Directing Change and Charting Progress Toward Health

1
Directing Change and Charting Progress Toward
Health

• Roles for System Dynamics and Social Navigation

Jack Homer Homer Consulting Voorhees, New Jersey
Bobby Milstein Centers for Disease Control and
PreventionAtlanta, Georgia
American Evaluation Association November 5,
2004 Atlanta, GA
2
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 lthttp//leahi.kcc.hawaii.edu/org/pvs/malama/
voyaginghome.htmlgt.
3
Broad Street, One Year Later
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."
Summers J. Soho a history of London's most
colourful neighborhood. Bloomsbury, London, 1989.
p. 117.
4
Public Health Goals Are Expandingand
Accumulating
The perfection of means and confusion of goals
characterizes our age. -- Albert Einstein

• Prevent disease and injury (1850 -- present)
• Promote health and development (1974 -- present)
• Assure the conditions in which people can be
  healthy (1988 -- present)

5
Understanding Dynamic ComplexityFrom a Very
Particular Distance
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Health Protection as a Dynamic System
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.
7
A Dynamic System Out of Control
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.
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.
8
The U.S. Health System is Remarkably Resistant
to Change
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
At least six times since the Depression, the
United States has tried and failed to enact a
national health insurance program.
-- Lee Paxman
Lee P, Paxman D. Reinventing public health.
Annual Reviews of Public Health 1997181-35.
9
Flaws in Previous Attempts at Health Reform in
America

• 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

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 lthttp//www.cpn.org/topics/health/hea
lthquestion.htmlgt.
10
Looking Through the Macroscope
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.
-- Joèel de Rosnay
Rosnay J. The macroscope a book on the systems
approach. Principia Cybernetica, 1997.
lthttp//pespmc1.vub.ac.be/MACRBOOK.htmlgt.
11
Seeing Beyond the Probable
Most organizations plan around what is most
likely. In so doing they reinforce what is, even
though they want something very
different. -- Ciement Bezold

• 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.
12
Re-Directing the Course of ChangeQuestions from
System Modeling and Social Navigation
Where?
How?
Why?
Who?
2020
2010
13
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
14
Tools for Navigational Analysis
Events
Time Series Models Describe trends

• Increasing
• Depth of causal theory
• Degrees of uncertainty
• Robustness for longer-term projection
• Value for developing policy insights

