Upload
everyonemd
View
716
Download
1
Embed Size (px)
DESCRIPTION
Moving medicine through mathematics.
Citation preview
A KAISER PERMANENTE INNOVATION
An Overview of the Archimedes Healthcare Model
The Archimedes ProjectKaiser Permanente
A KAISER PERMANENTE INNOVATION
This presentation will address three main topics:
• What the Archimedes model is
• How it can be used
• How we know it works
A KAISER PERMANENTE INNOVATION
Until now, there have been four main kinds of mathematical models in health care
• Biological modeling– e.g. glucose metabolism, Starling heart equation
• Clinical Medicine– e.g. Regression equations, Markov models
• Operations research / management science– e.g. Schedule operating rooms, plan hospitals
• Economic / system resources– e.g. Forecasting
A KAISER PERMANENTE INNOVATION
Archimedes is a new type of mathematical model of health care:
it includes all four components
Clinical medicine
Biological modeling
Care processes
System resources
A KAISER PERMANENTE INNOVATION
Archimedes is also new because it is anchored to reality
through clinical trials
Clinical medicine
Biological modeling
Care processes
System resources
A KAISER PERMANENTE INNOVATION
This presentation will address four main topics. Let’s begin with:
• What the Archimedes model is• How it can be used• How we know it works• What we plan to do with it• How you will be able to get access to it• What’s on this website
A KAISER PERMANENTE INNOVATION
Archimedes is
• Object oriented
• Continuous
• Physiology based
• Very deep and very broad
• and it operates at the level of detail that clinicians and administrators consider essential for making decisions
A KAISER PERMANENTE INNOVATION
Now let’s define those terms. This is what we mean by “object oriented”
• All the important objects in reality have corresponding objects in the model, one-to-one, at a high level of detail
Patients, organs, parts of organs
Facilities
Health care personnel
Equipment, supplies
Policies and procedures
Budgets, regulations, more
A KAISER PERMANENTE INNOVATION
More specifically, this means that
• There are thousands of simulated people in the model, each one of them different
• They can get sick, and go see simulated doctors• In simulated offices• And get simulated tests, that use simulated
pieces of equipment• And get simulated treatments• And so forth
A KAISER PERMANENTE INNOVATION
This is what we mean by “continuous”
• Biological variables that are continuous in reality are continuous in the model (e.g. BP, LDL cholesterol)– No “clinical states”, “strata”
• Time is continuous; any event can occur at any time– No “ticks”, “steps” or “annual jumps”
A KAISER PERMANENTE INNOVATION
The concept of “physiology based”needs more explanation. And we’re
going to need a volunteerI’ll
volunteer
Joe. Joe Miner
Thanks. What’s your name?
OK Joe. I hope you’re not
ticklish…
A KAISER PERMANENTE INNOVATION
… because we’re going to need to look inside
your belly.Can you come a bit
closer?
Sure
A little bit closer, if you can
How’s this?
ThatThatThat’’’s good.s good.s good.Nice belly, Joe.Nice belly, Joe.Nice belly, Joe.
Now weNow weNow we’’’re going to need to re going to need to re going to need to do a sort of xdo a sort of xdo a sort of x---rayrayray
OK.OK.The reason weThe reason we’’re re
doing this is that we doing this is that we want to show you that want to show you that
every simulated every simulated person in the model, person in the model, like Joe, has organs, like Joe, has organs,
such assuch as……
PancreasPancreasPancreasCirculatory Circulatory Circulatory systemsystemsystem
HeartHeartHeart
LiverLiverLiver
Fat cellsFat cellsFat cells
GutGutGut MuscleMuscleMuscle
And every organ has all of its types of cells, like these beta
cells of the pancreas
The organs and The organs and their cells carry out their cells carry out
metabolic metabolic functions,functions,such assuch as……
GLUCOSE UPTAKE BY FAT
GLUCOSE UPTAKE BY MUSCLE
SUGARS
HEPATIC GLUCOSE PRODUCTION
GLYCOGENGLYCOGENGLYCOGEN
GLUCOSEGLUCOSEGLUCOSE
CIRCULATING GLUCOSE
In the model, these In the model, these functions are regulated just functions are regulated just as they are in a real person. as they are in a real person. For example, in response to For example, in response to
the circulating levels of the circulating levels of glucose, the pancreatic beta glucose, the pancreatic beta
cells will secrete insulincells will secrete insulin
GLYCOGEN
GLUCOSE UPTAKE BY FAT
GLUCOSE UPTAKE BY MUSCLESUGARS
HEPATIC GLUCOSE PRODUCTION
GLUCOSE INSULIN
CIRCULATING GLUCOSE
And diseases can occur. And diseases can occur. For example, in a person For example, in a person with diabetes the effect of with diabetes the effect of
insulin on uptake of insulin on uptake of glucose by the muscle glucose by the muscle and fat is decreased.and fat is decreased.
