH metric results than gradient-based approaches. We have improved upon the CVaR approach, using the so-called Truncated CVaR (TCVaR), by excluding the hottest or coldest voxels in the structure from the calculations of the mean dose of the tail. Our approach applies an iterative sequence of convex approximations to improve the selection of the excluded voxels. Data Envelopment Analysis was used to quantify the sensitivity of TCVaR results to parameter choice and to compare the quality of a library of 256 TCVaR plans created for each of prostate, breast, and cervix treatment sites with commercially-generated plans.Results:In terms of traditional DVH metrics, TCVaR outperformed CVaR and the improvements increased monotonically as more iterations were used to identify and exclude the hottest/coldest voxels from the optimization problem. TCVaR also outperformed the Eclipse-Brachyvision TPS, with an improvement in PTVD95% (for equivalent organ-at-risk doses) of up to 5% (prostate), 3% (breast), and 1% (cervix).Conclusions:A novel optimization algorithm for HDR treatment planning produced plans with superior DVH metrics compared with a prior convex optimization algorithm as well as Eclipse-Brachyvision. The algorithm is computationally efficient and has potential applications as a primary optimization algorithm or quality assurance for existing optimization approaches.

Characterization of emergency department abandonment using a real-time location system.

BACKGROUND: Patients who present to emergency departments (EDs) for evaluation but are noted to have left without being seen (LWBS) are potentially at great risk. Governmental agencies, such as the Centers for Medicare and Medicaid, as well as hospitals and health organizations, are examining the factors which drive LWBS, including accurately quantifying patient tolerance to wait times and targeting interventions to improve patient tolerance to waiting. OBJECTIVE: Compare traditional methods of estimating time to LWBS with an objective method using a real-time location tracking system (RTLS); examine temporal factors associated with greater LWBS rates. METHODS: This is a retrospective cohort study of all ED visits to a large, suburban, quaternary care hospital in one calendar year. LWBS was calculated as patient registration to nurse recognition and documentation of patient abandonment (traditional method) vs registration to last onsite RTLS timestamp (study method). Descriptives of patterns of patient abandonment rates and patient demographic data were also included. RESULTS: Our study shows that traditional methods of measuring LWBS times significantly overestimate actual patient tolerance to waiting times (median 70, mean 92 min). Patients triaged to resource intensive categories (Emergency Severity Index (ESI) 2, 3) wait longer than patients triaged to less resource intensive categories (ESI 4, 5). CONCLUSION: Compared to traditional methods, RTLS is an efficient and accurate way to measure LWBS rates and helps set the stage for assessing the efficacy of interventions to reduce LWBS and reduce the gap between those seeking evaluation at emergency departments and those ultimately receiving it.

CCMapper: An adaptive NLP-based free-text chief complaint mapping algorithm.

OBJECTIVE: Chief complaint (CC) is among the earliest health information recorded at the beginning of a patient's visit to an emergency department (ED). We propose a heuristic methodology for automatically mapping the free-text data into a structured list of CCs. METHODS: A comprehensive structured list categorizing CCs was developed by experienced Emergency Medicine (EM) physicians. Using this list, we developed a natural language processing-based algorithm, referred to as Chief Complaint Mapper (CCMapper), for automatically mapping a CC into the most appropriate category (ies). We trained and validated CCMapper using free-text CC data from the Mayo Clinic ED in Rochester, MN. We developed a consensus-based validation approach to handle both indifferences and disagreements between the two EM physicians who manually mapped a random sample of free-text CCs into categories within the structured list. RESULTS: The kappa statistic demonstrated a high level of agreement (κ = 0.958) between the two physicians with less than 2% human error. CCMapper achieved a total sensitivity of 94.2% with a specificity of 99.8% and F-score of 94.7% on the validation set. The sensitivity of CCMapper when mapping free-text data with multiple CCs was 82.3% with a specificity of 99.1% and total F-score of 82.3%. CONCLUSION: Due to its simplicity, high performance, and capability of incorporating new free-text CC data, CCMapper can be readily adopted by other EDs to support clinical decision making. CCMapper can facilitate the development of predictive models for the type and timing of important events in ED (e.g., ICU admission).

Pattern-based strategic surgical capacity allocation.

Strategic allocation of limited operating room (OR) capacity to surgeons is crucial for the coordination of surgical work flow, including planning of consultation and surgery days, and staff assignment to perioperative teams. However, it is a challenging problem in practice, since the capacity allocation needs to be cyclic for schedule predictability and surgical team coordination, and also needs to satisfy surgeons' preferences. It is further complicated by the practice of surgeons sharing ORs. In this study, we propose a mathematical optimization model to coordinate capacity allocation among surgeons in order to improve the utilization of surgical capacity. We introduce the concept of capacity allocation patterns to account for schedule cyclicity and surgeons' preferences. Further, we develop a data-driven approach to coordinate OR sharing among surgeons based on their historical OR usage. The proposed methodology is applied to a case study with data from a surgical division at Mayo Clinic. Compared with the state-of-the-practice, the proposed approach shows a substantial potential in reducing the maximum number of ORs allocated daily to the division with little overtime. With a solution time of less than 0.5 s, the proposed methodology can be readily used as a decision support tool in surgical practice.

