Geriatrics, Gerontology and Older Patients: A Management Science Perspective

Abtin Ijadi Maghsoodi
Abtin Ijadi Maghsoodi
Department of Information Systems and Operations Management
University of Auckland, New Zealand
Paul Rouse
Prof. Paul Rouse
Department of Accounting and Finance
University of Auckland, New Zealand
Pavlov
Dr. Valery Pavlov
Department of Information Systems and Operations Management
University of Auckland, New Zealand
Walker
Asso. Prof. CameronWalker
Department of Engineering Science
University of Auckland, New Zealand
Parsons
Prof. Matthew Parsons
School of Health, University of Waikato, New Zealand
Waikato District Health Board, Hamilton, New Zealand 		   

1. Introduction
Mark Twain once said, “Age is an issue of mind over matter (…) If you don’t mind, it doesn’t matter…” However, the gradual impairment of biological functions due to deteriorative cell and structural component alterations over time is inevitable [1]. The United Nations reports that “by mid-century, one in six people globally will be aged 65 years or older” [2]; the global population aged 60 years was estimated around 962 million in 2017, more than twice as large as in 1980 when there were 382 million older people worldwide [2]. This number is expected to double again by 2050, projected to reach more than 1.5 billion. While life expectancy is rising and mortality rates are decreasing, it is unclear whether the additional years will be healthy. Meeting the health needs of older people is one of the most significant challenges of the 21st century. Therefore, a systematic approach to geriatric care planning is vital to explore the patients’ journey from beginning to end to develop the most efficient strategy for performance measurement and continuous improvement for older patients.
2. Geromtology & geriatric patients: Who will be there to care?
As we age, our body experiences many changes that ultimately impact our health. Older people are far more likely to suffer long-term conditions such as cardiovascular disease or diabetes, which tend to be more complex. Consequently, health systems across the Organisation for Economic Co-operation and Development (OECD) have prioritised the development of older person-specific services that integrate assessment and rehabilitation into treatment. Wards and indeed hospitals have been established that focus entirely on the health needs of older people (i.e., aged 65+). Multiple research projects have conducted various trials to evaluate the effectiveness of geriatric-specific interventions. Examples of the geriatric-specific models that were proposed to enhance the effectiveness of patients’ journey include the Acute Care for Elders (ACE), Hospitalized Elder Life Program (HELP), and Geriatric Evaluation and Management Units (GEMU) [3]. Although some evidence showed better health outcomes when older people were given care based on a personalised model, it is not clear which ‘pathways’ are best suited for their clinical journey due to limited literature on geriatric patients’ operations. Clinical pathways represent a form of guideline that could be perceived as a suitable tool for quality management, cost-cutting, and patient satisfaction. Processes and interventions within pathways have features that can be measured, analysed, improved, and controlled, providing opportunities for evaluation in terms of efficiency, effectiveness, and equity. For older patients, although the primary objective of investigating clinical pathways is to improve the effectiveness of the interventions (similar to conventional care), due to the complexity of their conditions, different strategies and policies should be utilised to reach better health outcomes and improve the geriatric-specific healthcare services.
3. Journey towards wellbeing and the role of OR/MS
The process of identifying and mapping clinical pathways is an efficient way to plan, standardise, and optimize the progression of administrative procedures and clinical treatments, which can reduce the complications and difficulties surrounding different phases that decision-makers need to address. In addition, the standardisation of pathways can reduce variability in service delivery. Utilizing various Operations Research and Management Science (OR/MS) methods to analyse and eliminate the bottlenecks and complications existing in the clinical pathways is beneficial for patients, practitioners, and health service managers. For patients, insights from their journey can enhance their experiences of the provided care, which is one of the important aspects of health literacy, and with bottlenecks eliminated, they can experience a better and improved health service. For practitioners, understanding the journey will help them gain knowledge of the patient’s perspective and their journey, so they would be able to optimise and enhance their pathways and provide better services. Finally, for health service managers, understanding the patients’ journey can help policymakers make informed decisions about where to focus funds, identify areas of inefficiency, and inform solutions to improve key metrics. OR/MS is a discipline that utilises advanced analytical methods to understand and optimize complex systems and aid in decision-making. OR/MS uses a wide range of problem-solving techniques and computational methods, including computer simulation, mathematical optimisation, statistics, and decision analyses, to help improve the operations of organisations. With its orientation towards improving efficiency, cost-effectiveness, and decision-making, OR/MS can be beneficial for analysing complex geriatric care issues. Evidence from the literature shows that despite the growing application of OR/MS in geriatric care [4, 5], the impact of OR/MS is still unknown in geriatric care operations as research studies rarely discuss the practicality and aftereffects of their findings or whether propositions were implemented.
