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PEMODELAN UNTUK PENGENDALIAN

PENYAKIT
Mengapa populasi tidak sehat?

• Kehendak Tuhan
• Miasma, udara buruk
• Kondisi lingkungan jelek, moral jelek (e.g., sanitation) 1840
• Penyebab tertentu untuk penyakit tertentu (e.g., germ theory) 1880
• Banyak penyebab dari penyakit tertetu (e.g., heart disease) 1950
• Penyebab tertentu, banyak penyakit (e.g., tobacco)
1960
• Banyak penyebab, banyak penyakit tanpa dinamika
umpan balik (e.g., multi-causality) 1980
• Interaksi dinamik, penyakit, penyebab dan intervensi (e.g.,
syndemics) 2000

Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention
Network, Centers for Disease Control and Prevention; April 15, 2008. <http://www.cdc.gov/syndemics/monograph/index.htm

Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
Mengubah Arah Perubahan
Menggunakan System Dynamics Modeling
Prevalence of Diagnosed Diabetes, United States
40
Historical
Data
30 Simulation
Million people

Experiments
in
Action Labs

20

Markov Model Constants


10 • Incidence rates (%/yr)
Trend is not • Death rates (%/yr)
• Diagnosed fractions
destiny! (Based on year 2000 data,
per demographic segment)
0
1980 1990 2000 2010 2020 2030 2040 2050

Honeycutt A, Boyle J, Broglio K, Thompson T, Hoerger T, Geiss L, Narayan K. A dynamic markov model for forecasting diabetes
prevalence in the United States through 2050. Health Care Management Science 2003;6:155-164.
Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through
simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494.
Fenomen Gunung Es – pada tingkat mana
intervensi sebuah system
MENANGGAPI KEJADIAN
Dapat bersikap
Reactive and
Responsive
More Leverage

Patterns of Adaptive and


Behavior Proactive

Systemic Creative and


Structure Transformative
Ketiganya dibutuhkan
Types of Models for
Policy Planning & Evaluation

Events
Time Series Models
Increasing:
Describe trends

• Depth of causal theory


• Robustness for longer- Multivariate Statistical Models
term projection Identify historical trend drivers
Patterns
• Value for developing and correlates
policy insights
• Degrees of uncertainty
Dynamic Simulation Models
• Leverage for change
Anticipate new trends,
learn about policy consequences,
Structure and set justifiable goals
Perlu perspektif lebih luas karena
pertimbangan jangka pendek hanya
menimbulkan…
• Efek samping negatip
• Efek positip terlalu lemah
• Resistensi
• Efek jangka panjang
berbeda dengan jangka
pendek
• Persoalan baru muncul

A broader, more
informed view can help
Kompleksitas Dinamik

Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.


Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999.
Available at <http://www.sustainabilityinstitute.org/pubs/Leverage_Points.pdf>.
Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
Dinamika Sistem
Simulasi Kompleksitas Dinamik

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 mid-
1970s
Sesuai untuk memahami
• Perbedaan efek jangka pendek dan panjang sebagai akibat tindakan
• Selang waktu (e.g., incubation period, time to detect, time to
respond)
• Akumulasi (e.g., prevalences, resources, attitudes)
• Umpan balik (reactions by various actors)
• Hubungan kausal tidak linear (e.g., threshold effects, saturation
effects)
• Perbedaan atau inkonsistensi tujuan atau nilai di antara pemangku
kepentingan Forrester JW. Industrial Dynamics. Cambridge, MA: MIT Press; 1961.
Sterman JD. Business Dynamics: Systems Thinking and Modeling for a Complex World. Boston,
MA: Irwin/McGraw-Hill; 2000.
Pemahaman struktural perilaku masalah

Problem Situation System Behavior System Structure


Ounces What if…?
8 Perc time Max open
1 1
Target 1 0.5
6
0.5 1

0
0 2 4 6 8 10 12 14 16 18 20
Seconds elapsed

System Equations System Model


1. Current water level = INTEG( Water flow , 0) Current water
2. Water flow = Water flow at full open * Faucet openness level
3. Water flow at full open = 1 ounce per second Water flow
4. Faucet openness = MAX (0, MIN (Maximum faucet openness
decision, Perceived water level gap / Water flow at full open )) Desired
5. Maximum faucet openness decision = 1 out of possible 1 Water flow at water level
6. Perceived water level gap = DELAY1I (Water level gap, full open
Water level gap
Time to perceive water level gap, 0)
7. Water level gap = Desired water level - Current water level
Faucet openness
8. Desired water level = 6 ounces
9. Time to perceive water level gap = 1 second
FINAL TIME = 20 seconds Maximum faucet
INITIAL TIME = 0 Perceived water
TIME STEP = 0.125 seconds
openness decision level gap

