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Directing Change and Charting Progress Toward Health

Roles for System Dynamics and Social Navigation

American Evaluation AssociationNovember 5, 2004

Atlanta, GA

Jack HomerHomer Consulting

Voorhees, New Jersey

Bobby MilsteinCenters for Disease Control and Prevention

Atlanta, Georgia

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Navigating Health Futures

"How do you know," I asked, "that in

twenty years those things that you

consider special are still going to be

here?" At first they all raised their

hands but when they really digested

the question every single one of them

put their hands down. In the end,

there was not a single hand up. No

one could answer that question…”

-- Nainoa Thompson

Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at <http://leahi.kcc.hawaii.edu/org/pvs/malama/voyaginghome.html>.

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Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117.

“No improvements at all had been

made...open cesspools are still to

be seen...we have all the materials

for a fresh epidemic...the water-

butts were in deep cellars, close to

the undrained cesspool...The

overcrowding appears to increase."

Broad Street, One Year Later

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Public Health Goals Are Expanding…and Accumulating

• Prevent disease and injury (~1850 -- present)

• Promote health and development (1974 -- present)

• Assure the conditions in which people can be healthy (1988 -- present)

“The perfection of means and confusion of goals characterizes our age.”

-- Albert Einstein

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Understanding Dynamic ComplexityFrom a Very Particular Distance

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Health Protection as a Dynamic System

Society's HealthResponse

Demand forresponse

TargetedProtection

SaferHealthierPeople Becoming

vulnerable

Becoming saferand healthier

PrimaryPrevention

VulnerablePeople Becoming

afflicted

SecondaryPrevention

Afflictedwithout

Complications Developingcomplications

TertiaryPrevention

Afflicted withComplications

Dying fromcomplications

AdverseConditions

GeneralProtection

Gerberding JL. CDC's futures initiative. Atlanta, GA: Public Health Training Network; April 12, 2004.

Jackson DJ, Valdesseri R, CDC Futures Health Systems Work Group. Health systems work group report. Atlanta, GA: Centers for Disease Control and Prevention, Office of Strategy and Innovation; January 6, 2004.

Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003.

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A Dynamic System Out of Control

Heirich M. Rethinking health care: innovation and change in America. Boulder CO: Westview Press, 1999.

Pear R. Health spending rises to record 15% of economy. The New York Times 2004 January 9.

The health sector now is one of

the most consequential parts of

the American economy,

employing more people than any

other area and tripling its share

of the gross domestic product in

the past 40 years.

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The U.S. Health System is Remarkably Resistant to Change

Lee P, Paxman D. Reinventing public health. Annual Reviews of Public Health 1997;18:1-35.

“At least six times since the

Depression, the United States has

tried and failed to enact a national

health insurance program.”

-- Lee & Paxman

“Policy resistance is the tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.”

-- Meadows, Richardson, Bruckman

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Flaws in Previous Attempts at Health Reform in America

Heirich M. Rethinking health care: innovation and change in America. Boulder CO: Westview Press, 1999.

Kari NN, Boyte HC, Jennings B. Health as a civic question. American Civic Forum, 1994. Available at <http://www.cpn.org/topics/health/healthquestion.html>.

Piecemeal approaches

Comprehensive strategies that are opposed by special interests

Assumption that healthcare dynamics are separate from other areas of public concern

Conventional analytic methods make it difficult to

Observe the health system as a large, dynamic enterprise

Craft high-leverage strategies that can overcome policy resistance

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“The macroscope filters details and amplifies that which links

things together. It is not used to make things larger or smaller but

to observe what is at once too great, too slow, and too complex

for our eyes.”

Rosnay J. The macroscope: a book on the systems approach. Principia Cybernetica, 1997. <http://pespmc1.vub.ac.be/MACRBOOK.html>.

-- Joèel de Rosnay

Looking Through the Macroscope

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Seeing Beyond the Probable

• PossibleWhat may happen?

• PlausibleWhat could happen?

• ProbableWhat will likely happen?

• PreferableWhat do we want to have happen?

Bezold C, Hancock T. An overview of the health futures field. Geneva: WHO Health Futures Consultation; 1983 July 19-23.

“Most organizations plan around what is most likely. In so doing they reinforce what is, even though they want something very different.”

-- Ciement Bezold

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Re-Directing the Course of ChangeQuestions from System Modeling and Social Navigation

20202010

How?

Why?

Where?

Who?

