Abstract
Dynamic resource allocation for prevention, screening, and treatment interventions in population disease management has received much attention in recent years due to excessive healthcare costs. In this paper, our goal is to design a model and an efficient algorithm to optimize sequential intervention policies under resource constraints to improve population health outcomes. We consider a discrete-time finite-horizon budget allocation problem with disease progression within a closed birth-cohort population. To address the computational challenges associated with large-state and multiple-period dynamic decision-making problems, we propose a low-fidelity approximation that preserves the population dynamics under a stationary policy. To improve the healthcare interventions in terms of population health outcomes, we then embed the low-fidelity approximation into a high-fidelity optimization model to efficiently identify a good non-stationary sequential intervention policy. Our approach is illustrated by a numerical example of screening and treatment policy implementation for chronic hepatitis C virus (HCV) infection over a budget planning period. We numerically compare our Multi-Fidelity Rollout Algorithm (MF-RA) to a grid search approach and demonstrate the similarity of sequential policy trends and closeness of overall health outcomes measured by quality-adjusted life-years (QALYs) and the total number of individuals that undergo screening and treatment for different annual budgets and birth-cohorts. We also show how our approach scales well to problems with high dimensionality due to many decision periods by studying time to elimination of HCV.
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Appendices
Appendix A: Computational Complexity and Properties of MF-RA
1.1 A.1 Computational Complexity of MF-RA
There are two primary sources of computation in MF-RA: the progression of the population as in Eq. 2, and the computation of LFM in Eq. 7 involving a matrix inverse.
Evaluating a complete sequential policy for the whole lifetime horizon requires nq population computations, i.e., population is evolved nq times using Eq. 2. An exhaustive search with np discretized policies, i.e., the grid search approach, would evaluate \((n_{p})^{n_{d}}\) possible sequential policies, in total
population computations, which is exponential in the number of decision periods nd.
In contrast, MF-RA requires far fewer population computations. In each decision period d ∈ {1,…,nd}, there is a total of np discretized policies that need to be evaluated. For one discretized policy at decision d, we need (nq − (d − 1)nq,dec) population computations to calculate QALYs from that time forward. Also, each discretized policy requires npnq,dec (nd − d) population computations in low-fidelity approximation (Step 2 in MF-RA) to iteratively calculate LFM. Note that in the last decision period nd, MF-RA does not need to compute LFM, so only population computations from nd to nq are needed.
As a result, the overall number of population computations in MF-RA is
In addition, the low-fidelity approximation conducts a matrix inversion, i.e., (I −Q(It))− 1,
times. Using Gauss-Jordan elimination, the computational complexity for each matrix inversion is \(O(|\mathcal {S}_{HS}|^{3})\); however, the matrix is very sparse. To summarize, the number of population computations of MF-RA is quadratic in the number of decision periods nd and the number of matrix inversions is quadratic in nd.
1.2 A.2 Properties of MF-RA
We characterize the structure of the overall QALYs in budget planning years with respect to the general form of a rollout algorithm. We show the proposed MF-RA has the property of sequential QALYs improvement, which indicates that, using the low-fidelity approximation, the policy obtained in the decision period d + 1 is no worse than the performance of the policies obtained in the decision period d.
A rollout algorithm is an iterative method that uses a heuristic to iteratively improve the objective function value of combinatorial optimization problems. Unlike dynamic programming, which calculates a recursive value function with boundary conditions, a rollout algorithm approximates the optimal value function by a designed heuristic approach [10]. To optimize healthcare interventions, we need more effective sequential actions. Thus, different from other applications of rollout algorithms by only adopting the rollout process once, e.g., stochastic scheduling [11], stochastic routing [67, 68], and multidimensional knapsack problem [14], MF-RA adopts two rollout processes by incorporating low-fidelity approximation into the high-fidelity model. The proposed MF-RA, combining discretized policies enumeration and low-fidelity approximation, satisfies the sequential QALYs improvement.
Proposition 1
Sequential QALYs Improvement of MF-RA MF-RA improves overall QALYs in every decision period.