GLYCOGEN
GLUCOSE UPTAKE BY FAT
GLUCOSE UPTAKE BY MUSCLESUGARS
HEPATIC GLUCOSE PRODUCTION
GLUCOSE INSULIN
Diabetes
Diabetes
Diabetes also affects the Diabetes also affects the effect of insulin on effect of insulin on
production of glucose by production of glucose by the liver cellsthe liver cells
GLYCOGEN
GLUCOSE UPTAKE BY FAT
GLUCOSE UPTAKE BY MUSCLESUGARS
HEPATIC GLUCOSE PRODUCTION
GLUCOSE INSULIN
Diabetes
IfIf we were to illustrate the we were to illustrate the biological variables and biological variables and
relationships in the model relationships in the model that affect the metabolism that affect the metabolism of glucose, it would look of glucose, it would look
something like thissomething like this
Type 1Diabetesfeature
Coronaryartery
stenosis
Race/ethnicity
Sex
Age
Gliburide
LDLcholesterol
Pulse \pressure
Arterialcompliance
Meanarterial
pressure
OGT
Diabetesdiagnosis
BMI
Height
Cardiacoutput
To theNeuropathy
model
To theNephropath
y model
To theCoronary
arterydiseasemodel
To theRetinopathy
model
Hypo-glycemia
Familyhistory
Diabetescardiac risk
factor
FPG
Randomplasmaglucose
OGTT test
Propensityto fatigue
Propensityto polyuria
Thirst
Fatigue
Polyuria
Perception
Memory
Patienttakes action
Blurredvision
Propensityto thirst
Propensityto blurred
vision
FPG
Diabetesblood
pressurefactor
Insulintreatment
Systolicblood
pressure
Peripheralresistance
Untreatedinsulin level
Insulinefficiency(Muscle)
Smoking
FPG
Randomplasma
glucose test
HbA1c test
FPG testRandomerror andvariation
Totreatmentmodels
Careprocesses
Triglycerides
Age, sex,race/
ethnicity
Type 2Diabetesfeature
Metformin
Diet andexercise
Weight
HDLcholesterol
Insulinproduction(Pancreas)
Unexplainedvariance in
OGT
Keto-acidosis
Fractionalchange in
Insulin
Urineketone test
Glucoseproduction
by liver
Normal liverglucose
production
Insulinefficiency
(Liver)
JointDiabetesfeature
Insulin level
Glucoseuptake by
muscle
A KAISER PERMANENTE INNOVATION
A KAISER PERMANENTE INNOVATION
Type 1Diabetesfeature
Coronaryartery
stenosis
Race/ethnicity
Sex
Age
Gliburide
LDLcholesterol
Pulse \pressure
Arterialcompliance
Meanarterial
pressure
OGT
Diabetesdiagnosis
BMI
Height
Cardiacoutput
To theNeuropathy
model
To theNephropath
y model
To theCoronary
arterydiseasemodel
To theRetinopathy
model
Hypo-glycemia
Familyhistory
Diabetescardiac risk
factor
FPG
Randomplasmaglucose
OGTT test
Propensityto fatigue
Propensityto polyuria
Thirst
Fatigue
Polyuria
Perception
Memory
Patienttakes action
Blurredvision
Propensityto thirst
Propensityto blurred
vision
FPG
Diabetesblood
pressurefactor
Insulintreatment
Systolicblood
pressure
Peripheralresistance
Untreatedinsulin level
Insulinefficiency(Muscle)
Smoking
FPG
Randomplasma
glucose test
HbA1c test
FPG testRandomerror andvariation
Totreatmentmodels
Careprocesses
Triglycerides
Age, sex,race/
ethnicity
Type 2Diabetesfeature
Metformin
Diet andexercise
Weight
HDLcholesterol
Insulinproduction(Pancreas)
Unexplainedvariance in
OGT
UKPDSdata
Keto-acidosis
Fractionalchange in
Insulin
Urineketone test
Glucoseproduction
by liver
Normal liverglucose
production
Insulinefficiency
(Liver)
JointDiabetesfeature
Insulin level
Glucoseuptake by
muscle
All of that, and many, many more variables that are important to the complications of diabetes and to other diseases, are being calculated continuously in every simulated person in the model
A KAISER PERMANENTE INNOVATION
And there are lots of simulated people, thousands in fact,
all of them with different risk factors,
physiologies, behaviors, et cetera.(The differences are shown as different colors of their
aprons)
A KAISER PERMANENTE INNOVATION
Thanks Joe, you can go back to the
model now.You’re
welcome.Good bye
A KAISER PERMANENTE INNOVATION
That was “physiology-based”. Let’s move on now.