Time to perceive
water level gap
Simulation and “Double-Loop Learning”
Real World
• Unknown structure
• Dynamic complexity
• Time delays
• Impossible experiments

Virtual World

• Implementation • Known structure


• Controlled experiments • Selected
• Game playing • Missing
• Inconsistency Decisions • Enhanced learning Information
• Delayed
• Short term
Feedback
• Biased
• Ambiguous

• Inability to infer Strategy, Structure, Mental • Misperceptions


dynamics from Decision Rules Models • Unscientific
mental models • Biases
• Defensiveness

Sterman JD. Learning in and about complex systems. System Dynamics Review 1994;10(2-3):291-330.
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
System Dynamics Health Applications
1970s to the Present
• Disease epidemiology
– Cardiovascular, diabetes, obesity, HIV/AIDS,
cervical cancer, chlamydia, dengue fever, drug-
resistant infections

• Substance abuse epidemiology


– Heroin, cocaine, tobacco

• Health care patient flows


– Acute care, long-term care

• Health care capacity and delivery


– Managed care, dental care, mental health care,
disaster preparedness, community health
programs

• Health system economics


– Interactions of providers, payers, patients, and
investors

Homer J, Hirsch G. System dynamics modeling for public health: Background and opportunities.
American Journal of Public Health 2006;96(3):452-458.
Memperhitungkan Umpan Balik
Single-Decision “Open Loop” View
Goals

Problem Decision Results

Situation

Feedback View Actions Delay


Delay

“Side
Goals Delay Delay
Effects”
Delay Delay

Delay Environment
Delay
Goals of Delay “Side
Delay
Others Effects”
Delay Actions of Delay
Others

Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin
McGraw-Hill, 2000.
Dinamika Kesehatan Populasi
Prevalence of
Vulnerability, Risk, or Disease
100%

Values for
Size of the Health & Equity
Safer, Healthier
Population
B Health
Protection
Taking the Toll Efforts
B
B
Responses -
Prevalence of Obstacles
to Growth
Vulnerability,
R Risk, or Disease Resources &
-
Drivers of Resistance
Growth R
Potential
Threats Reinforcers

Broader Benefits
& Supporters
0% Time

Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world.
Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008.
<http://www.cdc.gov/syndemics/monograph/index.htm>.
Types of Loops Underlying the Dynamics

Responses to Growth
Prevalence of - Personal responsibility
Vulnerability, Risk, or Disease - Urgent care
100%
- Preventive healthcare
- Better media messages
Values
- Better local for
options
Drivers of GrowthSize of the Health & Equity
- Risky habits Safer, Healthier
worse health - Better policies
Population
- Families & friends
- Media reinforce risky Bhabits Health
- Risky habitsTaking
riskythe
options
Toll
Protection
- Risky conditions poor policies B Efforts
B
Responses -
Prevalence of Obstacles
to Growth
Vulnerability,
R Risk, or Disease Resources &
-
Drivers of Resistance
Growth R
Potential Limiting Resources & Resistance
Threats Reinforcers
- Disease care squeezes prevention
- Vested interests defend status quo Broader Benefits
& Supporters
0% Time

Benefits & Supports


- Potential savings build support
- Broader benefits build support
Pemodelan dengan umpan-balik
memunculkan pertanyaan
• Bagaimana melemahkan “mesin” pertumbuhan masalah
kesehatan (melalui perbaikan sosial-ekonomi?)
• Apakah insentif untuk pilihan lebih sehat oleh orang-tua,
kepala sekolah, pimpinan perusahaan, wali kota dan lain-lain
• Adakah sumberdaya untuk melindungi kesehatan yang tidak
berkompetisi dengan layanan penyakit?
• Bagaimana industri dimotivasi untuk berubah tidak hanya
mempertahankan satus quo?
• Bagaimana manfaat mengurangi berat badan diperluas
sehingga mendorong investasi untuk pilihan-pilihan yang lebih
sehat (mencegah kanker, melawan depresi dan kecemasan)?
An Interactive & Scientific Modeling Process

• 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, comparing the model to reality,
and refining to achieve greater realism;

• Do “What If…” testing to identify intervention


strategies that might alleviate the problem;

• Do sensitivity testing 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
Homer JB. Why we iterate: scientific modeling in theory and practice. System Dynamics Review 1996;12(1):1-19.