People with Diagnosed Diabetes, US

0

5

10

15

1980 1985 1990 1995 2000

Mill

ion

peop

le

Data Source: CDC DDT and NCCDPHP. -- Change in measurement in 1996.

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Different Modeling Approaches For Different Purposes

Logic Models(flowcharts, maps or

diagrams)

System Dynamics(causal loop diagrams and

simulation models)

Forecasting Models

• Articulate steps between actions and anticipated effects

• Improve understanding about the plausible effects of a policy over time

• Focus on patterns of change over time (e.g., long delays, worse before better)

• Make accurate forecasts of key variables

• Focus on precision of point predictions and confidence intervals

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Time Series Models

Describe trends

Multivariate Stat Models

Identify historical trend drivers and correlates

Patterns

Structure

Events

Increasing:

• Depth of causal theory

• Degrees of uncertainty

• Robustness for longer-term projection

• Value for developing policy insights

Increasing:

• Depth of causal theory

• Degrees of uncertainty

• Robustness for longer-term projection

• Value for developing policy insights

Dynamic Simulation Models

Anticipate future trends, and find policies that maximize chances

of a desirable path

Tools for Navigational Analysis

Developed by Jack Homer, Homer Consulting

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Learning Through SimulationMission Ready 2004

“More than 100 CDC personnel from all levels of the organization participated in the Agency’s first ever full-scale internal

emergency management exercise.”

- CDC ConnectsMay 6, 2004

Nellis K, Birch K. Mission ready 2004: this is a test. CDC Connects, Centers for Disease Control and Prevention, 2004. <http://intranet.cdc.gov/ecp/insidestory/missionready.html>.

“It’s important to exercise your plan before an event really happens…You need to validate your procedures. You need to see that the plan and reality are the same. It’s also a

federal regulation to hold exercises. And it’s a good idea to get people thinking about their roles and how they will support the agency well before a crisis occurs.”

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Transforming the Future of Diabetes…

"Every new insight into Type 2 diabetes...

makes clear that it can be avoided--and

that the earlier you intervene the better.

The real question is whether we as a

society are up to the

challenge...Comprehensive prevention

programs aren't cheap, but the cost of

doing nothing is far greater..."

Gorman C. Why so many of us are getting diabetes: never have doctors known so much about how to prevent or control this disease, yet the epidemic keeps on raging. how you can protect yourself. Time 2003 December 8. Accessed at http://www.time.com/time/covers/1101031208/story.html.

…in an Era of Epidemic Obesity

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Setting Realistic ExpectationsHP 2010 Diabetes Objectives

BaselineHP 2010 Target

Percent Change

Reduce Diabetes–related Deaths Among Diagnosed

(5-6)

8.8 per 1,000

7.8 -11%

Increase Diabetes Diagnosis (5-4)

68% 80% +18%

Reduce New Cases of Diabetes (5-2)

3.5per 1,000

2.5 -29%

Reduce Prevalence of Diagnosed Diabetes

(5-3)

40 per 1,000

25 -38%

U.S. Department of Health and Human Services. Healthy People 2010. Washington DC: Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services; 2000. http://www.healthypeople.gov/Document/HTML/Volume1/05Diabetes.htm

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The Simple Physics of Diabetes

It is impossible for any policy to reduce prevalence

38% by 2010!

People withUndiagnosed

Diabetes

People withDiagnosedDiabetes Dying from Diabetes

Complications

DiagnosedOnset

InitialOnset

People withNormal

GlycemicLevels

As would stepped-up detection effort

Reduced death wouldadd further to prevalence

With a diagnosed onset flow of

1.1 mill/yr

And a death flow of 0.5 mill/yr

(4%/yr rate)

The targeted 29% reduction in diagnosed onset can only

slow the growth in prevalence

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20

30

40

50

60

70

1980 1985 1990 1995 2000 2005 2010

Pe

op

le w

ith

dia

gn

ose

d d

iab

ete

s p

er

1,0

00

Reported Simulated

Status Quo

Meet Detection Objective (5-4)

Meet Onset Objective (5-2)

HP 2010 Objective (5-3)

HP 2000 Objective

History and Futures for Diabetes PrevalenceReported Trends, HP Objectives, and Simulation Results

A

B

C

D

E

F

G

H

I

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Diabetes System Modeling ProjectWhere is the Leverage for Health Protection?

