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ORIGINAL ARTICLE

Programação linear aplicada a problemas da área de saúde*

Frederico Rafael Moreira1

Objective and Method: To present a mathematical modeling operacional; Otimização

technique by means of linear programming as an efficient tool to

solve problems related to optimization in healthcare. Two

applications are approached: formulation of a balanced diet at a INTRODUCTION

minimum cost and optimal allocation of resources for a set of Operations Research is a science designed to provide

medical interventions that comply with cost and medical visit quantitative tools to decision-making processes. It

restrictions. Results: The balanced diet proposed would comprise comprises a set of mathematical optimization and

1.4 glasses of skimmed milk/day and 100 g of salad/day (2/10 of a

simulation methods and models, such as Linear

500 g portion) at a total minimum cost of R$ 2.55/day. The optimal

solution for the allocation model among the five types of medical Programming, Non-linear Programming, Combinatory

intervention programs maximizing quality-adjusted life year was Optimization, Theory of Queues, Dynamic Programming,

established as follows: use of 100% of intervention type 4 and 50% Theory of Decisions, etc. Today, implementing

of intervention type 2, determining a maximum value of 20.5 QALY. optimized solutions by linear programming has reduced

Conclusion: In a world with increasingly scarce resources and costs by hundreds or even thousands dollars in many

every day more competitive, linear programming could be used to middle to large-sized companies in several

search optimized solutions for healthcare problems.

industrialized countries(1). Many researchers point out

Keywords: Resource allocation; Linear programming; Operations the development of linear programming method as one

research; Optimization of the most important scientific advances of the second

half of the 20th century. Unfortunately, few Brazilian

companies use some optimization technique in their

RESUMO processes, be them productive or not.

Objetivo e Método: Apresentar a técnica de modelagem Linear programming has demonstrated to be an

matemática via programação linear como eficiente ferramenta alternative solution to plan brachytherapy, replacing

para soluções de problemas que envolvam otimização para a área the traditional solutions based on trial and error(2).

de saúde. Duas aplicações foram tratadas: a formulação de uma Linear programming has been used to formulate

dieta balanceada a custo mínimo e a alocação ótima de recursos

balanced diets at minimum cost and complying with a

para um conjunto de intervenções médicas satisfazendo restrições

de custo e visitas médicas. Resultados: A dieta balanceada set of nutritional restrictions(3-4).

proposta seria composta por 1,4 copos de leite desnatado/dia e The main objective of this article is to present and

100 g de salada/dia (2/10 de porção de 500 g) a um custo mínimo disseminate the linear programming method, in order

total de R$ 2,55/dia. A solução ótima para o modelo de alocação to attain optimized solutions of healthcare problems

entre cinco tipos de programas de intervenção médica maximizando involving Economics and Nutrition. First, we present

os anos de vida ajustados para a qualidade foi assim determinada: the formulation of a diet at minimum cost using only

utilização de 100% da intervenção tipo 4 e 50% da intervenção tipo

two nutritional restrictions aiming at making

2 determinando valor máximo de 20,5 AVAQ’s. Conclusão: Frente

a um mundo competitivo e com recursos cada vez mais escassos, investigators in the field of healthcare more familiar

a programação linear pode ser utilizada na busca de soluções with the terms and potentialities of the method

otimizadas para problemas da área de saúde. reported.

1

Statistician of the Clinical Research Center, Teaching and Research Institute.

Corresponding author: Frederico Rafael Moreira - Hospital Israelita Albert Einstein - Av. Albert Einstein, 627/701 - Morumbi - Prédio Joseh Feher (Bloco A) - Piso Chinuch - CEP 05651-901 - São Paulo

(SP), Brazil. Tel.: (11) 3747.0456 - Fax: (11) 3747.0302 - e-mail: fredericorm@einstein.br

Received on July, 2003 – Accepted on November 20, 2003

106 Moreira FR

Later, we describe an optimized solution for The chart represented in figure 1 shows definitions and

problems related to allocation of medical interventions interactions among these components. A solution of a

that complies with a set of budget restrictions and problem is called optimal when the decision-making

medical visits. Decision trees have been applied to variables assume values that correspond to the maximum

economic analysis, such as cost-effectiveness, to choose or minimum value of the objective function and

the best management strategies. The trees may indicate complies with all restrictions of the model.