Forrester JW, Senge PM. Tests for building confidence in system dynamics models. In: Legasto A, Forrester JW,
Lyneis JM, editors. System Dynamics. New York, NY: North-Holland; 1980. p. 209-228.
Example: SARS in Taiwan, 2003
New Reported Cases
25

20
People/Day

15 SARS displays the


10
classic S-shaped
growth pattern
5 associated with the
0
diffusion of infectious
Feb/21 Mar/27 May/1 Jun/5 Jul/10 diseases…
Cumulative Reported Cases
400 …and new products,
innovations, social
300 norms, etc.
People

200

100

0
Feb/21 Mar/27 May/1 Jun/5 Jul/10
Traditional Approach: SEIR Model
Susceptible Exposed Infectious Recovered
Population Population
S Population E Population I R
Infection Emergence Recovery
Rate Rate Rate

• Most widely used paradigm in epidemiology


• Compartment model–individuals in given
state aggregated
• Deterministic or stochastic
• Disaggregation & heterogeneity handled by
adding compartments & interactions
Infection in the Standard SEIR Model

Average Average Duration


Incubation Time of Illness

- -
Susceptible Exposed Infectious Removed
Population Population
S Population E Population I R
Infection Emergence Removal
Rate Rate Rate
B
+ +
+ R +
Depletion
Contagion
R
+ Contagion
Total Infectious
Contacts +
+
+

Infectivity
Contact
Rates
Standard SEIR Model vs. SARS Data for Taiwan

Cumulative Cases
2,500

Model
1,875
People

1,250

625

Actual
0
0 14 28 42 56 70 84 98 112
Time (Day)
Expanding the Boundary: Behavioral Feedbacks
Average Average Duration
Incubation Time of Illness

- -
Susceptible Exposed Infectious Removed
Population Population
S Population E Population I R
Infection Emergence Removal
Rate Rate Rate
B
+ +
+ R +
Depletion
Contagion
R
DELAY
+ Contagion +
Total Infectious
Contacts + Media Attention &
+ Public Health
+ Warnings
Infectivity B
Contact
Social Distancing +
- Rates
Social DELAY
- Distancing

B
Safer Hygiene
Practices
+
Model with Behavioral Feedbacks vs. Data
Cumulative Cases
400

300
People

200
Actual

Model
100

0
0 14 28 42 56 70 84 98 112
Time (Day)
Practical Options in Causal Modeling

High

Impractical
Expansive
Too hard to verify,
Scope modify, and understand
(Breadth)

Focused
Simplistic

Low

Low High
Detail (Disaggregation)
Model Structure and Level of Detail
Depends on the Intended Uses and Audiences
• Set Better Goals (Planners & Evaluators)
– Identify what is likely and what is possible
– Estimate intervention impact time profiles
– Evaluate resource needs for meeting goals

• Support Better Action (Policymakers)


– Explore ways of combining policies for better results
– Evaluate cost-effectiveness over extended time periods
– Increase policymakers’ motivation to act differently

• Develop Better Theory and Estimates (Researchers)


– Integrate and reconcile diverse data sources
– Identify causal mechanisms driving system behavior
– Improve estimates of hard-to-measure or “hidden” variables
– Identify key uncertainties to address in intervention studies

Forrester JW. Industrial Dynamics (Chapter 11: Aggregation of Variables).


Cambridge, MA: MIT Press, 1961.
Tests for Building Confidence
in Simulation Models
Focusing on Focusing on
STRUCTURE BEHAVIOR

• Dimensional consistency • Parameter (in)sensitivity


ROBUSTNESS • Extreme conditions • Structure (in)sensitivity
• Boundary adequacy

• Face validity • Replication of behavior


REALISM • Parameter values • Surprise behavior
• Statistical tests

• Appropriateness for • Counterintuitive behavior


UTILITY audience and purposes • Generation of insights

Forrester 1973, Forrester & Senge 1980, Richardson and Pugh 1981
A Model Is…
An inexact representation
of the real thing That helps 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>
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>
Hospital Surge Capacity
(with West Virginia University, 2003-04)
• Overcrowding due to patient surges
in Emergency Dept. creates risk St. Joseph’s Hospital, Buckhannon, W.Va.
– Deterioration of patients while
awaiting ED admission
– Walking-out of patients who should
be treated or isolated
• Hospital disaster plans are required
to address surge capacity
– Flow-control methods, e.g. triage,
transfer, early discharge
– Reserve resources—nurses, beds,
supplies—are limited, esp. for rural
hospitals
– How best to deploy limited
resources?

Hoard M, Homer J, Manley W, et al. Systems modeling in support of evidence-based disaster planning for rural
areas. Intl J of Hygiene and Envir Health 2005; 208:117-125.

