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The CDC’s Diabetes Systems Modeling Project: Developing a New Tool for Chronic Disease Prevention and Control. Jack Homer, Andrew Jones, Don Seville Homer Consulting & Sustainability Institute Joyce Essien Rollins School of Public Health, Emory University Bobby Milstein Dara Murphy - PowerPoint PPT Presentation
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The CDC’s Diabetes Systems Modeling Project: Developing a New Tool for Chronic
Disease Prevention and Control
Jack Homer, Andrew Jones, Don Seville Homer Consulting & Sustainability Institute
Joyce EssienRollins School of Public Health, Emory University
Bobby MilsteinDara Murphy
Centers for Disease Control and Prevention
International SD ConferenceOxford, U.K.July 27, 2004
Client and Issue
SAFER • HEALTHIER • PEOPLE ™
• Client: CDC’s Division of Diabetes Translation– Policy and Epidemiology Branches
• Issue: What are the pros and cons of “upstream” (prevention) and “downstream” (control) efforts?
Upstream Prevention and Protection----------------------------------Total 3%
Downstream Care and Management--------------------------------Total 97%
Public Health Efforts Today
Growth of Obesity and Diabetes in the U.S.
Fraction Population Obese and Fraction with Diabetes
0%
10%
20%
30%
40%
1960 1970 1980 1990 2000
Frac
pop
'n o
bese
0.0%
1.5%
3.0%
4.5%
6.0%
Frac
pop
'n w
ith d
iabe
tes
CDC -- NHANES; NHIS (adjusted in '97)
Obese
DiabetesDiagnosed
& with Diagnosed Diabetes
Dx
diab
etes
TIME Magazine Cover Story,
8 December 2003.
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
CaloricIntake
PhysicalActivity
ClinicalManagement of
PreDiabetes
Ability to SelfMonitor
MedicationAffordability
Clinical Managementof Diagnosed
Diabetes
Access toPreventive Health
Services
Testing forDiabetes
Testing forPreDiabetes
Obese Fraction ofthe Population
Risk forPreDiabetes
Control ofPreDiabetes
Control ofDiabetes
Detection ofComplicated
Diabetes
Detection ofUncomplicated
Diabetes
Detection ofPreDiabetes
Adoption ofHealthy Lifestyle
Model Structure
BMI/Obesity Clinical Management of Diagnosed PreD &
Diabetes
DownstreamUpstream
Base RunObesity Prevalence
0.5
0.4
0.3
0.2
0.11980 1990 2000 2010 2020 2030 2040 2050
Time (Year)
Diabetes Prevalence0.15
0.125
0.1
0.075
0.051980 1990 2000 2010 2020 2030 2040 2050
Time (Year)
Deaths per Complicated0.08
0.07
0.06
0.05
0.041980 1990 2000 2010 2020 2030 2040 2050
Time (Year)
Deaths per Population0.0035
0.003
0.0025
0.002
0.00151980 1990 2000 2010 2020 2030 2040 2050
Time (Year)
Deaths per Population0.0035
0.003
0.0025
0.002
0.00151980 1990 2000 2010 2020 2030 2040 2050
Time (Year)
Downstream-Only Intervention
Blue: Base run; Red: Clinical mgmt of diagnosed up from 66% to 90%
Base
Downstream
Deaths per Population0.0035
0.003
0.0025
0.002
0.00151980 1990 2000 2010 2020 2030 2040 2050
Time (Year)
Upstream-Only Intervention
Blue: Base run; Red: Clinical mgmt up from 66% to 90%;Green: Caloric intake down 4% (99 Kcal/day)
DownstreamUpstream
Base
Deaths per Population0.0035
0.003
0.0025
0.002
0.00151980 1990 2000 2010 2020 2030 2040 2050
Time (Year)
Mixed Intervention
Blue: Base run; Red: Clinical mgmt up from 66% to 90%;Green: Caloric intake down 4% (99 Kcal/day);Black: Clin mgmt up to 80% & Intake down 2.5% (62 Kcal/day)
Base
DownstreamUpstream
Mixed
Linking Insights to Action1. Cross-stakeholder model-based
learning laboratories2. Analyzing the effectiveness of goal-
setting
Diagnosed Prevalence Fraction Relative to 2000 Value1.5
1.25
1
0.75
0.51990 1995 2000 2005 2010
Time (Year)
No progress +24%+14%
Meet onset goal(-29%)
Goals, Actual Performance, and Model Runs
2010 prevalence goal -38%
2000 prevalence goal -11%
+33%
“It felt like we flunked”
Prevalence *
Deaths
Small outflow, people can live for decades with the disease
Chronic DiseaseLevel rises until the inflow is less than the outflow
Onset *
Large inflow, double the outflow
* Diagnosed
“It is expected that if you do a good job, things ought to go
down.” – Diabetes Branch Leader
Prevalence
Acute Infectious Disease
Onset
Large inflow, but usually fast to reduce
Level falls as inflow quickly drops below outflow
Large outflow via recovery or death
Recovery Deaths
Think measles, flu or SARS
Three of the Resulting Actions
• Head of the division amended the 38% goal for prevalence to say that they are not aiming for a decline
• Clients now broadcasting an improved mental model for chronic disease
• Epidemiology and Policy leaders co-writing their first paper on using SD to improve internal consistency of goals
