An Introduction to Operations Research
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An Introduction to Operations Research or How can I make my health program better? Dr. Mark Micek, MD, MPH December 4, 2008. The Issue. It is difficult to… …effectively deliver scientifically proven health interventions in the “real world” …translate research into health program settings

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An introduction to operations research or how can i make my health program better

An Introduction to Operations Research

or

How can I make my health program better?

Dr. Mark Micek, MD, MPH

December 4, 2008


The issue

The Issue

  • It is difficult to…

    …effectively deliver scientifically proven health interventions in the “real world”

    …translate research into health program settings

  • Why?

    • Research generally occurs in controlled settings

      • Homogenous sample, controlled setting

    • Health programs exist in a complex setting

      • Heterogeneous clients, multiple settings

      • Dependent on external context of care-delivery system

        • i.e. policy, resource availability ($ and personnel), community perceptions


Example of difficulty translating proven treatment into practice

Example of difficulty translating proven treatment into practice

  • HAART reduces mortality among patients with HIV

    • BUT many eligible HIV-positive people don’t start HAART


Example of difficulty translating proven treatment into practice1

Example of difficulty translating proven treatment into practice

  • Short-course ARV therapy can decrease mother-to-child HIV transmission

    • BUT few HIV+ women receive treatment

Data from: Evaluation of United Nations-Supported Pilot Projects for the Prevention of Mother-to-Child Transmission of HIV: Overview of Findings. UNICEF, New York, 2003.


How can we improve the performance of our programs in an evidence based way

How can we improve the performance of our programs in an evidence-based way?

  • Use the principles of Operations Research


What is or generic definition

What is OR?Generic definition

  • “Use of systematic research techniques for program decision-making to achieve a specified outcome.”

    • [Population Council, 2006]

  • Goal = find a best possible solution to improve performance of the organization

    • Early examples in military, business

    • Use data, statistics, mathematical modeling

  • Goal (health care) = “to increase the efficiency, effectiveness, and quality of services delivered by providers, and the availability, accessibility, and acceptability of services desired by users”

    • [Population Council, 2002]


3 core principles of or

3 Core Principles of OR

  • Study health programs

  • Actively try to make the program better

  • Use results to improve the program

    Corollary: requires collaboration between managers and researchers


Core principle of or 1 study health programs

Core principle of OR #1:Study health programs

  • Health program is key to health care delivery

    • OR usually focuses on existing program

  • Research problem = program problem

  • Research intervention = program solution

    • Feasible within context of entire system

  • Assures problems and solutions are defined by realities of the health program system

  • Without involvement of a health program, it’s not OR


Health program as system

Health program as system

Health Program

Under managers’ control

Effects of Health Program

Inputs

Process

Outputs

Outcomes

Impact

  • Raw Materials:

  • Finances

  • Costs

  • Staff

  • Facilities

  • Activities:

  • Trainings

  • Supervision

  • Logistics

  • Reporting

  • Record keeping

  • Patient flow strategies

  • Products of program activities:

  • # condoms distributed

  • # people tested for HIV

  • # enrolling for HIV care

  • Change in health/well-being

  • HIV/STD incidence

  • # deaths

  • Effect on knowledge or behavior:

  • # youth using condoms

  • # women using pMTCT services

  • # starting ART

  • % adhering to ART


Health programs are complex systems

Health programs are complex systems

Test for HIV

Enroll in HIV clinic

CD4 testing

Start HAART (if eligible)

Adhere to HAART

Schedule appt with clinician

Pt returns to get blood drawn

Enroll in HIV clinic

Return for appt with clinician

Clinician orders CD4

Time and drop-off

Time and drop-off

Time and drop-off

Time and drop-off

Return for appointment with clinician

Schedule appt for results

Blood drawn

Time and drop-off

Time and drop-off


Core principle of or 2 actively try to make the program better

Core principle of OR #2:Actively try to make the program better

  • Better “understanding” of situation is not enough

  • Better can mean…

    • Improve access to services

    • Improve quality

    • Limit costs (find cost-effective strategies)

    • Improve health

  • Without actively trying to improve the program, it’s not OR


Core principle of or 3 use results to improve program

Core principle of OR #3:Use results to improve program

  • Using results can mean…

    • Implement new strategy on local / national scale

    • Influence national / international policy

    • Dissemination of results, develop “best practices”

  • OR successful only if results used to improve the program

    • Published papers are NOT a valid indicator of OR success


Corollary or requires collaboration between managers and researchers

Corollary: OR requires collaboration between managers and researchers

  • Program managers/policy-makers

    • Should be involved in ALL ASPECTS of research process

      • Understand health care system

      • Help ensure problem is important, solution is feasible

      • Help ensure results will be implemented

  • Researchers

    • Understand of research methodology

    • Responsible of recommending and implementing appropriate research techniques

  • Can be the same person


Broad methodologies of or

Broad methodologies of OR

  • Modeling (classic)

    • Develop mathematical model to mimic health care system

      • Manipulate to find the best possible “solution”

        • Optimize efficiency

        • Maximize Y given constraints X

  • Intervention-based (Population Council)

    • Design/test best way to deliver services

    • Similar to quality improvement (IHI/WHO)


Intervention based or

Intervention-based OR

Act

Plan

Study

Do


Steps in intervention based or

Steps in intervention-based OR

  • Identify program problem

    • Usually determined in ongoing program

    • Routine data (M&E, surveillance) vs. program evaluation

    • Under control of program manager

  • Generate program solution

    • Review workflow, talk to staff/clients

    • Consider exploratory study if causes/solution unknown

    • Must be feasible

  • Test program solution

    • Level of intervention: facility vs. individual

    • Data measurement: routine vs. added procedures

    • Allocation: non-randomized (quasi-experimental) vs. randomized (experimental)