Manley W, Homer J, et al. A dynamic model to support surge capacity planning in a rural hospital. 23rd Int’l SD
Conference, Boston, MA; July 2005. <http://cgi.albany.edu/~sdsweb/sds2005.cgi?P333>
Patient Flows and Feedback Loops
ED workload Elective surgeries
scheduled
ED staffing
Increased
Acuity
ED arrivals (by
Pts await / in
acuity, trauma, and
Post-ED directed to surgery Elective surgeries
contagion status)
surgery (trauma) postponed

Pts await ED Pts in ED Post-surgery


ED admits Post-ED discharges discharges
& facility transfers
ED walkouts Post-surgery
ED discharges directed to wards
& deaths
“Boarders”
ED directed to Post-ED directed
Deterioration diagnostic imaging to wards
while waiting Pts await
ward admit
Direct arrivals
Post-non-surgery to wards
directed to wards
Pts await / in Ward
Ward admits
elective workload
Elective non-surgery
non-surgeries
scheduled Ward
Pts in wards
Post-non-surgery Ward discharges staffing
discharges after full stay

Elective
non-surgeries Ward early
postponed discharges & facility
transfers
Cumulative ED Arrivals by Acuity:
Baseline Scenario
2000

1500
Patients

1000 Baseline, Severe

Baseline, Moderate
500
Baseline, Low
0
0 2 4 6 8 10 12 14 16 18 20
Days elapsed

Baseline (no surge) scenario


50 ED arrivals per day for 20 days.
Result: Volume well handled, no avoidable deaths from deterioration
Cumulative ED Arrivals by Acuity:
SARS Scenario
2000 36 pts Day 14
SARS, Severe
106 pts Day 10
1500 SARS, Moderate
Singapore pattern*
SARS, Low
Patients

50 pts Day 6
1000 Baseline, Severe

Baseline, Moderate
13 pts Day 2
500
Baseline, Low
0
0 2 4 6 8 10 12 14 16 18 20
Days elapsed
SARS outbreak scenario
Over the course of 13 days, 837 cumulative SARS ED arrivals, all requiring
isolation, in addition to baseline arrivals.
Result: Severe bottlenecks and many avoidable deaths
* CDC. Preparedness and Response in Healthcare Facilities: Public Health Guidance for Community-
Level Preparedness and Response to SARS (Supplement C). January 8, 2004.
SARS Policy Testing (20 Days Cumulative):
Deaths & Walkouts Due to ED Admit Wait
Deaths due to wait for ED admit ED walkouts

140 1000 940


Patients Patients 856
120 109 809
800
100 94 686

80 600

60 52
400
41
40
200
20
0 9
0 0
No Surge SARS base More ED More ward More ED & No Surge SARS base More ED More ward More ED &
Baseline nurses nurses ward nurses Baseline nurses nurses ward
nurses

Reserve nurses recruited from RNs off-duty, part-time, in offices, retired

Why is the ward nurse policy so much more effective?


The build-up of boarders brings ED admission to a halt.
Hospital Model Findings
• Recommendations affected by
ED Patient Backlog – SARS Scenario
particulars of the hospital and the type 120
of surge
100
– St. Joseph’s → need nurses, not beds
80
– SARS → need ward nurses the most
60
(the surge creates significant need for
inpatient stays, not just ED care) 40

• But model is broadly applicable 20

– Could develop optimal strategies— 0


best practices—customized to type of 0 2 4 6 8 10 12 14 16 18 20
hospital and type of surge Days elapsed

– Allows for systematic “all hazards” No additional nurses

planning More ED nurses


More ward nurses
More ED and ward nurses
Cardiovascular Disease Prevention
(with CDC and NIH, 2007-10)

• What are the key pathways of CV


risk, and how do these affect Access to and Tobacco taxes and
Quality of primary marketing of sales/marketing
Anti-smoking Access to and marketing
care provision primary care regulations
social marketing of smoking quit products
and services

health outcomes and costs? Sources of


stress
Smoking bans at
work and public
Access to and Utilization of places
Psychosocial

• How might interventions affect


marketing of mental quality primary
health services stress Smoking
care

Secondhand
Diagnosis smoke
Particulate air

the risk factors and outcomes in and control


pollution
Downward
trend in CV

the short- and long-term? Access to and


marketing of healthy
food options Healthiness
Chronic Disorders

High BP
event fatality

of diet
High First-time CV

• How might policy efforts be Junk food taxes and cholesterol events and
sales/marketing deaths
Obesity Diabetes
regulations

better balanced given limited Extent of


physical activity
Costs from CV and other risk
factor complications and
from utilization of services

resources? Access to and


marketing of physical
activity options
Access to and
marketing of weight
loss services

The CDC has partnered on this project with the Austin (Travis County), Texas,
Dept. of Health and Human Services. The model is calibrated to represent the
overall US, but is informed by the experience and local data of the Austin team.