Bridging the SD/Audience Divide
• Sometimes a stock/flow-dominated model is what client needs
• Help client to identify and communicate the shortcomings of old mental models and benefits of the new
Supplementary Materials
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
CaloricIntake
PhysicalActivity
ClinicalManagement of
PreDiabetes
Ability to SelfMonitor
MedicationAffordability
Clinical Managementof Diagnosed
Diabetes
Access toPreventive Health
Services
Testing forDiabetes
Testing forPreDiabetes
Obese Fraction ofthe Population
Risk forPreDiabetes
Control ofPreDiabetes
Control ofDiabetes
Detection ofComplicated
Diabetes
Detection ofUncomplicated
Diabetes
Detection ofPreDiabetes
Adoption ofHealthy Lifestyle
Possible Areas for Intervention
BMI/Obesity Clinical Management of Diagnosed PreD &
Diabetes
Now CDC is Exploring More “Upstream” Interventions
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
Risk forPreDiabetes
Control ofPreDiabetes
Control ofDiabetes
Detection ofComplicated
Diabetes
Detection ofUncomplicated
Diabetes
Detection ofPreDiabetes
Deaths from complications
Diabetesonset
Complicationsonset
CaloricIntakeMean body
weight/BMI
Basal metabolic
rate
Caloricbalance Physical
Activity
ObeseFraction of Population
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
Risk forPreDiabetes
Control ofPreDiabetes
Control ofDiabetes
Detection ofComplicated
Diabetes
Detection ofUncomplicated
Diabetes
Detection ofPreDiabetes
Past Focus of Interventions into the Diabetes System Has Been “Downstream”
Deaths from complications
Diabetesonset
Complicationsonset
Bridging the Divide
1. Learn client’s analytic needs and turn-ons
2. “Go Native” in language and form
3. Help client to identify and communicate shortcomings of old mental models
Missing Goals Was Attributed as Failure
• “The current epidemiology of type 2 diabetes could be used to argue that the [National Diabetes Prevention and Control Program] has been a monumental failure… [One] hypothesis, that this is a little known government bureaucracy spending large sums of money without achieving the desired goals, cannot be refuted based on the information at hand.”
• Anonymous reviewer of paper by client
What We Did
• Used model to check realism of objectives
• We “Went Native” in language and form– Fit to their variable names– Results in table format, not graphs
We’ll Focus On the Two Stocks that, Together, are “Diagnosed Prevalence”
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
Risk forPreDiabetes
Control ofPreDiabetes
Control ofDiabetes
Detection ofComplicated
Diabetes
Detection ofUncomplicated
Diabetes
Detection ofPreDiabetes
Deaths from complications
Diabetesonset
Complicationsonset
CaloricIntakeMean body
weight/BMI
Basal metabolic
rate
Caloricbalance Physical
Activity
ObeseFraction of Population
The Public Health Challenge of Chronic Disease
• Leading cause of illness, disability, and death in developed countries– 70-80% of U.S. health care claims
– Over 50% of U.S. adult population have at least one chronic disease; 25% have two or more
• A systems approach is needed – Dynamic complexity: Long delays of disease progression
– Need SD for better goal-setting, priorities, coordination
– Need to understand over-time impacts of “upstream” and “downstream” interventions
Safer,HealthierPeople
VulnerablePeople
AfflictedPeople withoutComplications
AfflictedPeople with
Complications
Primaryprevention
Secondaryprevention
Tertiaryprevention
Generalprotection
Targetedprotection
Society's Health Response
Dying fromcomplications
SAFER • HEALTHIER • PEOPLE ™
Chronic Disease Interventions, and the CDC’s Stated Mission
“CDC: Enhancing Health Protection!” – Dr. Julie Gerberding, Director
“UPSTREAM” “DOWNSTREAM”
Diabetes Stocks & Flows
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
Risk forPreDiabetes
Control ofPreDiabetes
Control ofDiabetes
Detection ofComplicated
Diabetes
Detection ofUncomplicated
Diabetes
Detection ofPreDiabetes
Deaths from complications
Diabetesonset
Complicationsonset
CaloricIntake
Mean body weight/BMI
Basal metabolic rate
Caloricbalance Physical
Activity
ObeseFraction of Population
In 2000, They Set HP 2010 GoalsBaseline~2000
HP 2010 Target
Percent Change
Reduce Prevalence of Diagnosed Diabetes
(5-3)
40 per 1,000 25 -38%
Reduce Diabetes–related Deaths
Among Diagnosed (5-6)
8.8 per 1,000 7.8 -11%
Increase Diabetes Diagnosis (5-4) 68% 80%
+12Percentpoints
“It is expected that if you do a good job, things ought to go down.”