Tools and techniques used in OR/MS usually replicate manufacturing systems to analyse the healthcare procedures. The process of identifying and mapping clinical pathways can be a clear instance of this approach. Various studies have drawn attention to the fact that OR/MS for geriatric care is beneficial in scenarios where conducting a real-world study might be considered impossible, impractical, too costly, or unethical [6-8]. More practical examples could be such as when choosing between implementing intervention “A” or “B”, when controlled trials to compare a wide variety of available options would be unreasonable, or in case of geriatric patients when the risk of mortality is high and practical implications might have adverse effects. Other examples include the servicing of patient flow being modelled as a job shop scheduling optimization problem [4, 5], and the evaluation of potential interventions being conducted via modelling to compare a wider variety of options than would be feasible via randomised control trial or when the risk of mortality is high and practical implications might have adverse effects [6-8]. Additionally, OR/MS for geriatric care is also useful for complex financial evaluations such as assessing the most cost-effective intervention among various options or evaluating the optimal approach to allocate limited resources. Consequently, by investigating various stages of the patients’ journeys and their associated operational and clinical flow, OR/MS tools can improve geriatric care operations.
3.1 Patient flow management: go with the flow
Healthcare organisations tend to manage critical tensions between cost-saving, services improvement, and equity of access while operating under capacity constraints and fluctuations in patient demand. Improving patient flow should be a priority to effectively match supply with demand given limited hospital resources. Patient flow can be defined as the movement of patients through healthcare facilities which involves medical care, resources (e.g., practitioners, nurses, beds, and more) and systems ensuring that patients are getting appropriate care at each point of their journey from admission to discharge while maintaining quality and patient satisfaction. Marshall et al. [9] suggest patient flow can be viewed from operational and clinical perspectives. From an operational perspective, it is the movement of patients through a set of locations in a healthcare facility. Clinical patient flow signifies the progression of a patient’s health status. In recent years, operational and clinical patient flows have been analysed as the objective in OR/MS literature. Investigations showed many of these concepts were developed based on “Lean Thinking” [10], which has inspired broad discussions among studies on this direction in healthcare systems.
3.2 Admission & emergency department: the first impression
The first stage of the patient journey is their presentation to the hospital at the Emergency Department (ED), accessed via ambulance or self-admission. Hospital admissions increase with age, which is why there are higher hospitalization rates in the older population than in the younger population. EDs are primary treatment facilities responsible for providing medical/surgical care to patients needing immediate care, overseeing acute and emergency presentations of both young and older patients. Approximately 58% of the population aged 75 years old have had at least one visit to an ED, compared to 39% of those of all ages [11]. Due to the availability of coexisting complications, once older patients are in ED, they are more likely to have an adverse condition and be admitted to a critical care unit. According to Hwang and Morrison [11], the physical space of the current ED models is not aligned with the priorities and needs of geriatric patients. An essential aspect of the patient flow in ED is associated with complexities arising from day-to-day variability, resulting in overcrowding, limited resources, and bed blocking. The appearance of these problems shed light on an important connection between OR/MS techniques and ED operations to establish concepts such as capacity pooling, bed planning, staffing, and scheduling, which could be addressed with methodologies including simulation modelling, mathematical programming and optimization, queueing theory, Markov models and Markov decision processes. Although ED admissions have been analysed in recent years, the literature on this topic associated with geriatric patients considering patient flow is still narrow.