Here’s what we mean by “broad and deep”• Object oriented
• Continuous
• Physiology based
• Very deep and very broad
• and it operates at the level of detail that clinicians and administrators consider essential for making decisions
A KAISER PERMANENTE INNOVATION
“Very broad and very deep ” means that the model includes
• Not only– Anatomy, Physiology, Pathology, Signs and
symptoms, Tests and treatments
• But also– Patient and provider behaviors – Care processes: e.g. guidelines, disease
management, CQI– System resources: e.g. facilities, personnel,
equipment, supplies, costs …
A KAISER PERMANENTE INNOVATION
To get the idea of “very deep and very broad”, let’s follow a problem from the
cellular level to the parking lot• All the simulated people in the model have all the
important organs. E.g. hearts, kidneys, immune systems…
• All the simulated organs have all the important parts. E.g. hearts have coronary arteries, ventricles, myocardium, sino-atrial node…
• All the part have all the important subparts. e.g. arteries have lumens, walls…
• All the organs and their parts have functions. e.g. arteries carry blood to the myocardium
A KAISER PERMANENTE INNOVATION
There’s more
• Things can go wrong with the organs or their functions. e.g. coronary arteries can occlude.
• When something goes wrong, it affects other things. e.g. when arteries occlude, blood flow to the myocardium is reduced. When blood flow is reduced, the feels pain (angina).
• All the simulated patients have behaviors; when the pain reaches a threshold, the patient makes a simulated call to a simulated hospital.
• Simulated telephone operators at simulated call centers use simulated protocols to triage calls.
A KAISER PERMANENTE INNOVATION
And still more• Patients go to simulated emergency
departments. (This is where the parking lot comes in)
• They are seen by simulated personnel (e.g., nurses).
• Simulated tests are performed…tests use equipment and supplies
• Diagnoses are made…and mistakes are made
• Patients are admitted, rooms are occupied, …• Treatments are given…
A KAISER PERMANENTE INNOVATION
You get the idea. “Very broad” and “very deep” means that the effects of any encounter keep ramifying through
the simulated health care system, just as happens in the real world
• Logistics happen…• Utilization occurs…• Outcomes occur…• Costs occur…
A KAISER PERMANENTE INNOVATION
There’s one more thing to discuss,the level of detail
• Object oriented• Continuous• Physiology based • Very deep and very broad•• It operates at the level of detail that It operates at the level of detail that
clinicians and administrators consider clinicians and administrators consider essential for making decisionsessential for making decisions
A KAISER PERMANENTE INNOVATION
The level of detail is determined by the people who will use the model
• If a clinician says that a particular variable is critical to their own thinking, and the model won’t be credible without it …
• We include the variable– e.g. ejection fraction, insulin level, “beta cell
fatigue”, peripheral resistance• Ditto for administrators
– E.g. there are 37 different types of office visits
A KAISER PERMANENTE INNOVATION
Now let’s talk about:
• What the Archimedes model is• How it can be used• How we know it works
A KAISER PERMANENTE INNOVATION
The purpose of Archimedes is to create a virtual world
• Virtual people • who have virtual physiologies• get virtual diseases• have virtual signs and symptoms• go to virtual doctors• get virtual tests and treatments• and have virtual outcomes• just like real people
A KAISER PERMANENTE INNOVATION
• Guidelines• Disease management programs• Nursing algorithms• Changes in care processes• Continuous quality improvement programs• Performance measures and targets
If it works, then we can use the virtual world to try out, evaluate, explore, optimize, plan,
improve, predict…lots of different things.Such as…
A KAISER PERMANENTE INNOVATION
• Priority setting• Strategic goals• Research• How “ideal” research trials translate to
“real” clinical settings• Logistics, use of resources• Costs, cost-effectiveness, and value• Planning
And more…
A KAISER PERMANENTE INNOVATION
The idea is that we can use the virtual world to learn the effects of lots of different types of
interventions that would be infeasible to study through empirical methods (more research), for a
variety of reasons:• Too high a cost• Too long time needed for a new study• Too many patients needed• Unwillingness of patients and/or physicians to
participate• Too large a number of options to study• Technologies that are changing too rapidly
A KAISER PERMANENTE INNOVATION
This is very important, because
• An empirical study – e.g. an evaluation study or clinical trial – of a single intervention will – cost hundreds of thousands, or even
hundreds of millions of dollars– require hundreds, or thousands of people– take years
• Whereas an Archimedes simulation takes much less time and costs less
A KAISER PERMANENTE INNOVATION
Sounds good. And I’m happy to help out. But if you don’t mind, I’ve got a question.All this is premised on an assumption that it works
right. How do you know that it works?