Homer J, Milstein B, Wile K, Pratibhu P, Farris R, Orenstein D. Modeling the local dynamics of
cardiovascular health: risk factors, context, and capacity. Preventing Chronic Disease 2008;5(2).
Available at http://www.cdc.gov/pcd/issues/2008/apr/07_0230.htm
Homer J, Milstein B, Wile K, Trogdon J, Huang P, Labarthe D, Orenstein D. Simulating and evaluating
local interventions to improve cardiovascular health. In submission to Preventing Chronic Disease.
Other CVD Intervention Models
System Dynamics: Heart Failure
Homer J, Hirsch G, et al. Models for collaboration: how system dynamics helped a community
organize cost-effective care for chronic illness. System Dynamics Review 2004; 20(3):199-222.

Markov: Coronary Heart Disease


Weinstein MC, Coxson PG, et al. Forecasting coronary heart disease incidence, mortality, and cost:
the coronary heart disease policy model. American J Public Health 1987; 77(11):1417-1426.

Micro-simulation (Archimedes): CVD


Kahn R, Robertson RM, et al. The impact of prevention on reducing the burden of cardiovascular
disease. Circulation 2008; 118(5):576-585.

Statistical/Monte Carlo: Coronary Heart Disease


Kottke TE, Gatewood LC, et al. Preventing heart disease: is treating the high risk
sufficient? J Clinical Epidemiology 1988; 41(11):1083-1093.

Our model is the most extensive to date in integrating evidence on


multiple risk factor pathways, potential interventions, and outcome costs.
Risk Factors for CVD

Utilization of
Psychosocial
quality primary
stress Smoking
care

Secondhand
Diagnosis smoke
Particulate air
and control
pollution
Downward
trend in CV
event fatality
Chronic Disorders
Healthiness High BP
of diet
High First-time CV
cholesterol events and
deaths
Obesity Diabetes

Extent of
physical activity

Obesity, Smoking, High BP, High Cholesterol, and Diabetes are modeled as dynamic
stocks—with multiple inflows and outflows (e.g., see next slide)

Data sources: NHANES, NHIS, MEPS, AHA/NIH reports, Census, Vital Statistics,
Framingham risk calculators, literature on risk factors and costs
Obesity Stock-Flow Structure

Non-obese
adults aging Obese adults
Non-obese aging Obese teens
teens turning 18 turning 18
Adults becoming
obese
Non-obese Obese
non-CVD non-CVD
Non-obese adults Obese adult
adults Adults becoming
adult immigration
immigration non-obese

Non-obese Non-obese Obese adult Obese adults


adult deaths adults surviving deaths surviving CV event
CV event

Homer J, Milstein B, Dietz W, et al. Obesity population dynamics: exploring historical growth and plausible
futures in the U.S. Proc. 24th Int’l System Dynamics Conference; Nijmegen, The Netherlands; July 2006.
Tobacco and Air Quality Interventions
Tobacco taxes and
sales/marketing
Anti-smoking Access to and marketing
regulations
social marketing of smoking quit products
and services

Smoking bans at
work and public
Utilization of places
Psychosocial
quality primary
stress Smoking
care

Secondhand
Diagnosis smoke
Particulate air
and control
pollution
Downward
trend in CV
event fatality
Chronic Disorders
Healthiness High BP
of diet
High First-time CV
cholesterol events and
deaths
Obesity Diabetes

Extent of
physical activity

Data sources: NHANES, NHIS, MEPS, AHA/NIH reports, Census, Vital Statistics,
Framingham risk calculators, literature on risk factors and costs
Health Care Interventions
Access to and Tobacco taxes and
Quality of primary marketing of sales/marketing
Anti-smoking Access to and marketing
care provision primary care regulations
social marketing of smoking quit products
and services

Smoking bans at
work and public
Utilization of places
Psychosocial
quality primary
stress Smoking
care

Secondhand
Diagnosis smoke
Particulate air
and control
pollution
Downward
trend in CV
event fatality
Chronic Disorders
Healthiness High BP
of diet
High First-time CV
cholesterol events and
deaths
Obesity Diabetes

Extent of
physical activity

Data sources: NHANES, NHIS, MEPS, AHA/NIH reports, Census, Vital Statistics,
Framingham risk calculators, literature on risk factors and costs
Interventions Affecting Stress
Access to and Tobacco taxes and
Quality of primary marketing of sales/marketing
Anti-smoking Access to and marketing
care provision primary care regulations
social marketing of smoking quit products
and services
Sources of
stress
Smoking bans at
work and public
Access to and Utilization of places
marketing of mental Psychosocial
quality primary
health services stress Smoking
care

Secondhand
Diagnosis smoke
Particulate air
and control
pollution
Downward
trend in CV
event fatality
Chronic Disorders
Healthiness High BP
of diet
High First-time CV
cholesterol events and
deaths
Obesity Diabetes