3.3 Readmission: you may have to fight a batter more than once!
Readmission can be defined as “unplanned or acute admissions following by discharge from an earlier admission” [12]. Reducing the number of hospital readmissions, based on periods varying between 1 day and 12 months after discharge, is a critical approach towards improving health care quality and lowering associated costs. According to Felix et al. [13], poor care coordination after discharge and inadequate follow-up are considered two main factors which affect hospital readmissions. Many studies have attempted at optimising readmission using OR/MS approaches. For example, Liu et al. [14] developed an effective check-up plan to monitor patients following discharge, using various check-up methods based on a delay-time analysis model to identify the optimal type of check-ups to implement post-discharge monitoring plans. Helm et al. [15] proposed a novel approach integrating prediction models with machine learning and Bayesian survival analysis and delay-time models of readmissions to empirically generate an individualized estimate of the time to the readmission density function to optimize a post-discharge monitoring schedule and staffing plan to support monitoring needs. Flood et al. [16] suggested the ACE model to examine variable direct costs from this interdisciplinary unit compared with the conventional care unit. Similarly, Hansen et al. [17] have drawn attention to the fact that various research studies have used geriatric-specific models, e.g., ACE and GEMU, to reduce hospital readmission in older patients. While the readmission rate has been considered a significant component of OR/MS studies, this measure has always been considered a secondary factor in geriatric studies. There is not a single study that has considered this factor individually.
3.4 Hospital discharge and discharge planning: the way to go home?
“…Hospital discharge describes the point at which inpatient hospital care ends, with ongoing care transferred to other primary, community, or domestic environments. Hospital discharge is not an endpoint, but rather one of the multiple transitions within the patient’s care journey…” [18]. Due to the multi-layer nature of discharges and the complexity of coordinating a significant number of factors, hospital discharges can be vulnerable, time-dependent, and high-risk episodes in the patient pathways. A notable example of such vulnerability is delayed discharges. Delayed discharges mostly have adverse effects on older patients. One of the leading solutions to comprehend delayed discharges is discharge planning. Goncalves-Bradley et al. [19] defined the process of discharge planning as the development of a personalised plan for patients who must leave the hospital with the goal of containing costs and improving patient health outcomes. Discharge planning aims to minimise the length of stay and unplanned readmission to enhance the coordination of services following discharge from the hospital. In the past few decades, discharge planning for geriatric patients has gained significant recognition as a process requiring improvements. Approximately 30% of older patients experience some type of delay in their discharge process, which makes them exposed to additional hospital-related risks, create emotional and physical dependency, incur additional costs, and restrict the availability of inpatient beds. Discharge without appropriate actions can also lead to patient recovery complications. Therefore, effective discharge planning for hospitalised older patients is necessary for hospital procedures. The early study of Cable and Mayers [20] can be regarded as one of the first attempts in discharge planning. Since then, identifying components of a proper hospital discharge for older patients has been a topic of various clinical and OR/OM research studies.
4. Journey towards a more inclusive and diverse geriatric care
Demographic changes and the growing demands on healthcare systems are among the greatest challenges of the next decades. This may be one of the primary reasons why healthcare-related problems especially for geriatric patients, are becoming the next trend. However, a reshaping of the current healthcare system should take place due to balancing the mismatch of supply and demand and the inequity in the delivery of public health interventions internationally [21]. Due to systemic and life-long discrimination, certain populations of older adults have been facing barriers in accessing the care they need and suffer poorer health as a result. However, along with the growing consensus on the importance of identifying and tackling such inequities in healthcare delivery, concerns have been raised regarding the conceptual clarity and rigour of research in this field. Therefore, a crucial need for greater attention to measurement, control, and optimization of geriatric care has been highlighted. Although in the past recent years, many studies have analysed different aspects of health delivery for older adults, the literature is very limited. Therefore, a more focused emphasis is required to plan, standardise, and optimize the progression of geriatric care procedures and treatments. Evidence from the literature shows OR/MS tools and techniques have a significant potential to plan and optimise geriatric care procedures.

 

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