I mean, I know that my
equations are working fine. But I’m not so certain about the other
jokers who are in here with me.
A KAISER PERMANENTE INNOVATION
Thanks Joe, that is indeed a crucial question:
• What the Archimedes model is• How it can be used• How do we know it works?
A KAISER PERMANENTE INNOVATION
Here’s how:
• We compare what happens in the virtual world with what happens in the real world,
• in lot’s of different settings,• that test the parts of the model that will be
used for the types of applications we want to do– i.e. similar people, similar treatments, similar
outcomes
A KAISER PERMANENTE INNOVATION
The trial is conducted
They get the treatments specified in the protocols of the trial
A trial involves people who meet the entry criteria for the trial
And the outcomes are measured
The best way to do this is to use The best way to do this is to use clinical trials because we know the clinical trials because we know the
most about themmost about them
A KAISER PERMANENTE INNOVATION
Real clinicaltrial
Treatments
People RealOutcomes
We count the outcomes, using the same definitions and protocols
We use the same criteria to select people
We have simulated physicians follow the same treatment protocols
And we compare the results
We use the virtual world of the model to We use the virtual world of the model to simulate the realsimulate the real--world trialworld trial
We let the model do its thing
A KAISER PERMANENTE INNOVATION
There are 10 steps involved in performing a validation
1. We start with a large population of simulated people, just like a simulated city
2. We identify the inclusion criteria for the trial3. We randomly select from the large
population a sample who meet the inclusion criteria for the trial
4. Confirm that major characteristics match (“Table 1”)
5. Randomize the simulated people
A KAISER PERMANENTE INNOVATION
There are 10 steps involved in performing a validation (Cont’d)
6. Identify the treatment protocols used in the trial
7. Have simulated providers apply the treatment protocols to the simulated people
8. Have the simulated providers apply the follow-up protocols
9. Record the results seen in the real trial10. Compare the simulated results to the real
results
A KAISER PERMANENTE INNOVATION
You can think of these validations as being previews of real applications• We used the populations that were in the
trials– But we could have used the population that
would be candidates for your guideline (or performance measure, etc)
• Similarly for the tests, treatments, outcomes, etc.
A KAISER PERMANENTE INNOVATION
VA-HIT
IDNTUKPDSHPS
LewisDPPWOSCOPS
IRMALIPIDLLRC
MICRO-HOPECAREHHS
DCCT secondary4-SSHEP
DCCT primaryHOPEMRC
Archimedes has been validated Archimedes has been validated against these trials, so faragainst these trials, so far
A KAISER PERMANENTE INNOVATION
Here’s an example: the Heart protection Study
• Population: adults age 40 – 80, at high risk of MI because of high LDL, or other arterial occlusive disease, or diabetes
• Treatments: Simvastatin vs. placebo
• Size: 20,500
• Duration: 6 years
A KAISER PERMANENTE INNOVATION
Major Coronary Events in Heart Protection Study
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5Years
Frac
tion
of p
atie
nts
Placebo group
Treated group
Solid lines are the real results
This was the rate of major coronary artery This was the rate of major coronary artery events in the placebo and treated groupsevents in the placebo and treated groups
A KAISER PERMANENTE INNOVATION
The dotted lines showed what the The dotted lines showed what the model calculatedmodel calculated
Major Coronary Events in Heart Protection Study
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5Years
Frac
tion
of p
atie
nts
Dotted lines are the model’s results
Placebo group
Treated group
A KAISER PERMANENTE INNOVATION
Here’s another example, the Diabetes Prevention Program
• Population: men and women over age 25. broad range of racial and ethnic groups. Prediabetes (IGT or IFG)
• Treatments: intensive lifestyle vs. Metformin vs. standard care
• Size: 3000• Mean duration: 2.8 years
A KAISER PERMANENTE INNOVATION
DPP: Diabetes Progression
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
0 1 2 3 4 5Time (years)
Frac
tion
ControlMetforminLifestyle
In this case, the results were calculated by In this case, the results were calculated by the model the model beforebefore the real results were the real results were
known. This is what the model predicted.known. This is what the model predicted.
