Applied Systems Thinking Prize Seminar

Understanding the Dynamic Dimensions of Health Protection Policies

CDC-NIH System Dynamics Collaborative for Disease Control and Prevention (SD-CDC Team)
Joyce Essien, Jack Homer, Gary Hirsch, Andrew Jones, Doc Klein, Patty Mabry, Bobby Milstein, Diane Orenstein, Kristina Wile

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ASysT Prize Seminar Alexandria, VA July 25, 2008

What Are System Dynamics Models and How Do We Use Them?

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Dynamic Complexity arises because systems are

Changing over time Tightly coupled Governed by feedback Nonlinear: changing dominant structure History-dependent Self-organizing Adaptive Counterintuitive Policy resistant Characterized by tradeoffs

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Basic Problem Solving Orientations

Single-Decision Open Loop View
Goals Problem Situation Decision Results

Feedback View
Goals

Delay

Actions
Delay

Delay

Delay Delay

Side Effects

Delay Delay

Environment
Delay Delay Delay

Goals of Others
Delay

Side Effects
Delay

Actions of Others

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Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

Learning In and About Dynamic Systems

Real World
Unknown structure Dynamic complexity Time delays Impossible experiments

Virtual World
Known structure Implementation Controlled experiments Game playing Information Decisions Enhanced learning Inconsistency Feedback Short term Selected Missing Delayed Biased Ambiguous

Inability to infer Strategy, Structure, Decision Rules dynamics from mental models

Mental Models

Misperceptions Unscientific Biases Defensiveness

Sterman JD. Learning in and about complex systems. System Dynamics Review 1994;10(2-3):291-330.
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Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

A Model Is
An inexact representation of the real thing They help us understand, explain, anticipate, and make decisions

All models are wrong, some are useful. -- George Box

Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review 2002;18(4):501-531. Available at <http://web.mit.edu/jsterman/www/All_Models.html>
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Sterman J. A sketpic's guide to computer models. In: Barney GO, editor. Managing a Nation: the Microcomputer Software Catalog. Boulder, CO: Westview Press; 1991. p. 209-229. <http://web.mit.edu/jsterman/www/Skeptic%27s_Guide.html>

System Dynamics: Addressing Dynamic Complexity

Origins Jay Forrester, MIT, Industrial Dynamics, 1961 (One of the seminal books of the last 20 years.-- NY Times) Public policy applications starting late 1960s Population health applications starting mid1970s

Good at Capturing
Differences between short- and long-term consequences of an action Time delays (e.g., incubation period, time to detect, time to respond)

Accumulations (e.g., prevalences, resources, attitudes)

Behavioral feedback (reactions by various actors) Nonlinear causal relationships (e.g., threshold effects, saturation effects) Differences or inconsistencies in goals/values among stakeholders

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Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

Brief Background on System Dynamics Modeling

Compartmental models resting on a general theory of how systems change (or resist change) often in ways we dont expect Developed for corporate policies in the 1950s, and applied to health policies since the 1970s Concerned with understanding dynamic complexity Accumulation (stocks and flows)
Stock Flow Feedback influence

Feedback (balancing and reinforcing loops)

Used primarily to craft far-sighted, but empirically based, strategies Anticipate real-world delays and resistance

Identify high leverage interventions

Modelers engage stakeholders through interactive workshops
Forrester JW. Industrial Dynamics. Cambridge, MA: MIT Press; 1961.
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Sterman JD. Business Dynamics: Systems Thinking and Modeling for a Complex World. Boston, MA: Irwin/McGraw-Hill; 2000.

An (Inter) Active Form of Policy Planning/Evaluation

System Dynamics is a methodology to Map the salient forces that contribute to a persistent problem; Convert the map into a computer simulation model, integrating the best information and insight available; Compare results from simulated What If experiments to identify intervention policies that might plausibly alleviate the problem; Conduct sensitivity analyses to assess areas of uncertainty in the model and guide future research; Convene diverse stakeholders to participate in model-supported Action Labs, which allow participants to discover for themselves the likely consequences of alternative policy scenarios

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Finding the Right System Boundary: SARS in Taiwan

New Reported Cases
25 20

People/Day

15 10 5 0 Feb/21 400 300

Mar/27

May/1

Jun/5

Jul/10

Cumulative Reported Cases

SARS displays the classic S-shaped growth pattern associated with the diffusion of infectious diseases
and new products, innovations, social norms, etc.