Multivariate Stat Models Identify historical
trend drivers and correlates
Patterns
Dynamic Simulation Models Anticipate future
trends, and find policies that maximize chances
of a desirable path
Structure
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 Agencys
first ever full-scale internal emergency
management exercise. - CDC ConnectsMay 6, 2004
Its important to exercise your plan before an
event really happensYou need to validate your
procedures. You need to see that the plan and
reality are the same. Its also a federal
regulation to hold exercises. And its a good
idea to get people thinking about their roles and
how they will support the agency well before a
crisis occurs.
Nellis K, Birch K. Mission ready 2004 this is a
test. CDC Connects, Centers for Disease Control
and Prevention, 2004. lthttp//intranet.cdc.gov/ecp
/insidestory/missionready.htmlgt.
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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.h
tml.
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Setting Realistic ExpectationsHP 2010 Diabetes
Objectives
Baseline HP 2010 Target Percent Change
Reduce Diabetesrelated 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
People with
Undiagnosed
Initial
Diabetes
Onset
With a diagnosed onset flow of 1.1 mill/yr
Diagnosed
Onset
People with
Diagnosed
Dying from Diabetes
Diabetes
Complications
It is impossible for any policy to reduce
prevalence38 by 2010!
And a death flow of 0.5 mill/yr (4/yr rate)
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History and Futures for Diabetes
PrevalenceReported Trends, HP Objectives, and
Simulation Results
Reported
Meet Detection Objective (5-4)
I
Status Quo
G
Meet Onset Objective (5-2)
H
F
D
C
HP 2000 Objective
HP 2010 Objective (5-3)
E
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Diabetes System Modeling ProjectWhere is the
Leverage for Health Protection?
People with
People with
People with
Undiagnosed,
Undiagnosed,
Undiagnosed
Uncomplicated
Complicated
PreDiabetes
Diabetes
Diabetes
People with
Normal
Glycemic
Levels
People with
People with
People with
Diagnosed,
Diagnosed,
Diagnosed
Uncomplicated
Complicated
PreDiabetes
Diabetes
Diabetes
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.
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Diabetes System Modeling ProjectWhere is the
Leverage for Health Protection?
PreDiabetes
Diabetes
Detection
Detection
Developing
Diabetes from Undx
Developing
PreDiabetes
Complications from
PreD,
People with
People with
Dying from Undx
Onset
Undx diab
People with
Undiagnosed,
Undiagnosed,
Complications
Undiagnosed
Uncomplicated
Complicated
PreDiabetes
Diabetes
Diabetes
Recovering from
People with
PreDiabetes
Normal
Diagnosing
Diagnosing
Diagnosing
Uncomplicated
Glycemic
Complicated
PreDiabetes
Diabetes
Diabetes
Levels
Developing
People with
People with
Dying from
Complications
People with
Diagnosed,
Diagnosed,
Complications
Recovering from
Diagnosed
Uncomplicated
Complicated
PreDiabetes
Diabetes
PreDiabetes
Diabetes
Diabetes
Onset
Risk for
PreDiabetes Diabetes
Diabetes
PreDiabetes
Control
Control
Obese Fraction of
the Population
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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
Diagnosed Diabetes of Adults
Obese of Adults
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.
24
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
25
Deaths Due to Diabetes per Capita Has Fallen
People with Diabetes per Thousand Adults
Complications Deaths per Thous People w Diabetes
100
40
Model Output
Model Output
90
30
80
20
70
Among people with diabetes, fewer dying every year
More people with diabetes
10
60
0
50
1980
1985
1990
1995
2000
2005
1980
1985
1990
1995
2000
2005
Time (Year)
Time (Year)
Deaths from Comps of Diabetes Per Thous Adults
2.5
2
Combine to mean fewer U.S. adults dying from
diabetes per thousand!
1.5
1
Model Output
0.5
0
1980
1985
1990
1995
2000
2005
Time (Year)
26
Anticipating the Future (1) Prevalence Under
Status Quo Assumptions
Obese Fraction of Adult Population
People with Diabetes per Thousand Adults
0.6
130
Model Output
Model Output
0.45
110
0.3
90
Prevalence continues to increase.
0.15
Even if we assume the obesity epidemic has
peaked
70
0
50
1980
1990
2000
2010
2020
2030
2040
2050
1980
1990
2000
2010
2020
2030
2040
2050
Time (Year)
Time (Year)
27
Anticipating the Future (2) Deaths Under Status
Quo Assumptions
Complications Deaths per Thous w Diabetes
People with Diabetes per Thousand Adults
40
130
And if we can maintain current levels of care
30
110
20
90
If prevalence continues to increase,
but no continued improvement
10
70
0
50
1980
1990
2000
2010
2020
2030
2040
2050
1980
1990
2000
2010
2020
2030
2040
2050
Time (Year)
Time (Year)
Deaths from Complications of Diabetes Per
Thousand Adults
2.5
Then prevalence overwhelms the improved care to
boost the burden
1.25
1980
1990
2000
2010
2020
2030
2040
2050
Time (Year)
28
The Diabetes Learning Lab in Action
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How Strong Will Interventions Have to Be to
Alter the Status Quo?
PreDiabetes
Diabetes
Detection
Detection
PreDiabetes
Complications from
People with
People with
Onset
People with
Undiagnosed,
Undiagnosed,
Complications
Undiagnosed
Uncomplicated
Complicated
PreDiabetes
Diabetes
Diabetes
Recovering from
People with
PreDiabetes
Normal
Diagnosing
Diagnosing
Diagnosing
Uncomplicated
Glycemic
Complicated
Diabetes
PreDiabetes
Levels
Diabetes
Developing
People with
People with
Dying from
Complications
People with
Diagnosed,
Diagnosed,
Complications
Recovering from
Diagnosed
Uncomplicated
Complicated
PreDiabetes
Diabetes
PreDiabetes
Diabetes
Diabetes
Onset
Risk for
PreDiabetes
Diabetes
PreDiabetes
Control
Control
Obese Fraction of
the Population
30
Anticipating Change Over Time
Sketch the new future that would be created when.
Diagnosed Diabetes Population per Thousand
Deaths from Complications of Diabetes per Thousand
(Status quo)
(Status quo)
Lines can go off the graph area if you want
31
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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Hygeias Constellation Protecting Health Through
Public Work
Public health is probably the most successful
system of science and technology combined, as
well as social policy, that has ever been
devisedIt 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.
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What Exactly is Public Work?
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. Cent
er for Democracy and Citizenship. The concept and
philosophy of public work. Center for Democracy
and Citizenship, 2001. Available at
lthttp//www.publicwork.org/1_2_philosophy.htmlgt.
34
Widespread Interest in the Promise of a Systems
Orientation
See http//www.cdc.gov/syndemics/ajph-systems.htm
Submission Deadline February 1, 2005