We Looked at the Stock/Flow Internal Consistency of the Objectives
It is physically impossible for the diagnosed
prevalence to fall at all, much less 38%
If the diagnosis flow rises
sufficient to boost the fraction
diagnosed by 12 points
And if the deaths flow drops 11%
People withNormal
GlycemicLevels
People withUndiagnosed
DiabetesDiabetesonset
People withDiagnosedDiabetes
Diagnosisrate
Deaths fromcomplications
We Looked at the Stock/Flow Internal Consistency of the Objectives
People withNormal
GlycemicLevels
People withUndiagnosed
Diabetes
People withDiagnosedDiabetes
Diabetesonset
Diagnosisrate
Deaths fromcomplications
It is physically impossible for the diagnosed
prevalence to fall at all, much less 38%
If the diagnosis flow rises
sufficient to boost the fraction
diagnosed by 12 points
And if the deaths flow drops 11%
Unexpected Behavior from the ModelDiagnosed Prevalence Fraction Relative to 2000 Value
1.5
1.25
1
0.75
0.51990 1995 2000 2005 2010
Time (Year)
No continued progress
Meet prevalence goal -38%
+24%+13%
Meet onset goal
“It is expected that if you do a good job, things ought to go down.”
– Diabetes Branch Leader
Exploring the Existing Mental Model: Infectious Disease
“Even here in chronic disease, we are still living
with the model that you find the patients, you give them a shot, and they recover.”
People withNormal Health
People withUndiagnosed
Infectious Disease
People withDiagnosed
Infectious Disease
Onset
Diagnosis rate
Deaths fromcomplications
Interventions in infectious diseases boost an important
outflow: recovery
Recovery
Diagnosed Prevalence Fraction Relative to 2000 Value1.5
1.25
1
0.75
0.51990 1995 2000 2005 2010
Time (Year)
No progress +24%Meet detection goal +42%
+13%Meet onset goal
(-29%)
Unexpected Behavior from the Model
Meet prevalence goal -38%
“It is expected that if you do a good job, things ought to go down.”
– Diabetes Branch Leader
Then 2000, they set goals for 2010, including Diagnosed Prevalence
People withNormal
GlycemicLevels
People withUndiagnosed
Diabetes
People withDiagnosedDiabetes
Diabetesonset
Diagnosisrate
Deaths fromcomplications
Yet another aimed for the deaths flow to drop 11%
Another aimed for a 29%
reduction in the onset rate
One goal aimed to boost the
fraction diagnosed by 12
points
Can they meet the goal of a 38% drop in diagnosed
prevalence?
Exploring the Existing Mental Model: Acute Infectious Disease
People withNormal Health
People withUndiagnosed
Infectious Disease
People withDiagnosed
Infectious Disease
Onset
Diagnosis rate
Deaths fromcomplications
2. Those who don’t die, recover naturally and
quickly
Recovery
Think measles, flu or SARS
1. People who die, die
soon
3. Quarantines and vaccinations can cut onset
significantly
When you cut the inflow to a bathtub with two big
drains, the water level falls quickly
In 2000, They Set HP 2010 Goals
• In 2000, they set a goal of 38% reduction in diagnosed prevalence by 2010
• At same time, other goals for diagnosis and care– Fraction diagnosed up 12 percentage points– Reduce diabetes–related deaths among diagnosed by
11%
“It is expected that if you do a good job, things ought to go down.”
– Diabetes Branch Leader
History of Healthy People 2000• In 1990, stakeholders set “Healthy People 2000”
objectives
• Goal for diagnosed prevalence was an 11% reduction between 1990 and 2000
• During 90s, significant advances
• Combined effect by 2000 was 33% increase in diagnosed prevalence fraction
• “It felt like we flunked” – Program person
-11%
+33%
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
CaloricIntake
PhysicalActivity
ClinicalManagement of
PreDiabetes
Ability to SelfMonitor
MedicationAffordability
Clinical Managementof Diagnosed
Diabetes
Access toPreventive Health
Services
Testing forDiabetes
Testing forPreDiabetes
Obese Fraction ofthe Population
Risk forPreDiabetes
Control ofPreDiabetes
Control ofDiabetes
Detection ofComplicated
Diabetes
Detection ofUncomplicated
Diabetes
Detection ofPreDiabetes
Adoption ofHealthy Lifestyle
Drivers Calibrated Using National Survey Data
BMI/Obesity
20%
81%
85%
84%86%60%
480 Kcal/day
2,465 Kcal/day
66%
(Values shown are estimates for 2004.)
66%
Clinical Management of Diagnosed PreD &
Diabetes