Curing Inefficiency in Healthcare

The new healthcare reform law aims to make large-scale improvements to the nation's healthcare system. But even small changes in health settings can produce meaningful results. Assistant professors Donald Lee and Elisa Long are among a growing body of operations researchers who are using the tools of their field to make healthcare delivery more efficient and cost-effective.

"The U.S. spends 16% of its GDP on healthcare," says Lee. "If every hospital could implement simple changes to save a few thousand dollars here and there, that would have a significant impact on the national healthcare budget."

"In the recent healthcare legislation," adds Long, "there was talk about comparative effectiveness and cost-effectiveness. Our nation spends so much money on healthcare, yet we don't get as much benefit from it as we can. So the fundamental question is, can we be better at allocating limited healthcare resources?"

Long builds decision analytic models of healthcare interventions to look at their cost-effectiveness. Much of her research focuses on the HIV epidemic. She has examined HIV resource allocation, for example, identifying the most effective portfolio of HIV interventions that can be applied to the particular epidemics in various regions including, Russia, India, and Uganda. She also developed a mathematical model to assess the cost-effectiveness of partially effective vaccines. In a new project, the CDC has asked Long to update this model with new clinical trial data.

"They want to know how good a vaccine needs to be before they consider implementing it. What essential characteristics would it have? How many infections could it prevent? Who should be targeted for vaccination? It's exciting to apply these research methodologies to a real-world policy question."

Lee's research uses statistical learning ideas to optimize healthcare delivery. He develops methods to extract information from large data sets that can be used to make decisions in healthcare. He has studied pay for performance in the dialysis industry from such data, gleaning dialysis providers' responses to financial incentives by examining how they react to changes in Medicare payment rates.

"Knowledge of the providers' profit motives allows Medicare to adjust its payment system to induce higher quality of care from providers. That's an important premise of pay for performance."

Lee and his colleagues are also building a decision tool to help patients who need kidney transplants. Patients will be able to enter characteristics like gender, ethnicity, and blood type, and get customized predictions of how long they can expect to wait to receive a cadaveric donor kidney and of their mortality rate. "Given these two things, they can judge for themselves whether it's better to approach a relative for a live donation now or keep waiting for a cadaveric donor. The key question is, how do you estimate the uncertain wait time?"

This same question lies behind a project that Lee and Long are collaborating on to improve patient triage in Yale-New Haven Hospital's Emergency Department. Like most hospitals, Yale-New Haven is seeing increased demand as people without insurance use the emergency room for primary care. The result is an overloaded system where the least-sick patients end up waiting hours to be seen and many leave before they receive care.

"You only know that they left sometime between registration and being called for treatment," says Lee. "If we can estimate when a patient's propensity to abandon the triage increases sharply, say after waiting an hour, then that immediately gives us a ballpark for what the target maximum wait time should be."

Once they learn about how long it takes patients to be served, Lee and Long will turn to a traditional operations research tool. "We're going to build a simple queuing model and simulate the effects on patient wait time if on certain days, the emergency department expands upstairs to a suite of overflow beds, using a real-time decision tool," explains Long.
"There are simple things that can be done to squeeze out inefficiencies from the healthcare system. Right now they are just sitting there like low-hanging fruit," concludes Lee.