Cesarean Delivery Model · natural childbirth Types of childbirth delivery Cesarean delivery...

Cesarean Delivery ModelMeeting the challenge to reduce rates of Cesarean delivery

Alan Mills FSA MAAA NDNovember 13, 2014

1. Background

2. The U.S. Cesarean delivery challenge

3. Cesarean Delivery Model design

4. Results

Agenda

1. Background

Vaginal deliverynatural childbirth

Types of childbirth delivery

Cesarean deliverysurgical intervention

Cesarean delivery problems

Poor psychosocial outcomes Risks of major abdominal surgery Pulmonary disorders Compromised breast feeding Complications for later births Increased perinatal mortality Greater cost

Netherlands (14%)

World cesarean delivery rates – 2008

Source: World Health Organization

U.S. cesarean delivery rates – 2013

NJ

MA

WA

OR

CA

NV

AZ

UT CO

WY

MT

ID

ND

SD

NE

KS

OK

TX

AR

MO

IA

MN

WI

IL IN

KY

TN

MS

LA

AL GA

FL

SC

NC

VAWV

OH

MIPA

NY

ME

AK

HI

DE

MD

VTNH

CTRI

NM

35.1 – 46.0 30.1 – 35.0 25.1 – 30.0 20.1 – 25.0

Source:

Highest rate: 38.9%

Lowest rate: 22.4%

U.S. cesarean delivery rates

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

2013:32.7%

1965:4.5%

Source:

$- $5 $10 $15 $20 $25 $30 $35 $40 $45

Heart conditions

Normal birth/live born

Trauma-related disorders

Cancer

Osteoarthritis and other non-traumatic joint disorders

COPD, asthma

Gallbladder, pancreatic, and liver disease

Kidney Disease

Other CNS disorders

Systemic lupus and connective tissues disorders

U.S. hospital inpatient expenditures – 2011(ages 0 – 65, $ billions)

Source:

How can we reduce the U.S Cesarean delivery rate

to a reasonable level (10% - 15%)?

1. Focus on individual States

2. Bring together the State’s major stakeholders:LegislatorsHealth agenciesHealth insurersMedicaidClinicians (Obstetricians, Certified Nurse Midwives, Licensed Midwives)Women

3. Use AnyLogic simulations as the focus

My approach

Reasons for using AnyLogic

One cogent framework accessible to all stakeholders: GIS visualization Sophisticated agent-based modeling Scalable for many agents State charts and flow diagrams for agent behavior Interface with Excel Robust experiment types Message passing

Why agent based modeling?

Many heterogeneous agents interacting over time Independent agent behavior Importance of space Network effects Feedback

Agents

Women Obstetricians Certified nurse midwives (CNMs) Licensed midwives (LMs) Hospitals Health insurers Medicaid

Data

Data from the State:

Synthetic data Women Obstetricians, CNMs, LMs

Actual data Hospitals Insurers

WomenChoose primary birth attendantRequest delivery attendance

ObstetriciansChoose HospitalDecide delivery methodSubmit claim

CNMsChoose HospitalChoose backup ObstetricianRefer delivery attendanceAttend vaginal birthSubmit claim

LMsChoose backup ObstetricianRefer delivery attendanceAttend vaginal birthSubmit claim

HospitalsSubmit claim

Insurers/MedicaidPay claim

Key behaviors

WomenChoose primary birth attendantRequest delivery attendance

ObstetriciansChoose HospitalDecide delivery methodSubmit claim

CNMsChoose HospitalChoose backup ObstetricianRefer delivery attendanceAttend vaginal birthSubmit claim

LMsChoose backup ObstetricianRefer delivery attendanceAttend vaginal birthSubmit claim

HospitalsSubmit claim

Insurers/MedicaidPay claim

Messages

Key behaviors

10. Outputmessages

1. Input messages

7. Context

8. Produceoutput

Agent

9. Sendoutput

3. Motivations 4. Attributes

6. Rules5. Experience

2. Getinput

General behavior model

Example behavior:Choose primary birth attendant

Agent: Woman1. Input messages: Childbirth month (data item)2. Get input: NA3. Motivations: Desired birth attendant type (data item)4. Attributes: Residence latitude and longitude (data item)5. Experience: NA6. Rules: NA7. Context: NA8. Produce output: Get Identifier of nearest desired birth attendant type9. Send output: Send output to Woman attributes10.Output messages: Clinician Identifier

10. Outputmessages1. Input

messages

8. Produceoutput

Agent

9. Sendoutput

3. Motivations 4. Attributes

Example behavior:Choose primary birth attendant

“Message” Class parameters: Message type Sending agent type Sending agent identifier Woman identifier Delivery method Amount

Messages are passed using “send(Object, Agent)”through AnyLogic’s standard “connections” link.

Message passing

Environment (GIS)

Visualization

HospitalsWomen

Obstetricians

Certified Nurse Midwives(CNMs)

Licensed Midwives(LMs)

Insurers

Visualization: Washington State

Model demonstration: Visualization

User interface

Model demonstration: User interface

4. Results

Significance of the Cesarean Delivery Model

First holistic model of the Cesarean delivery challenge Stakeholder focus for Cesarean delivery reform First step toward a complete health system model First step toward reusable agents and behaviors

Model demonstration: Results

Key results

Payment reform by itself won’t work as intended A multi-faceted approach is required Retooling the workforce will take time

Questions or comments?

1. Background



4. Results

Review

[email protected]

Thank you

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