People withUndiagnosed,Uncomplicated

Diabetes

People withDiagnosed,

UncomplicatedDiabetes

People withDiagnosed,Complicated

Diabetes

People withUndiagnosedPreDiabetes

People withDiagnosed

PreDiabetes

People withUndiagnosed,Complicated

DiabetesPeople with

NormalGlycemic

Levels

DiagnosingDiabetes

DiagnosingDiabetes

Diabetes Detection

Dying fromComplications

DevelopingComplications

Diabetes Control

PreDiabetes Detection

DiagnosingPreDiabetes

DiabetesOnset

PreDiabetes Control

Homer J, Jones A, Seville D, Essien J, Milstein B, Murphy D. The CDC diabetes system modeling project: developing a new tool for chronic disease prevention and control. 22nd International Conference of the System Dynamics Society; Oxford, England; 2004.

PreDiabetesOnset

Recovering fromPreDiabetes

Recovering fromPreDiabetes

Obesity Prevention

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Diabetes System Modeling ProjectWhere is the Leverage for Health Protection?

People withUndiagnosed,Uncomplicated

Diabetes

People withDiagnosed,

UncomplicatedDiabetes

People withDiagnosed,Complicated

Diabetes

DiagnosingUncomplicated

Diabetes

People withUndiagnosedPreDiabetes

People withDiagnosed

PreDiabetes

DiagnosingPreDiabetes

DevelopingComplications from

Undx diab

DevelopingDiabetes from Undx

PreD,People with

Undiagnosed,Complicated

Diabetes

DiagnosingComplicated

Diabetes

Dying from UndxComplications

People withNormal

GlycemicLevels

DiabetesDetection

Obese Fraction ofthe Population

Risk forPreDiabetes & Diabetes

Caloric Intake PhysicalActivity

PreDiabetesControl

DiabetesControl

PreDiabetesDetection

MedicationAffordability

Ability to SelfMonitor

ClinicalManagement of

PreDiabetes

Adoption ofHealthy Lifestyle

Clinical Managementof Diagnosed

Diabetes

LivingConditions

PersonalCapacity

PreDiabetesTesting for

Access toPreventive Health

Services Testing forDiabetes

PreDiabetesOnset

Recovering fromPreDiabetes

Recovering fromPreDiabetes Diabetes

Onset

Dying fromComplications

DevelopingComplications

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Using Available Data to Calibrate a Model

Information Sources Data

U.S. Census• Adult population and death rates• Health insurance coverage

National Health Interview Survey• Diabetes prevalence• Diabetes detection

National Health and Nutrition Examination Survey

• Prediabetes prevalence

• Weight, height, and body fat

• Caloric intake

Behavioral Risk Factor Surveillance System

• Glucose self-monitoring• Eye and foot exams• Participation in health education• Use of medications

Professional Literature

• Physical activity trends• Effects of control and aging on onset, progression, death, and costs• Expenditures

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Confirming Fit to History

Homer J, Jones A, Seville D, Essien J, Milstein B, Murphy D. The CDC diabetes system modeling project: developing a new tool for chronic disease prevention and control. 22nd International Conference of the System Dynamics Society; Oxford, England; 2004.

0%

2%

4%

6%

8%

1980 1985 1990 1995 2000 2005 2010

Diagnosed diabetes % of adults

Data (NHIS)

Simulated

0%

2%

4%

6%

8%

1980 1985 1990 1995 2000 2005 2010

Diagnosed diabetes % of adults

Data (NHIS)

Simulated

0%

10%

20%

30%

40%

1980 1985 1990 1995 2000 2005 2010

Obese % of adults

Data (NHANES)

Simulated

0%

10%

20%

30%

40%

1980 1985 1990 1995 2000 2005 2010

Obese % of adults

Data (NHANES)

Simulated

Diagnosed Diabetes % of AdultsObese % of Adults

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What Drives the Burden of Diabetes?We Have Seen Two Primary Forces at Work

Great Progress in Reducing the Burden

for the Average Person with Diabetes

Huge Growth in Number of People

with Diabetes

Overall, Total Population Burden Held at Bay

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Deaths Due to Diabetes per Capita Has Fallen

Combine to mean fewer U.S. adults dying from diabetes per thousand!