People

200 100
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0 Feb/21

Mar/27

May/1

Jun/5

Jul/10

Traditional Approach: SEIR Model

Susceptible Population S Recovered Population R

Infection Rate

Exposed Population E

Emergence Rate

Infectious Population I

Recovery Rate

Most widely used paradigm in epidemiology

Compartment modelindividuals in given state aggregated

Deterministic or stochastic Disaggregation & heterogeneity handled by adding compartments & interactions

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Infection in the Standard SEIR Model

Average Incubation Time Susceptible Population S Exposed Population E Emergence Rate + R
Contagion

Average Duration of Illness Infectious Population I Removal Rate + Removed Population R

Infection Rate B + + Depletion

R
Contagion

+ Infectivity

+ Total Infectious Contacts + + Contact Rates

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Standard SEIR Model vs. SARS Data for Taiwan

Cumulative Cases
2,500

Model
1,875
People

1,250

625

0 0
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Actual
14 28 42 56 70 Time (Day) 84 98 112

Expanding the Boundary: Behavioral Feedbacks

Average Incubation Time Susceptible Population S Exposed Population E Emergence Rate + R
Contagion

Average Duration of Illness Infectious Population I Removal Rate + Removed Population R

Infection Rate B + + Depletion

R
Contagion

+ Total Infectious Contacts + + Infectivity +

DELAY
+ Media Attention & Public Health Warnings +

B Contact Rates B Safer Practices

Hygiene Social Distancing

Social Distancing

DELAY

+
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Model with Behavioral Feedbacks vs. Data

Cumulative Cases
400

300
People

200

Actual Model

100

0 0
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14

28

42

56 70 Time (Day)

84

98

112

How Much Detail is Best?

System dynamics studies problems from a very particular distance', not so close as to be concerned with the action of a single individual, but not so far away as to be ignorant of the internal pressures in the system. -- George Richardson

Forrester JW. Industrial Dynamics (Chapter 11: Aggregation of Variables). Cambridge, MA: MIT Press, 1961.
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Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991

Practical Options in Causal Modeling

High Farsighted Impractical
Too hard to verify, modify, and understand But a fine-grained model can inform a far-sighted model, and vice versa.

Scope (Breadth)

(e.g., many system dynamics models)

Finegrained Simplistic Low Low

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(e.g., many agent-based models)

High

Detail (Disaggregation)

Attempt to Fix Health Care Cost Problem: Lower Physician Reimbursements

Problem

Fix

Health Care Costs

Reimbursement to Physicians

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Unintended Consequence: Reduced Primary Care Availability Increases Costs

Fix

Problem

Health Care Costs

Reimbursement to Physicians

Unintended Consequences
Hospital Admissions Income of Primary Care Physicians

R
Acute Events Due to Chronic Conditions

Patients Going to ER's for Primary Care

R
Retirements and New Entries

Availability and Quality of Disease Management for Chronic Conditions

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Availablity of Primary Care in Physicians Offices and Clinics

Ingredients for Transforming Population Health A Short Menu of Policy Proposals

Expand insurance coverage Improve quality of care Change reimbursement rates

Improve operational efficiency

Simplify administration Offer provider incentives

Enable healthier behaviors

Build safer environments Create pathways to advantage

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CDCs Health Protection Game

Prototype Preview
Bobby Milstein Centers for Disease Control and Prevention BMilstein@cdc.gov http://www.cdc.gov/syndemics Jack Homer Homer Consulting JHomer@comcast.net Gary Hirsch Independent Consultant GHirsch@comcast.net

>>>> These slides are from a prototype model.<<<< Please do not cite or quote without permission.
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Milstein B, Homer J, Hirsch G. The health protection game: prototype design, preliminary insights, and future directions. Atlanta, GA: Centers for Disease Control and Prevention; May 8, 2008.

Rules of the Health Protection Game

Goal Navigate the U.S. health system toward greater health and equity Task Prioritize intervention options across nine policy domains

Decisions Craft health protection strategies over 8 rounds (from 2010-2050), using feedback available every five years
Scoring Achieve the best results across four criteria simultaneously

Save lives (i.e., reduce the mortality rate)

Improve well-being (i.e., reduce unhealthy days) Achieve equity (i.e., reduce unhealthy days due to Disadvantage) Lower healthcare costs (i.e., reduce expenses per capita) Appropriate implementation expenses (i.e., subsidy, program cost) Game Setup A population in dynamic equilibrium, with fixed rates of birth and net immigration, experiencing high starting levels of mortality, unhealthy life, social inequity, and healthcare costs

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No changes are due to trends originating outside the health sector such as aging, migration, economic cycles, technology, climate change, etc.

Navigating Health Futures

Getting Out of a Deadly, Unhealthy, Inequitable, and Costly Trap
Four Problems in the Current System: High Morbidity, Mortality, Inequity, Cost
10 6 0.2 6,000

0 0 0 4,000 2000

How far can you move the system?