  • Use/disseminate results

    • Continue/expand successful interventions

    • Influence national/international policy

    • OR not typically “generalizable” but can be relevant for similar programs (“best practices”)


Common or study designs experimental quasi experimental

Common OR study designs(Experimental/quasi-experimental)

Pre-post control /non-equivalent control group

Simple time-series (some control for time)

Step-wedge time-series (better control for time)


Example 1 hiv testing in pmtct program in rwanda

Example 1: HIV testing in pMTCT program in Rwanda

Program problem:

  • 18% of women tested for HIV in a pMTCT program in Rwanda did not return for results

  • System has 2-3 day delay in getting HIV test results

  • What is a potential solution?

  • How could we test this solution?

  • Source: An Approach to Rapid Scale-up: Using HIV/AIDS Treatment and Care as an Example. WHO. Geneva, 2004.


    Example 1 hiv testing in pmtct program in rwanda1

    Example 1: HIV testing in pMTCT program in Rwanda

    Problem: 2-3 day delay in getting HIV test results  18% did not return for results

    Potential solution: Same-day results

    Test of solution: Time series, dropout ~0 post-intervention

    Source: An Approach to Rapid Scale-up: Using HIV/AIDS Treatment and Care as an Example. WHO. Geneva, 2004.


    Example 2 low number of people starting art per month

    Example 2: Low number of people starting ART per month


    Example 2 low number of people starting art per month1

    Example 2: Low number of people starting ART per month

    • What is the program’s problem?

      • Do we need more information to determine what the cause of the problem is?

    • What is the program’s solution?

      • Do we know enough to develop a solution?

    • What should our next step be?


    Identify steps required to start art

    Identify steps required to start ART


    Using programmatic data where are patients lost

    Using programmatic data:Where are patients lost?

    Step 1

    Step 2

    Step 3

    Step 4


    Using programmatic data what are priorities to address

    Using programmatic data:What are priorities to address?


    Why do haart eligible patients not start arvs step 4

    Why do HAART-eligible patients not start ARVs (step 4)?

    • Poor follow-up also reported as reason for not starting HAART in other studies

      • Giordano TP et al, Factors Associated with the Use of Highly Active Antiretroviral Therapy in Patients Newly Entering Care in an Urban Clinic. JAIDS, 32:399-405.


    Improving rates of starting arvs in haart eligible patients

    Reasons for poor follow-up

    Pre-HAART procedure too cumbersome

    Dissatisfaction with services

    Trouble paying transportation costs

    Poor understanding of clinic procedures

    Stigma of going to HIV clinic

    Death

    Potential solutions

    Change workflow around HAART-eligible patients

    Improve counseling

    Improve relationship between patients and health care workers

    Decentralize ARV services

    Improving rates of starting ARVs in HAART-eligible patients


    Number of hiv pregnant women enrolled at art site 30 days after hiv testing

    Number of HIV+ pregnant women enrolled at ART site <30 days after HIV testing

    2500

    2000

    Total HIV +

    1500

    Enrolled

    1000

    34%

    22%

    76%

    500

    74%

    0

    Beira

    Chimoio

    Nhamatanda

    Catandica

    Off-site ART clinic

    On-site ART clinic

    30%

    75%

    On-site ART vs. Off-site ART clinic: OR 7.2

    (CI 5.9-8.8, p<0.001)


    Art eligible starting art total and 90 days sofala and manica 2004 2007

    ART-eligible starting ART (Total and <90 days), Sofala and Manica, 2004-2007

    100.0%

    90.0%

    ART Total

    80.0%

    ART <90days

    70.0%

    60.0%

    50.0%

    40.0%

    30.0%

    20.0%

    10.0%

    0.0%

    Caia

    Beira

    Manica

    Chitobe

    Gondola

    Chimoio

    Marromeu

    Catandica

    Ponta Gea

    1o de Maio

    Nhamatanda

    Espungabera

    Integrated

    Integrated

    Vertical

    Vertical

    Total stated on ART:

    Vertical 50% vs. Integrated 65% (p<0.001)

    ART <90 days:

    Vertical 37% vs. Integrated 59% (p<0.001)

    N=9,193


    Other examples of or

    Other examples of OR


    Or resources

    OR resources

    • Designing HIV/AIDS Intervention Studies: An Operations Research Handbook. Andrew A. Fisher and James Foreit. The Population Council, New York, 2002. Available at: http://www.popcouncil.org/pdfs/horizons/orhivaidshndbk.pdf

    • An Approach to Rapid Scale-up: Using HIV/AIDS Treatment and Care as an Example. World Health Organization, Geneva, 2004. Available at: http://www.who.int/entity/hiv/pub/prev_care/en/rapidscale_up.pdf

    • The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. Institute for Health Care Improvement. Cambridge, MA, 2003. Available at http://www.ihi.org/NR/rdonlyres/BCA88D8F-35EE-4251-BB93-E2252619A06D/0/BreakthroughSeriesWhitePaper2003.pdf

    • Population Council / Horizons program on HIV/AIDS OR: http://www.popcouncil.org/horizons/


    An introduction to operations research or how can i make my health program better

    Next session: December 18th, 2008

    Listserv: [email protected]

    Email: [email protected]


    Next session december 18 th 2008 robert harrington opportunistic infections

    Next session: December 18th, 2008

    Robert Harrington

    Opportunistic Infections


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