which interventions use less resource and represent

better quality of life. However, these techniques do

An algebraic representation of a generic formulation of

not show how to effectively allocate resources in several linear programming model could be presented as

medical intervention programs because they are not follows:

optimization models. Thus, the second application has

the purpose of presenting algebraic modeling by linear To maximize or minimize the objective function:

programming as a complementary tool to the traditional

methods of economic analysis in health. Z = c1 x1 + c2 x2 +............ cn xn (a)

It is subject to restrictions:

METHODS

a11 x1 + a12 x2 +.............. a1n x n ≤r1 (b)

Describing a linear programming method: Optimization a21 x1 + a22 x2 +.............. a2n xn ≤r2 (c)

models are defined by an objective function composed .... .......

of a set of decision-making variables, subject to a set of am1 x1 + am2 x2 +............. a m n x n ≤r m (d)

restrictions, and presented as mathematical equations. x j ≥ 0 (j = 1,2,............,n) (e)

The objective of optimization is to find a set of decision-

making variables that generates an optimal value for

the objective function, a maximum or minimum value where:

depending on the problem, and complies with a set of

restrictions imposed by the model. Such restrictions (a) represents the mathematical function encoding the

are conditions that limit the decision-making variables objective of the problem and is called objective function

and their relations to assume feasible values. In linear (Z) in linear programming, this function must be linear.

programming models, the objective function is linear, (b)-(e) represents the linear mathematical function

that is, it is defined as a linear combination of decision- encoding the main restrictions identified.

making variables and a set of constants, restricted to a (e) non-negativity restriction, that is, the decision-

set of linear equality or inequality equations. Therefore, making variables may assume any positive value or zero.

we have a model composed of an objective function, “xj” corresponds to the decision-making variables that

restrictions, decision-making variables and parameters. represent the quantities one wants to determine to

optimize the global result.

“c i” represents gain or cost coefficients that each

variable is able to generate.

Figure 1. Linear programming model components “rj “ represents the quantity available in each resource.

“ai j” represents the quantity of resources each decision-

Objective function making variable consumes.

Measure of effectiveness as a mathematical

function of decision-making variables. It maximizes

or minimizes a measure of performance The diet problem: Description: To illustrate an

It is subject to application of linear programming in diet formulation,

Restrictions let us assume that a diet, for justifiable reasons, is

Set of linear equality or inequality equations that restricted to skimmed milk and a salad using well-known

the decision-making variables must comply with. ingredients. We know that the nutritional requirements

will be expressed as vitamin A and calcium controlled

by their minimum quantities (in milligrams). Table 1

summarizes the quantity of each nutrient available in

Components

foods and their daily requirement for good health

Decision-making variables Parameters conditions of an individual, as well as the unitary cost

Unknown variables that will be determined They are previously

by the solution of the model. They are known constants or

of these foods. The objective is to minimize the total

continuous and non-negative variables. coefficients diet cost and comply with nutritional restrictions.

Linear programming applied to healthcare problems 107

Table 1. Costs, nutrients and predetermined nutritional restrictions Table 2. QALY, intervention cost and medical visits values

Nutrient Milk (glass) Salad (500 mg) Minimum Nutritional Identification of

Requirement intervention Intervention cost N. of medical

Vit. A 2 mg 50 mg 11 mg programs QALY (x 103 monetary units) visits (x 103)

Calcium 50 mg 10 mg 70 mg 1 10 100 40

Cost/unit R$1.50 R$3.00 2 15 50 50

3 15 50 50

4 13 40 15

Decision-making variables: 5 9 120 30

X1 = quantity of milk (in glasses)/day Maximum value 300 40

X2 = quantity of salad (in 500 g portions)/day

Objective function (Z): The function to be minimized

– total diet cost – is the objective function of this • Decision-making variables

problem. It is defined by the combination of foods X1 Xi = fraction of each intervention i to be designated

(milk) and X2 (salad) and their unit costs, R$ 1.50 (one by the model.

real and fifty cents) and R$ 3,00 (three reals), • Objective function

respectively. The cost function is a linear function of To maximize the function Z defined as total quality-

X1 and X2, that is: Z = 1.5X1 + 3.0X2 adjusted life year due to interventions:

10X1 + 15X2 + 15X3 + 13X4 + 9X5

Restrictions: The total quantity of vitamin A in this The parameters of this equation represent the

diet should be equal or greater than 11 mg. The food number of QALY obtained as a result of the

formulation should provide at least 70 mg of calcium. intervention i.