2005

2010

2015

2020

2025

2030

2035

2040

2045

2050

Death rate per thousand Unhealthy days per capita Health inequity index Healthcare spend per capita

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High-Level Map of Health System Dynamics

Most parts of the health systemso often discussed separatelyare in fact connected

Environmental hazards Disease prevalence Behavioral risks Morbidity & mortality Effective health care provision Insurance coverage Socioeconomic disadvantage Health equity - Health care access Sufficiency of providers Number of providers Quality of care Health care costs Reimbursement rates Provider net income

Operational & administrative overhead

Attractiveness of health care professions

Incentives for provider training and practice

Strong public leadership is needed to change the modifiable drivers (shown in italics)

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Adapted from: Milstein B, Homer J, Hirsch G. Leading health system change using The Health Protection Game. Syndemics Prevention Network, Centers for Disease Control and Prevention; Work in Progress, May 2008.

DRAFT: May 8, 2008

Selected Estimates for Model Calibration

Parameter
Advantaged & Disadvantaged Prevalence

Proxy
Household Income (< or $25,000)

Initial Values (~2000)

Advantaged = 79% Disadvantaged = 21%

Sources
Census

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Selected Estimates for Model Calibration

Parameter
Advantaged & Disadvantaged Prevalence Symptomatic Disease/Injury Prevalence Asymptomatic Chronic Disease Prevalence No Health Problems Prevalence Mortality Morbidity Health Equity Health Insurance Sufficiency of Primary Care Providers Emergency Care for Nonurgent Problems Unhealthy Behavior Prevalence
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Proxy
Household Income (< or $25,000) Self-rated health is good, fair, or poor High blood pressure (HBP) High cholesterol (HC) Asymp = Tot Chron - Symp Self-rated health is excellent or very good No HBP or HC Deaths per 1,000 Unhealthy days per month per capita Unhealthy days (or deaths) attributable to disadvantage Lack of insurance coverage Number of PCPs per 10,000 Acute non-urgent visits in ER or outpatient department Smoking Physical inactivity Neighborhood not safe

Initial Values (~2000)

Advantaged = 79% Disadvantaged = 21% Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%) Overall = 40% (54.5% tot chron - 14.5% Symp) D/A Ratio (tot chronic) = 1.15 (= 61%/53%) Overall = 33% Advantaged = 36% Disadvantaged = 24% Overall = 8.4 D/A Ratio = 1.80 Overall = 5.25 D/A Ratio = 1.78

Sources
Census

BRFSS JAMA NHANES JAMA BRFSS NHANES Vital Statistics AJPH BRFSS Census BRFSS Census AMA Austin Study NAMCS BRFSS JAMA Austin Study BRFSS JAMA Austin Study

Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4%

Overall = 15.6% D/A Ratio = 1.82 Overall = 8.5 per 10,000 D/A Ratio = 0.71 Overall = 19% D/A Ratio = 5.5 Overall = 34% D/A Ratio = 1.67 Overall = 26% D/A Ratio = 2.5

Unsafe Environment Prevalence

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Exploring Intervention Scenarios

Cut Reimbursements to Office-Based Physicians by 20%
10 6 0.2 6,000
7.5 4.5 0.15 5,500 5 3 0.1 5,000 2.5 1.5 0.05 4,500 0 0 0 4,000 2000

Scoring Criteria: Deaths, Unhealthy Days, Inequity, Cost

Prototype Model Output

2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

Death rate per 1,000 Unhealthy days Health inequity index Healthcare spending per capita

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>>>> These results are from a prototype model.<<<< Please do not cite or quote without permission.c

Additional Preliminary Findings

Universal Coverage (with Leadership) Lowers morbidity and mortality quickly Increases cost significantly (greater volume of mediocre services, which do little to prevent disease) Worsens inequity (greater demand exacerbates pre-existing provider shortage for disadvantaged) Lowers morbidity and mortality quickly, more so than Universal Coverage (more people benefit) Costs rise initially, then fall (the benefits of disease prevention accrue gradually) Worsens inequity (better quality services exacerbate pre-existing provider shortage for disadvantaged) Consistent pattern of strong, sustained improvements in morbidity, mortality, cost, and equity Takes time to generate significant effects (~10 years) Works in three ways, all favoring the disadvantaged: (1) fewer upstream risks lower disease prevalence, which in turn (2) eases demand on scarce provider resources; and (3) reduces costs and improves health care access
Average unhealthy days per capita
6

Quality of Care (with Leadership)

Upstream Health Protection (with Leadership)

6,000 5,500

Health care spending per capita

Prototype Model Output Quality Coverage Protection
0.2
0.15

Health inequity index (morbidity)

Quality Coverage

Prototype Model Output Coverage

5

5.5

5,000 4,500

0.1 0.05

Protection

4.5 4 2000

Quality Protection
2010
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2020

2030

2040

4,000 2050 2000

Prototype Model Output

2050 0 2000 2010 2020 2030 2040 2050

2010

2020

2030

2040

Game-based Wayfinding Dialogues Combine Science and Social Change

Potential champions need more than visionary direction. They want plausible pathways and visceral preparation.
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