A Time-Driven Activity-Based Costing Analysis of Emergency Department Scribes.

OBJECTIVE: To apply time-driven activity-based costing (TDABC) methodology to determine emergency medicine physician documentation costs with and without scribes. METHODS: This was a prospective observation cohort study in a large academic emergency department. Two research assistants with experience in physician-scribe interactions and ED workflow shadowed attending physicians for a total of 64 hours in the adult emergency department. A tablet-based time recorded was used to obtain estimates for physician documentation time on both control (no scribe) and intervention (scribe) shifts. RESULTS: Control shifts yielded approximately 3 hours of documentation time per 8 hours of clinical time (2 hours during the shift, 1 hour following the shift). When paired with a scribe, attending physician documentation decreased to 1 hour and 45 minutes during a shift and 15 minutes of postshift documentation. The physician cost estimate for documentation without and with a scribe is 644 and 488 dollars, respectively. CONCLUSIONS: When one looks at the time saved by the provider, scribes appear to be a financially sound decision. TDABC methodology demonstrated that scribes afford a cost-effective solution to ED clinical documentation and serves as a tool to develop an accurate costing system, based on actual resources and processes, and allowed for understanding of resource use at a more granular level.

Tollgate-based progression pathways of ALS patients.

OBJECTIVE: To capture ALS progression in arm, leg, speech, swallowing, and breathing segments using a disease-specific staging system, namely tollgate-based ALS staging system (TASS), where tollgates refer to a set of critical clinical events including having slight weakness in arms, needing a wheelchair, needing a feeding tube, etc. METHODS: We compiled a longitudinal dataset from medical records including free-text clinical notes of 514 ALS patients from Mayo Clinic, Rochester-MN. We derived tollgate-based progression pathways of patients up to a 1-year period starting from the first clinic visit. We conducted Kaplan-Meier analyses to estimate the probability of passing each tollgate over time for each functional segment. RESULTS: At their first clinic visit, 93%, 77%, and 60% of patients displayed some level of limb, bulbar, and breathing weakness, respectively. The proportion of patients at milder tollgate levels (tollgate level < 2) was smaller for arm and leg segments (38% and 46%, respectively) compared to others (> 65%). Patients showed non-uniform TASS pathways, i.e., the likelihood of passing a tollgate differed based on the affected segments at the initial visit. For instance, stratified by impaired segments at the initial visit, patients with limb and breathing impairment were more likely (62%) to use bi-level positive airway pressure device in a year compared to those with bulbar and breathing impairment (26%). CONCLUSION: Using TASS, clinicians can inform ALS patients about their individualized likelihood of having critical disabilities and assistive-device needs (e.g., being dependent on wheelchair/ventilation, needing walker/wheelchair or communication devices), and help them better prepare for future.

Patient-Care Team Contact Patterns Impact Treatment Length of Stay in the Emergency Department.

Real-time location systems (RTLS) has found extensive application in the healthcare setting, that is shown to improve safety, save cost, and increase patient satisfaction. More specifically, some studies have shown the efficacy of RTLS leading to an improved workflow in the emergency department. However, due to substantial implementation costs of such technologies, hospital administrators show reluctance in RTLS adoption. Our previous preliminary studies with RFID data in the emergency department (ED) demonstrated for the first time the quantification of `patient alone time' and its relationship to outcomes such as 30-day hospitalization. In this study, we use ED RTLS data to analyze patient-care team contact time (PCTCT) and its relationship to the total treatment length of stay (LOS) in ED. An observational cohort study was performed in the ED using RTLS data from Jan 17 - Sep 17, 2017, which included a total of 51,697 patients. PCTCT within the first hour of a patient's placement in a treatment bed was calculated and its relationship to treatment LOS was analyzed while controlling for confounding factors affecting treatment LOS. Results show that treatment LOS is highly correlated with the ED crowding captured by the patient-perprovider ratio, negatively correlated to the physician and resident visit frequency, and positively correlated to nurse visit frequency. The results can inform designing new guidelines for ideal patient-care team interactions and be used to determine optimal ED staffing levels and care team composition for effective care delivery.

Getting to the Heart of the Matter: A Triage Model to Improve Utilization of Cardiology Consultative Services.