To prove MF-RA improves overall QALYs over time, we need to use two useful properties developed in rollout algorithms: sequential consistency and sequential improvement. In our population health outcome maximization problem, sequential consistency means that, given current population size, MF-RA is able to generate the same population evolution afterward regardless of earlier population size. That is, given \(\mathbf {N}_{1+(d-1)n_{q,dec}}\) at decision period d, if MF-RA generates the sequential policies \(\left \{I^{(t)*}\right \}_{t\in \mathcal {T}_{d}\cup \mathcal {T}_{d + 1}\cup {\cdots } \mathcal {T}_{n_{d}}}\) and associated population evolution \(\left \{\mathbf {N}_{t}\right \}_{t\in \mathcal {T}_{d}\cup \mathcal {T}_{d + 1}\cup {\cdots } \mathcal {T}_{n_{d}}}\), then given \(\mathbf {N}_{1+(d)n_{q,dec}}\) at decision period d + 1, MF-RA will generate the sequential policies \(\left \{I^{(t)*}\right \}_{t\in \mathcal {T}_{d + 1}\cup {\cdots } \cup \mathcal {T}_{n_{d}}}\) and associated population evolution \(\left \{\mathbf {N}_{t}\right \}_{t\in \mathcal {T}_{d + 1}\cup {\cdots } \cup \mathcal {T}_{n_{d}}}\). Sequential improvement in MF-RA means that the overall QALYs improves over time. That is, maximum QALYs calculated at decision period d (Equation (20)) is no better than maximum QALYs calculated at decision period d + 1 (Equation (21)). Note that the low-fidelity approximation (step 2 in MF-RA) is also a rollout algorithm and holds these two properties.
We prove in (a) that the low-fidelity approximation satisfies sequential consistency, as well as MF-RA in (b). Then, according to the theorem in [10], the sequential consistency of MF-RA allows us to claim its sequential improvement.
1.2.1 (a) Sequential Consistency of Low-Fidelity Approximation
Starting from \(\mathbf {N}_{1+(d-1)n_{q,dec}}\), maximizing LFM iteratively generates sequential policies
and the corresponding sequence of population size
(shown in Eqs. 22–24). Due to the fact that
if starting from \(\mathbf {N}_{1+dn_{q,dec}}\), then \(\mathbf {N}_{1+(d + 1)n_{q,dec}}\ldots \)\(\mathbf {N}_{1+(d-1)n_{q,dec}}\) is calculated by Eq. (25) and (26).
Therefore, whenever low-fidelity approximation generates the sequence of population size
starting from \(\mathbf {N}_{1+(d-1)n_{q,dec}}\), it also generates the sequence of population evolution
starting from \(\mathbf {N}_{1+dn_{q,dec}}\). Thus, the low-fidelity approach is sequentially consistent, which helps us to prove that MF-RA is also sequentially consistent.
1.2.2 (b) Sequential Consistency of MF-RA
With the same population size \(\mathbf {N}_{1+(d-1)n_{q,dec}}\) and the budget constraints, MF-RA enumerates the discretized intervention policies in decision period d in the same discretized rule. In addition, due to the sequential consistency of the low-fidelity approximation, MF-RA examines the same promising sequential policies and thus derives the same best policy I(t)∗, \(t\in \mathcal {T}_{d}\) and proceeds to the next population size \(\mathbf {N}_{1+dn_{q,dec}}\). Therefore, MF-RA generates the same sequence of population evolution \(\left \{\mathbf {N}_{1+(d-1)n_{q}d},\mathbf {N}_{1+dn_{q,dec}},\ldots ,\mathbf {N}_{1+(n_{d}-1)n_{q,dec}}\right \}\) regardless of the population size before decision period d. That is, starting from any population size in the sequential population size generated by MF-RA, MF-RA is able to generate the same sequential population size afterward.
1.2.3 (c) Sequential Improvement of MF-RA
By applying the theorem in [10], we can claim that MF-RA satisfies sequential improvement, and since MF-RA determined the best policy by calculating and comparing accumulating overall QALYs, it is capable of improving overall QALYs when rolling out to the next decision period.
Appendix B: Detail of the Transition Probability Matrix for HCV Progression
We provide the details of the transition matrix for HCV progression. The transition probabilities from group A to other groups are functions of the decision variables
The transition probabilities from group B to other groups are functions of the decision variables
We denote \(\theta _{a,r,waiting}^{ij}\) as the fraction of patient population of age a ∈{40 − 49, 50 − 59, 60 − 69} and gender r ∈{female,male} who are not going through treatment and transit from health status i to health status j, and \(\theta _{a,r,ongoing}^{ij}\) as the fraction of patient population of age a and gender r who are going through treatment and transit from health status i to health status j, i,j ∈{H, F0-F4, R1-R3, DC, HCC, LT, ALT, M}. The complete transition probability matrix is in Equation (27), where Pa,female (IA,t, IB,t) and Pa,male (IA,t, IB,t) are 20 × 20 sub-matrices of transition probabilities for female and male, respectively, a ∈{40 − 49, 50 − 59, 60 − 69}. The transition probabilities are summarized in Fig. 7 and Tables 6–8.
Appendix C: Details on Input Data
Appendix D: Supplementary Figures and Tables for Experiments
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Ho, TY., Liu, S. & Zabinsky, Z.B. A Multi-Fidelity Rollout Algorithm for Dynamic Resource Allocation in Population Disease Management. Health Care Manag Sci 22, 727–755 (2019). https://doi.org/10.1007/s10729-018-9454-6
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DOI: https://doi.org/10.1007/s10729-018-9454-6