Syndemics Prevention Network Directing Change and Charting Progress Toward Health Roles for System...
-
Upload
brook-dalton -
Category
Documents
-
view
214 -
download
1
Transcript of Syndemics Prevention Network Directing Change and Charting Progress Toward Health Roles for System...
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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>.
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
Understanding Dynamic ComplexityFrom a Very Particular Distance
Syndemics
Prevention Network
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.
Syndemics
Prevention Network
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.
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
“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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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.
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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.”
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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)
Syndemics
Prevention Network
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
Syndemics
Prevention Network
The Diabetes Learning Lab in Action
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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
Syndemics
Prevention Network
Hygeia and Panacea“In no single thing do men approach the Gods more nearly,
than in the giving of safety to mankind.”– Cicero
Syndemics
Prevention Network
“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
Syndemics
Prevention Network
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?
Syndemics
Prevention Network
Widespread Interest in the Promise of a Systems Orientation
See: http://www.cdc.gov/syndemics/ajph-systems.htm
Submission Deadline: February 1, 2005