Extent of
physical activity

Data sources: NHANES, NHIS, MEPS, AHA/NIH reports, Census, Vital Statistics,
Framingham risk calculators, literature on risk factors and costs
Healthy Diet Interventions
Access to and Tobacco taxes and
Quality of primary marketing of sales/marketing
Anti-smoking Access to and marketing
care provision primary care regulations
social marketing of smoking quit products
and services
Sources of
stress
Smoking bans at
work and public
Access to and Utilization of places
marketing of mental Psychosocial
quality primary
health services stress Smoking
care

Secondhand
Diagnosis smoke
Particulate air
and control
pollution
Downward
trend in CV
Access to and event fatality
Chronic Disorders
marketing of healthy
food options Healthiness High BP
of diet
High First-time CV
Junk food taxes and cholesterol events and
sales/marketing deaths
Obesity Diabetes
regulations

Extent of
physical activity

Data sources: NHANES, NHIS, MEPS, AHA/NIH reports, Census, Vital Statistics,
Framingham risk calculators, literature on risk factors and costs
Physical Activity & Weight Loss Interventions
Access to and Tobacco taxes and
Quality of primary marketing of sales/marketing
Anti-smoking Access to and marketing
care provision primary care regulations
social marketing of smoking quit products
and services
Sources of
stress
Smoking bans at
work and public
Access to and Utilization of places
marketing of mental Psychosocial
quality primary
health services stress Smoking
care

Secondhand
Diagnosis smoke
Particulate air
and control
pollution
Downward
trend in CV
Access to and event fatality
Chronic Disorders
marketing of healthy
food options Healthiness High BP
of diet
High First-time CV
Junk food taxes and cholesterol events and
sales/marketing deaths
Obesity Diabetes
regulations

Extent of
physical activity
Access to and
Access to and marketing of weight
marketing of physical loss services
activity options

Data sources: NHANES, NHIS, MEPS, AHA/NIH reports, Census, Vital Statistics,
Framingham risk calculators, literature on risk factors and costs
Adding Up the Costs
Access to and Tobacco taxes and
Quality of primary marketing of sales/marketing
Anti-smoking Access to and marketing
care provision primary care regulations
social marketing of smoking quit products
and services
Sources of
stress
Smoking bans at
work and public
Access to and Utilization of places
marketing of mental Psychosocial
quality primary
health services stress Smoking
care

Secondhand
Diagnosis smoke
Particulate air
and control
pollution
Downward
trend in CV
Access to and event fatality
Chronic Disorders
marketing of healthy
food options Healthiness High BP
of diet
High First-time CV
Junk food taxes and cholesterol events and
sales/marketing deaths
Obesity Diabetes
regulations

Extent of Costs from CV and other risk


physical activity factor complications and
from utilization of services
Access to and
Access to and marketing of weight
marketing of physical loss services
activity options

Data sources: NHANES, NHIS, MEPS, AHA/NIH reports, Census, Vital Statistics,
Framingham risk calculators, literature on risk factors and costs
A Base Case Scenario for Comparison
Assumptions for Input Time Series through 2040

• Prior to 2004, model reflects historical…


– Decline in fraction of workplaces allowing smoking (1990-2003)
– Decline in air pollution (1990-2001)
– Decline in CV event fatality (1990-2003)
– Increase in diagnosis and control of high blood pressure, high
cholesterol, and diabetes (1990-2002)
– Rise & fall in youth smoking (1991-2003)
– Rise in youth obesity (1990-2002, 2002-2020P)
• After 2004, make simple yet plausible assumptions…
– Assume no further changes in contextual factors affecting risk factor
prevalence (aside from rise in youth obesity)
– Changes in risk prevalence after 2004 are due to “bathtub” adjustment
process (incidence still exceeding outflows) and population aging
– Provides an easily-understood basis for comparisons
Base Case Trajectories 1990-2040
Access to and Tobacco taxes and
Quality of primary marketing of sales/marketing
Anti-smoking Access to and marketing
care provision primary care regulations
social marketing of smoking quit products
and services
Sources of
stress
Smoking bans at
work and public
Access to and places
marketing of mental Psychosocial Utilization of Air pollution
health services quality primary Smoking control regulations
stress
care Smoking
prevalence
Secondhand
Secondhand
Particulate air
Diagnosis smoke
smoke
pollution
Particulate air
and control exposure PM2.5
pollution
<Aircontrol
pollution
regulations> Downward
trend in CVCV event
Access to and event fatality
fatality multiplier
marketing of healthy
Uncontrolled
Chronic Disorders
food options Healthiness Prevalences
of diet High BP
High cholesterol
High First-time CV
Junk food taxes and cholesterol
High blood pressure events and CVD
sales/marketing Obesity deaths per 1000
Obesity
prevalence
deaths
regulations Diabetes <Populati Population
Diabetes Age 65+ fraction
on aging> aging
of the population