We could not take into account negative quantities of • Restrictions

food; thus, X1 and X2 should be non-negative quantities Budget restrictions:

(X1 ≥ 0; X2 ≥ 0) 100X1 + 50X 2 + 50X3 + 40X4 + 120X5 ≤ 300. The

cost, including all interventions, should not exceed

Mathematical model for the diet problem 300,000 monetary units.

Visits: 40X1 + 50X2 + 50X3 + 15X4 + 30X5 ≤40

To minimize Z = 1.5X1 + 3X2

Xi ≥ 0; Xi ≤1 i = 1, 2, 3, 4, 5. The decision-making

x1, x2

variables may assume any value between 0 and 1.

it is subject to

2X1 + 50X2 ≥ 11 (vitamin A restriction) Mathematical Model

50X1 + 10X2 ≥ 70 (calcium restriction) To maximize Z = 10X1 + 15X2 + 15X3 + 13X4 + 9X5

X1 ≥ 0; X2 ≥ 0 (non-negativity restriction) x1, x2, x3, x4, x5

It is subject to a set of restrictions:

Description of the problem of healthcare resource 100X1 + 50X2 + 50X3 + 40X4 + 120X5 ≤300

allocation: Researchers want to allocate resources

40X1 + 50X2 + 50X3 + 15X4 + 30X5 ≤40

among five medical intervention programs for a certain

population aiming at maximizing the quality-adjusted 0 ≤ X 1 ≤ 1; 0 ≤ X2 ≤ 1; 0 ≤ X 3 ≤ 1; 0 ≤ X 4 ≤ 1; 0 ≤ X5 ≤ 1

life year (QALY). QALY is a measure that considers

quantity and quality of life related to the medical

RESULTS

intervention applied. It is estimated that a maximum

of 300,000 monetary units be spent and the number of Graphic solution for the diet problem

medical visits is expected to remain as 40,000, at most. When we deal with decision-making variables (two

It is also assumed that each patient receives only foods), a geometric representation is possible and

one intervention. Moreover, fraction values of QALY, convenient for didactic purposes. In order to explore

intervention costs and number of medical visits are the geometry of the problem, the restrictions were first

allowed. The objective it to maximize total QALY represented in a Cartesian plan (figure 2), identifying

accumulated by interventions in order to comply with the feasible region, that is, the region of the Cartesian

the budget restrictions and the number of medical visits plan that complies with the set of restrictions of the

described in table 2. model. Second, we have to minimize cost, which is a

108 Moreira FR

constant for each combination of X1 and X2. Hence, of a 500 g-portion), corresponding to total minimum

different costs generate parallel lines where cost is a cost of R$ 2.55.

constant in each line. Then, the cost lines were drawn

in the graphic to obtain the minimum cost that complies Solution for the resource allocation problem: The

with nutritional restrictions. Observe that cost (z)

optimized solution for the model of medical intervention

decreases as we move towards the intersection of lines program allocation calculated by Microsoft Excel Solver

that identify calcium and vitamin A restrictions. The corresponds to the complete use (100%) of the

exact point in which cost is minimized corresponds to

intervention program number 4 and a fraction of 50%

the intersection of these lines. This point is easily found for the intervention program number 2, not using the

by simultaneously determining the solution of the interventions number 1, 3 and 5 (X1 = 1; X2 = 0.5; X3 = 0;

equations: 2X1 + 50X2 = 11 and 50X1 + 10X2 = 70.

X4 = 1; X5 = 0). This numerical solution provides a

This solution, X1 = 1.4 and X2 = 0.2, corresponds to maximum value of 20.5 QALY for the objective function

the total minimum cost of Z = R$ 2.55. In other words, of this model.

the optimal solution corresponds to a diet of 1.4 glasses

The graphic solution is easily obtained when there

of skimmed milk/day and 100 grams of salad/day (2/10 are two decision-making variables (as shown in the

of a 500 g-portion), at a minimum cost of R$ 2.55. example of diet). When there are three decision-

making variables it is still possible to have a graphic

solution despite the difficulty in identifying the

2 Calcium intersections between the planes defined in a three-

dimensional space. In cases of four or more decision-

making variables, graphic solution is impossible and

1.5 the only alternative is an analytical solution by Simplex

Method.