A KAISER PERMANENTE INNOVATION
The dotted lines are what the model The dotted lines are what the model predicted. The solid lines are the results predicted. The solid lines are the results
that were eventually published.that were eventually published.DPP: Diabetes Progression
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
0 1 2 3 4 5Time (years)
Frac
tion
ControlMetforminLifestyle
A KAISER PERMANENTE INNOVATION
Here’s an example of a long term trial that measured the effects of treatment on
complications of diabetes: UKPDS• Population: middle aged men and women, with
newly diagnosed type 2 diabetes
• Treatments: intensive treatment vs. conventional treatment
• Size: 3900
• Duration: 15 years
A KAISER PERMANENTE INNOVATION
UKPDS: MI (fatal and non-fatal)
0
0.05
0.1
0.15
0.2
0.25
0.3
0 2 4 6 8 10 12 14Time (years)
Frac
tion
of p
atie
nts
Conventional treatment
Intensive treatment
The solid lines are the real results
This shows the effect of treatment on the This shows the effect of treatment on the most important outcome: heart attacksmost important outcome: heart attacks
A KAISER PERMANENTE INNOVATION
UKPDS: MI (fatal and non-fatal)
0
0.05
0.1
0.15
0.2
0.25
0.3
0 2 4 6 8 10 12 14Time (years)
Frac
tion
of p
atie
nts
The dotted lines are the model’s results
This is what was calculated by the modelThis is what was calculated by the model
Conventional treatment
Intensive treatment
A KAISER PERMANENTE INNOVATION
0
0.1
0.2
0.3
0.4
0.5
0.6
0 0.1 0.2 0.3 0.4 0.5 0.6Results from trials
Res
ults
cal
cula
ted
by m
odel
We have done this for 74 different combinations We have done this for 74 different combinations of populations, treatments and outcomes. This of populations, treatments and outcomes. This chart compares results calculated by the model chart compares results calculated by the model (y(y--axis) against results of the real trial (xaxis) against results of the real trial (x--axis). axis).
Each dot represents an arm of a trial. The real result of the trial is plotted against the result calculated by the model. Perfect erfect correspondence would correspondence would be the 45be the 45ºº lineline
A KAISER PERMANENTE INNOVATION
One would not expect perfect correspondence because of random factors, related to the number of people in the trial
• 71 of 74 are well within sampling error• The other 3 have good explanations
– either it just missed (e.g. p = .04) (which is to be expected statistically)
– or the description of the trial was incomplete • 54 of 74 are within ± 1 standard deviation• For all 74 exercises: r = 0.99
A KAISER PERMANENTE INNOVATION
For some of the trials, some of the data from the trial were used to help build
parts of the model. The other trials are 100% independent
• For the exercises that were not used at all to build the model (100% independent), the correlation between the model and the trial was still extremely high
• The correlation was still r = 0.99
A KAISER PERMANENTE INNOVATION
These validations are important for several reasons
• They give us confidence that for applications that are spanned by validations, the model is accurate
• They illustrate the types of applications that the model can do
• No other model of clinical medicine has been validated in this way
• The alternative to the model, expert judgment, has not been validated in this way either (no offense intended)
A KAISER PERMANENTE INNOVATION
The “span” of the validations is important, because it indicates the types of populations,
organ systems, and treatments we can be confident about
A KAISER PERMANENTE INNOVATION
Imagine that the disease that we want to understand is represented by an island.
We need to completely map out and reach every part of that island
A KAISER PERMANENTE INNOVATION
Imagine that the available research can be represented as radio beacons on the island.
The bigger and better the trial, the wider its signal.
A KAISER PERMANENTE INNOVATION
Now suppose that Archimedes has been validated against all of those trials.