Extent of Costs from CV and other risk


physical activity factor
Totalcomplications
consequence and from
Access to and utilization
costs of services
per capita
Access to and marketing of weight
marketing of physical loss services
activity options
Estimated Impacts of a 15-Component
Intervention, with Sensitivity Ranges Reductions vs.
Base Case
4 CVD DEATHS

Deaths from CVD per 1000


The 15 components include: Base Case
(1) “Care” [3 interventions] 0%
(2) “Air” (smoking/pollution) [6], 20%
(3) “Lifestyle”: Nutrition, physical (15-26%)
activity, & stress reduction [6] 2
Combined 15 interventions
with sensitivity range
The model contains 56 causal 60%
linkages requiring the estimation
Deaths if all risk factors = 0
of relative risks, effect sizes, or
initial values, most of which 0
involved some level of 1990 2000 2010 2020 2030 2040
uncertainty.
Capita (2005 dollars per year)
Total Consequence Costs per

3,000
DIRECT
DIRECT &
& INDIRECT
INDIRECT COSTS
COSTS
The upper edge of the sensitivity
range results when all uncertain Base Case
0%
parameters are set to their 2,000
“lowest plausible impact” values. 26%
The lower edge results when all (19-33%)
are set to their “greatest Combined 15 interventions
with sensitivity range
plausible impact” values. 1,000

Costs if all risk factors = 0


80%
0
1990 2000 2010 2020 2030 2040
Contributions of 3 Intervention Clusters
(Clusters layered in cumulatively) Reductions vs.
Base Case

Deaths from CVD per 1000


4
CVD DEATHS
Contributions to CVD death reduction: Base Case
1) Primary Care 0%
(1) Care: strong from the start; 9%
(2) Air: good from the start (less 20%
pollution, secondhand smoke) and 2 3) + Nutrition, Physical
growing (due to smoking decline) to Activity, and Stress
2) + Air Quality & Tobacco
6.5% 60%
(3) Lifestyle: small at first but growing to
Deaths if all risk factors = 0
5%
0
1990 2000 2010 2020 2030 2040

DIRECT & INDIRECT COSTS


Total Consequence Costs per
Capita (2005 dollars per year)
Contributions to cost savings: 3,000
1) Primary Care
(1) Air: strong from the start
(pollution, SHS) and growing Base Case
0%
(due to smoking decline) to 2,000
18.5% 26%
(2) Lifestyle: small at first but 3) + Nutrition, Physical
2) + Air Quality & Tobacco
Activity, and Stress
growing to 8.5% 1,000
(3) Care: negligible (not cost saving)
Costs if all risk factors = 0 80%

0
1990 2000 2010 2020 2030 2040
National Health Policy Model & Game
(with CDC, 2008-09)
• Americans pay the most for
health care, yet suffer high rates
of morbidity and premature
mortality—esp. high among the
poor and uneducated
• About 16% of Americans have
no insurance coverage
• Over 75% of Americans think the
current system needs
fundamental change
• Many health leaders realize we
need a broader view of health,
including health protection and
health equity

Nolte E, McKee CM. Measuring the health of nations: updating an earlier analysis. Health Affairs 2008; 27(1):58-71.
Blendon RJ, Altman DE, Deane C, Benson JM, Brodie M, Buhr T. Health care in the 2008 presidential primaries.
New England Journal of Medicine 2008;358(4):414-422.
Gerberding JL. Protecting health—the new research imperative. JAMA 2005; 294(11):1403-1406.
Gerberding JL. CDC: protecting people's health. Director's Update; Atlanta, GA; July, 2007.
The U.S. Health Policy Arena is
Dense with Diverse Issues
Insurance
Extent of overhead
care Overuse of
Healthier ERs
behaviors
Reimbursement
Adherence to rates
care guidelines
Safer
environments
Access
to care Out-of-pocket
costs
Socioeconomic
disparities Overuse of
Insurance specialists
coverage
Primary Provider
care supply efficiency
Citizen
Involvement
Simulating the Health System
Integrating prior findings and estimates
• On costs, prevalence, risk factors, health disparities,
health care utilization, insurance, quality of care, etc.
• Our own previous health system modeling*

Simplifying as appropriate
• Three states of health: Disease/injury, Asymptomatic
disorder, No significant health problem
• Two SES categories: Advantaged, Disadvantaged
(allowing study of disparities and equity)
• Start in equilibrium (all variables unchanging),
approximating the U.S. in 2003
• Some complicating trends not included for simplicity:
aging, migration, technology, economy, etc.