Salad

1 DISCUSSION

The demand for efficient decisions in healthcare

delivery gives opportunity to application of optimization

0.5 techniques in problems related to resource allocation,

which could be a complementary tool to economic

a Vitamin A

0.2 evaluation models. The numerical results presented in

Zx =2.55 the modeling of medical intervention program

0.5 1 1.5 2

Milk allocation show this potential applicability (X1 = 0; X2 =

50%; X3 = 0; X4 = 100%; X5 = 0). The diet proposed in

the second model provides a reduced number of

Figure 2. The feasible region is limited by the lines 2X 1 + 50X 2 = 11 restrictions, decision-making variables (milk and salad)

(vitamin A) and 50X 1 + 10X 2 =70 (calcium) and is identified by the arrows.

and the type of restriction used since it has the didactic

The lines in red (lines z) represent the ‘objective function’ to be minimized

in order to have a minimum cost diet. The point in black (letter a) determines purpose of demonstrating that this type of algebraic

the optimal solution X 1 = 1.4 X 2 = 0.2, corresponding to a minimum cost of modeling and its reporting to physicians are efficient.

R$ 2.55 (line in bold red).

Low-income populations could benefit from formulation

of balanced diets at a minimum cost, prepared based

Analytical solution for the diet problem: The Simplex on foods available and/or affordable, thus complying

Method is an algorithm created to algebraically obtain with dozens or hundreds of restrictions. Potential

a solution. An algorithm is a set of rules that must be applications of optimization methods may include

followed step by step, so that, in the end, the desired assessment of economic impact of several therapies by

result is attained. The Simplex Method was created by means of diseases and evaluation of product prices.

George Dantzig and other scientists of the American For instance, optimized prices of product components

Air Force Department, in 1947 (5). Microsoft Excel could be assessed considering some restrictions, such

Solver uses a basic implementation of Simplex Method as expenses with research and development, cost of

to solve linear programming problems. The optimal alternative treatments, marketing strategies and

solution obtained for this problem by Microsoft Excel estimates for sales projection. Mathematical modeling

Solver indicates a diet composed of 1.4 glasses of skimmed using linear programming may be applied to problems

milk/day and 100 grams of salad/day (X1 = 1.4; X2 = 0.2 related to optimized resource allocation in healthcare.

Linear programming applied to healthcare problems 109

The objective could be, for example, to maximize QALY and every day more competitive, the search of optimized

and life years, or to minimize the number of individuals solutions to replace traditional methods based on

who develop complications, the cost of treatment, as well common sense and trial and error may become an issue

as to define the components for diet formulation or of survival for many organizations.

medications. Technical information about construction

of these models is found in Bazarra(6) and Hillier &

Lieberman(7). Large-sized models involving hundreds of REFERENCES

restrictions and variables may be solved by means of 1. Lieberman G, Hillier F. Introduction to mathematical programming. New York:

McGraw-Hill; 1991.

algebraic modeling software, such as AIMMS (Advanced

Interactive Mathematical Modeling System), GAMS 2. D’Souza WD, Meyer RR, Thomadsen BR, Ferris MC. An iterative sequential

mixed-integer approach to automated prostate brachytherapy treatment plan

(General Algebraic Modeling System), AMPL (Algebraic optimization. Phys Med Biol 2001;46:297-322.

Mathematical Programming Language), LINDO (Linear 3. Colavita C & D’Orsi R. Linear programming and pediatric dietetics. Br J Nutr

Interactive and Discrete Optimizer). Technical information 1990;64:307-17.

comparing this software is found in the publication 4. Henson S. Linear programming analysis of constraints upon human diets. J

OR/MS Today, August 2001(8). Agric Econ 1991;42:380–93.

5. Dantzig GB. Origins of the simplex method In: Nash SG, editor. A history of

scientific computing. New York: ACM Press; 1990.

CONCLUSION 6. Bazaraa MS, Jarvis J, Sherali HD. Linear programming and network flows. 2nd

ed. New York: Wiley, 1990.

The type of algebraic modeling presented in this article

7. Hiller FS, Lieberman GJ. Introduction to operations research. New York: Mc-

known as linear programming could be considered a Graw Hill, 2000.

useful tool to support decision-making processes in 8. Fourer R. 2001 Software Survey: linear programming. OR/MS Today

healthcare. In a world with increasingly scarce resources 2001;28:58-68.

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