Complications Deaths per Thous People w Diabetes40

30

20

10

0

1980 1985 1990 1995 2000 2005Time (Year)

People with Diabetes per Thousand Adults

100

90

80

70

60

501980 1985 1990 1995 2000 2005

Time (Year)

More people with diabetes

Deaths from Comps of Diabetes Per Thous Adults2.5

2

1.5

1

0.5

0

1980 1985 1990 1995 2000 2005Time (Year)

Among people with diabetes, fewer dying every year

Model OutputModel Output

Model Output

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Anticipating the Future (1) Prevalence Under Status Quo Assumptions

After adelay

Obese Fraction of Adult Population

0.6

0.45

0.3

0.15

0

Even if we assume the obesity epidemic has peaked…

People with Diabetes per Thousand Adults

130

110

90

70

50

1980 1990 2000 2010 2020 2030 2040 2050Time (Year)

Prevalence continues to increase.

Model OutputModel Output

1980 1990 2000 2010 2020 2030 2040 2050Time (Year)

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And if we can maintain current levels of care

but no continued improvement…

If prevalence continues to increase,

People with Diabetes per Thousand Adults130

110

90

70

50

1980 1990 2000 2010 2020 2030 2040 2050Time (Year)

Complications Deaths per Thous w Diabetes40

30

20

10

0

1980 1990 2000 2010 2020 2030 2040 2050Time (Year)

Deaths from Complications of Diabetes Per Thousand Adults2.5

1.25

1980 1990 2000 2010 2020 2030 2040 2050Time (Year)

Then prevalence overwhelms the improved care to boost the burden

Anticipating the Future (2) Deaths Under Status Quo Assumptions

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The Diabetes Learning Lab in Action

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How Strong Will Interventions Have to Be to Alter the Status Quo?

People withUndiagnosed,Uncomplicated

Diabetes

People withDiagnosed,

UncomplicatedDiabetes

People withDiagnosed,Complicated

Diabetes

DiagnosingUncomplicated

Diabetes

People withUndiagnosedPreDiabetes

People withDiagnosed

PreDiabetes

DiagnosingPreDiabetes

Complications fromPeople with

Undiagnosed,Complicated

Diabetes

DiagnosingComplicated

Diabetes

Complications

People withNormal

GlycemicLevels

DiabetesDetection

Obese Fraction ofthe Population

Risk forPreDiabetes

Caloric Intake PhysicalActivity

PreDiabetesControl

DiabetesControl

PreDiabetesDetection

MedicationAffordability

Ability to SelfMonitor

ClinicalManagement of

PreDiabetes

Adoption ofHealthy Lifestyle

Clinical Managementof Diagnosed

Diabetes

PreDiabetesTesting for

Access toPreventive Health

Services Testing forDiabetes

PreDiabetesOnset

Recovering fromPreDiabetes

Recovering fromPreDiabetes Diabetes

Onset

Dying fromComplications

DevelopingComplications

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Deaths from Complications of Diabetes Per Thousand Adults

2.5

2.25

2

1.75

1.5

1.25

1980 1990 2000 2010 2020 2030 2040 2050Time (Year)

Sketch the new future that would be created when….

Anticipating Change Over Time

Diagnosed Diabetes Population per Thousand Adults

110

90

70

50

30

1980 1990 2000 2010 2020 2030 2040 2050Time (Year)

Lines can go off the graph area if you want

(Status quo)

Diagnosed Diabetes Population per Thousand

(Status quo)Deaths from Complications of Diabetes per Thousand

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Hygeia and Panacea“In no single thing do men approach the Gods more nearly,

than in the giving of safety to mankind.”– Cicero

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“Public health is probably the most successful system of science and technology combined, as well as social policy, that has ever been

devised…It is, I think, a paradigmatic model for how you do concerned,

humane, directed science.”

-- Richard Rhodes

Rhodes R. Limiting human violence: an emerging scientific challenge. Sarewitz D, editor. Living With the Genie: Governing Science and Technology in the 21st Century; New York, NY: Center for Science, Policy, and Outcomes; 2002.

Hygeia’s ConstellationProtecting Health Through Public Work

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Public work is sustained, visible, serious effort by a diverse mix of ordinary people that creates things of lasting civic or public significance.

Mitchell Siporin. Jane Addams memorial. Illinois Federal Art Project, WPA, 1936. Fine Arts Collection, General Services Administration.

Center for Democracy and Citizenship. The concept and philosophy of public work. Center for Democracy and Citizenship, 2001. Available at <http://www.publicwork.org/1_2_philosophy.html>.

What Exactly is Public Work?

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Widespread Interest in the Promise of a Systems Orientation

See: http://www.cdc.gov/syndemics/ajph-systems.htm

Submission Deadline: February 1, 2005