Using this visual image, we can talk about the usefulness of Archimedes for new applications
A KAISER PERMANENTE INNOVATION
If you ask it a question about this part of the island (A), it should do extremely well
A
A KAISER PERMANENTE INNOVATION
If you ask it a question about this part of the island (B), it should do very well
B
A KAISER PERMANENTE INNOVATION
If you ask it a question about this part of the island (C), it should do fairly well
C
A KAISER PERMANENTE INNOVATION
If you ask it a question about this part of the island (C), it should do fairly well,
but we’d like to see a new trial done down here
C
A KAISER PERMANENTE INNOVATION
If you ask it a question about this part of the island (D), we’ll say “OK, but only use the
model for “what if” type questionsWe’d rather help you design a new trial
D
A KAISER PERMANENTE INNOVATION
If you ask it a question about that is out in the ocean (E), We’ll say “Archimedes can’t do that yet. Help us raise some money and
we’ll build a new model for that”
E
A KAISER PERMANENTE INNOVATION
With that in mind, it is important that Archimedes has been validated for a wide
range of populationsAverage riskHypercholesterolemiaDiastolic hypertensionSystolic hypertensionMany risk factorsAngina or MIDiabetesMI average CholesterolMI high CholesterolPre diabetes
Newly diagnosed diabetesType 1, uncomplicatedType 1, retinopathyType 1, moderate to severe nephropathyType 2, uncomplicatedType 2, mild nephropathyType 2, moderate nephropathyYoung, Middle age, Old
A KAISER PERMANENTE INNOVATION
…and organ systems
• Liver• Pancreas• Heart• Vascular• Nerves
• Muscle• Fat• Kidneys• Eyes• Lungs• Gut
A KAISER PERMANENTE INNOVATION
…and treatments
• Nothing (placebo)• Cholestyramine• Gemfibrozil• Anti-hypertensive• Pravastatin• Simvastatin• ACE Inhibitors
• Angiotensin –II-receptor antagonists
• Insulin• Metformin• Sulphonylurea • General diet advice• Intensive lifestyle
A KAISER PERMANENTE INNOVATION
That’s what we mean when we say that Archimedes is anchored to reality
Clinical medicine
Biological modeling
Care processes
System resources
(74 anchors)
A KAISER PERMANENTE INNOVATION
What does all this mean?
• It is possible to write equations that represent human physiology, disease, treatments and outcomes using existing information
• In the “virtual world” created by these equations, simulated patients behave like patients in the real world, …
• …at least as we know it through the most important epidemiological studies and clinical trials
A KAISER PERMANENTE INNOVATION
It means the virtual world can be used for many purposes, such as
• Guidelines• Performance measures• Disease management programs• Continuous quality improvement• Strategic goals and priority setting• Research planning• Estimating patient-specific outcomes
A KAISER PERMANENTE INNOVATION
And that’s good, because it’s a whole lot easier to explore problems and
programs in the virtual world
• Much faster
• Much less expensive
• Much more flexible
• Can explore many more options
• Can tell you the critical points to watch
A KAISER PERMANENTE INNOVATION
If you want to use the model, there is one more thing you will need to understand • Real people like you will still have to make the
final decisions • Archimedes will give you much better
information than you’ve ever had before • But there are always elements of a decision that
can not be quantified and that require value judgments
• This is the role of humans• Thus the model is a just a tool -- a very powerful
tool, but just a tool
A KAISER PERMANENTE INNOVATION
Type 1Diabetesfeature
Coronaryartery
stenosis
Race/ethnicity
Sex
Age
Gliburide
LDLcholesterol
Pulse \pressure
Arterialcompliance
Meanarterial
pressure
OGT
Diabetesdiagnosis
BMI
Height
Cardiacoutput
To theNeuropathy
model
To theNephropath
y model
To theCoronary
arterydiseasemodel
To theRetinopathy
model
Hypo-glycemia
Familyhistory
Diabetescardiac risk
factor
FPG
Randomplasmaglucose
OGTT test
Propensityto fatigue
Propensityto polyuria
Thirst
Fatigue
Polyuria
Perception
Memory
Patienttakes action
Blurredvision
Propensityto thirst
Propensityto blurred
vision
FPG
Diabetesblood
pressurefactor
Insulintreatment
Systolicblood
pressure
Peripheralresistance
Untreatedinsulin level
Insulinefficiency(Muscle)
Smoking
FPG
Randomplasma
glucose test
HbA1c test
FPG testRandomerror andvariation
Totreatmentmodels
Careprocesses
Triglycerides
Age, sex,race/
ethnicity
Type 2Diabetesfeature
Metformin
Diet andexercise
Weight
HDLcholesterol
Insulinproduction(Pancreas)
Unexplainedvariance in
OGT
UKPDSdata
Keto-acidosis
Fractionalchange in
Insulin
Urineketone test
Glucoseproduction
by liver
Normal liverglucose
production
Insulinefficiency
(Liver)
JointDiabetesfeature
Insulin level
Glucoseuptake by
muscle
But watch out. I’m
gaining on you.