OBJECTIVE: To assess the impact of a triage system of emergency department (ED) referrals for outpatient cardiology appointments. PATIENT AND METHODS: We implemented a triage system of ED referrals for outpatient cardiology appointments among patients with a cardiovascular chief complaint deemed safe to leave the ED but needing outpatient follow-up. There were 303 and 267 unique patients in the pre-triage implementation and post-triage implementation cohorts, respectively. We collected retrospective billing data to assess ED return visits, hospitalizations, cardiology outpatient visits, and cardiovascular testing. The pre-triage implementation cohort included patients with an ED visit date between January 1, 2014, and December 31, 2014. The post-triage implementation cohort included patients with an ED visit date between July 1, 2015, and June 30, 2016. RESULTS: The triage model reduced the number of ED-referred cardiovascular service appointments by 73.0% (195 of 267 patients). Additionally, the "no-show" rate for appointments decreased from 17.8% (54 of 303 patients) to 7.9% (21 of 267 patients). There was no increase in ED return visits or unplanned hospitalizations in the posttriage cohort. Finally, the triage model was not associated with an increase in resource-intensive cardiovascular testing (eg, imaging stress tests or computed tomography). CONCLUSION: Triage of ED referrals for outpatient cardiovascular service appointments reduced cardiology appointment utilization with no impact on return ED visits, hospitalizations, or cardiovascular testing.

Improving Accuracy of Noninvasive Hemoglobin Monitors: A Functional Regression Model for Streaming SpHb Data.

OBJECTIVE: The purpose of this paper is to develop a method for improving the accuracy of SpHb monitors, which are noninvasive hemoglobin monitoring tools, leading to better critical care protocols in trauma care. METHODS: The proposed method is based on fitting smooth spline functions to SpHb measurements collected over a time window and then using a functional regression model to predict the true HgB value for the end of the time window. RESULTS: The accuracy of the proposed method is compared to traditional methods. The mean absolute error between the raw SpHb measurements and the gold standard hemoglobin measurements was 1.26 g/Dl. The proposed method reduced the mean absolute error to 1.08 g/Dl. [1] Conclusion: Fitting a smooth function to SpHb measurements improves the accuracy of Hgb predictions. SIGNIFICANCE: Accurate prediction of current and future HgB levels can lead to sophisticated decision models that determine the optimal timing and amount of blood product transfusions.

Application of Constrained Optimization Methods in Health Services Research: Report 2 of the ISPOR Optimization Methods Emerging Good Practices Task Force.

BACKGROUND: Constrained optimization methods are already widely used in health care to solve problems that represent traditional applications of operations research methods, such as choosing the optimal location for new facilities or making the most efficient use of operating room capacity. OBJECTIVES: In this paper we illustrate the potential utility of these methods for finding optimal solutions to problems in health care delivery and policy. To do so, we selected three award-winning papers in health care delivery or policy development, reflecting a range of optimization algorithms. Two of the three papers are reviewed using the ISPOR Constrained Optimization Good Practice Checklist, adapted from the framework presented in the initial Optimization Task Force Report. The first case study illustrates application of linear programming to determine the optimal mix of screening and vaccination strategies for the prevention of cervical cancer. The second case illustrates application of the Markov Decision Process to find the optimal strategy for treating type 2 diabetes patients for hypercholesterolemia using statins. The third paper (described in Appendix 1) is used as an educational tool. The goal is to describe the characteristics of a radiation therapy optimization problem and then invite the reader to formulate the mathematical model for solving it. This example is particularly interesting because it lends itself to a range of possible models, including linear, nonlinear, and mixed-integer programming formulations. From the case studies presented, we hope the reader will develop an appreciation for the wide range of problem types that can be addressed with constrained optimization methods, as well as the variety of methods available. CONCLUSIONS: Constrained optimization methods are informative in providing insights to decision makers about optimal target solutions and the magnitude of the loss of benefit or increased costs associated with the ultimate clinical decision or policy choice. Failing to identify a mathematically superior or optimal solution represents a missed opportunity to improve economic efficiency in the delivery of care and clinical outcomes for patients. The ISPOR Optimization Methods Emerging Good Practices Task Force's first report provided an introduction to constrained optimization methods to solve important clinical and health policy problems. This report also outlined the relationship of constrained optimization methods relative to traditional health economic modeling, graphically illustrated a simple formulation, and identified some of the major variants of constrained optimization models, such as linear programming, dynamic programming, integer programming, and stochastic programming. The second report illustrates the application of constrained optimization methods in health care decision making using three case studies. The studies focus on determining optimal screening and vaccination strategies for cervical cancer, optimal statin start times for diabetes, and an educational case to invite the reader to formulate radiation therapy optimization problems. These illustrate a wide range of problem types that can be addressed with constrained optimization methods.