* E.g., Homer, Hirsch, Milstein. Chronic illness in a complex health economy: the perils and promises of
downstream and upstream reforms. System Dynamics Review 2007; 23:313-343.
Connecting the Concepts:
Start with the Outcome Measures

Morbidity & Health


mortality care costs

Health
inequity
Several Drivers of Health Care Costs

Insurance
complexity
Asymptomatic Disease Morbidity & Health
disorders & injury mortality care costs
Reimbursement
rates
Receipt of quality
health care
Health
inequity Use of specialists
& hospitals for
non-urgent care
Quality Health Care Improves Health Outcomes

Insurance
complexity
Asymptomatic Disease Morbidity & Health
disorders & injury mortality care costs
- Reimbursement
- rates
Receipt of quality
Quality of
health care care delivered
-
Health
inequity Insurance Use of specialists
Health care coverage & hospitals for
Socioeconomic
disadvantage access non-urgent care
- -
-

Sufficiency of
Self-pay fraction primary care
for the insured providers
The “Medically Disenfranchised” (= gagal akses
ke layanan medis) Live in Areas Where PCPs
(DLP = dokter layanan primer) are in Short
Supply

PCPs per 10,000 population in Travis County, Texas


(GP/FP/IM/Ped+ObGyn+Geriat; Texas DSHS 2004-06)
20

15

10

0
East Travis West Travis

The Robert Graham Center, with the National Association of Community Health Centers. “Access Denied: A
Look at America’s Medically Disenfranchised”, Washington, DC, 2007.
PCP Sufficiency: Supply vs. Demand

Insurance
complexity
Asymptomatic Disease Morbidity & Health
disorders & injury mortality care costs
Reimbursement
- -
rates
Receipt of quality
Quality of
health care - care delivered
Health Gatekeeper
inequity Insurance Use of specialists requirement -
Health care coverage & hospitals for - PCP net
Socioeconomic
disadvantage access non-urgent care income
- -
- - - -
-
Sufficiency of -
Self-pay fraction primary care Number of
for the insured primary care PCP training
providers
providers & placement
programs

Primary care
efficiency
Upstream Determinants of Disease & Injury

Environmental
hazards
Insurance
complexity
Asymptomatic Disease Morbidity & Health
disorders & injury mortality care costs
Reimbursement
- -
Behavioral rates
risks
Receipt of quality
Quality of
health care - care delivered
Health Gatekeeper
inequity - Insurance Use of specialists requirement -
Health care coverage & hospitals for - PCP net
Socioeconomic
disadvantage access non-urgent care income
- -
- - - -
-
Sufficiency of -
Self-pay fraction primary care Number of
for the insured primary care PCP training
providers
providers & placement
programs

Primary care
efficiency
From Model to an Interactive Game

• Experiential learning for health leaders


• Four simultaneous goals: save lives, improve health, achieve
health equity, and lower health care cost
• Intervene without expense, risk, or delay
• Not a prediction, but a way for multiple stakeholders to explore
how the health system can change
Milstein B, Homer J, Hirsch G. The "Health Run" policy simulation game: an adventure in US health reform. International System
Dynamics Conference; Albuquerque, NM; July 26-30, 2009.
Options for Intervening in the Health System
A Short Menu of Major Policy Proposals
Expand insurance coverage Improve primary care efficiency

Improve quality of care Coordinate care

Expand primary care supply Enable healthier behaviors

Simplify insurance
Build safer environments

Change self pay fraction


Create pathways to advantage

Change reimbursement rates Strengthen civic muscle


“Winning” Involves Not Just Posting High Scores,
But Understanding How and Why You Got Them
Scorecard
Results in Context

Compare
Progress Runs
Report
Some Policy Conclusions

• Expanded coverage and improved quality


would improve health but, if done alone,
would raise costs and worsen equity

• Expanding primary care capacity to eliminate


shortages (esp. for the poor) would reduce
costs and improve equity

• Cutting reimbursement rates would reduce


costs but worsen health outcomes

• Upstream protection (behavioral and


environmental remedies) would—
increasingly over time—reduce costs,
improve health, and improve equity

Milstein B, Homer J, Hirsch G. Are coverage and quality enough? A dynamic systems approach to health
policy. Draft paper currently in CDC clearance.
System Dynamics:
Looking Further for the Key

Dunia bersifat kompleks dan banyak hal


tidak diukur dengan baik.
(The key is not always under the light.)
Sistem Dinamik memungkinkan struktur
kausal dan jenis data yang lebih luas.
Model tersebut sering menuju ke
kesimpulan berbeda.
Sistem Dinamik penting untuk
mendukung perencanaan dan kebijakan.