syndemics prevention network expanding the scope and effectiveness of public health work:...
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Syndemics
Prevention Network
Expanding the Scope and Effectiveness of Public Health Work: Opportunities for Dynamic Modeling
Public Health Association of AustraliaCanberra
September 29, 2009
Bobby MilsteinSyndemics Prevention Network
U.S. Centers for Disease Control and [email protected]
http://www.cdc.gov/syndemics
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of
the Centers for Disease Control and Prevention.
Syndemics
Prevention Network
Imperatives for Protecting Health
Gerberding JL. Protecting health: the new research imperative. Journal of the American Medical Association 2005;294(11):1403-1406.
Typical Current State“Static view of problems that are studied in isolation”
Proposed Future State“Dynamic systems and syndemic approaches”
“Currently, application of complex systems theories or syndemic science to health protection challenges is in its infancy.”
-- Julie Gerberding
Syndemics
Prevention Network
Epi·demic
• The term epidemic is an ancient word signifying a kind of relationship wherein something is put upon the people
• Epidemiology first appeared just over a century ago (in 1873), in the title of J.P. Parkin's book "Epidemiology, or the Remote Cause of Epidemic Diseases“
• Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work
Elliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972.
Martin PM, Martin-Granel E. 2,500-year evolution of the term epidemic. Emerging Infectious Diseases 2006. Available from http://www.cdc.gov/ncidod/EID/vol12no06/05-1263.htm
National Institutes of Health. A Short History of the National Institutes of Health. Bethesda, MD: 2006. Available from http://history.nih.gov/exhibits/history/
Parkin J. Epidemiology; or the remote cause of epidemic diseases in the animal and the vegetable creation. London: J and A Churchill, 1873.
A representation of the cholera epidemic of the nineteenth century.Source: NIH
“The pioneers of public health did not change nature, or men, but adjusted the active relationship of men to certain aspects of nature so that the relationship became one of watchful and healthy respect.”
-- Gil Elliot
Syndemics
Prevention Network
Syn·demic
• The term syndemic, first used in 1992, strips away the idea that illnesses originate from extraordinary or supernatural forces and places the responsibility for affliction squarely within the public arena
• It acknowledges the importance of relationships and signals a commitment to understanding population health as a fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful ways
Confounding
Connecting*
Synergism
Syndemic
Events
System
Co-occurring
* Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping
Each member of society is a system citizen in the literal sense of
being a (potential) agent of change in the systems of which he or she is a part
Each member of society is a system citizen in the literal sense of
being a (potential) agent of change in the systems of which he or she is a part
Findings from a review ofpublic health literature, 1970-2005
Syndemics
Prevention Network
Syndemic Orientation
Expanding the Scope of Public Health Work“Public health imagination involves using science to expand the
boundaries of what is possible.”
-- Michael Resnick
EpidemicOrientation
People and Problemsin Places Over Time
BoundaryCritique
Governing Dynamics
Ca
us
al
Ma
pp
ing
Plausible Futures
DynamicModeling
Navigational Freedoms
De
mo
cra
tic
Pu
bli
c W
ork
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. <http://www.cdc.gov/syndemics/monograph/index.htm>.
Syndemics
Prevention Network
Developing Foresight and Public Strength
How shall we respond to health challenges? Likely consequences?
Costs? Time-frame?
How to catalyze action?
Dynamic Hypothesis (Causal Structure)
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acute andrehab care for
cardiovascular events
Use of qualitypreventive care
Use of weightloss services
by obese
Use of help servicesfor distress
Bans on smokingin public places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk foodinterventions
(N=4)
Physical activityinterventions
(N=6)
Heart-unhealthy diet
Physicalinactivity Distress
Efforts to promoteprovision and use of
quality preventive care
Sodiumreduction
Trans fatreduction
Excesscalorie diet
Fruit &vegetable
interventions(N=3)
CVD deaths,disability,and costs
Excesssodium diet
Air pollutionreduction
Tobaccointerventions
(N=4)
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
System
Plausible Futures (Policy Experiments)
Dynamics
Years of Life Lost40 M
30 M
20 M
10 M
01990 2000 2010 2020 2030 2040
Homer JB. Why we iterate: scientific modeling in theory and practice. System Dynamics Review 1996;12(1):1-19.
System Dynamics ModelingDynamic Modeling for Complex Policy Environments
Good at Capturing
• Differences between short- and long-term consequences
• Time delays (e.g., asymptomatic periods, time to detect/respond)
• Accumulations (e.g., prevalences, resources, attitudes)
• Behavioral feedback (reactions by various actors)
• Nonlinear causal relationships (e.g., threshold effects, saturation effects)
• Differences in goals/values among stakeholders
Origins • Jay Forrester, MIT, Industrial Dynamics, 1961
(“One of the seminal books of the last 20 years.”-- NY Times)• Population health applications starting mid-1970s
Background References on System Dynamics Modeling
Forrester JW. Industrial Dynamics. Cambridge, MA: MIT Press; 1961.
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006;96(3):505-514.
Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. AJPH 2006;96(3):452-458.
Homer JB, Oliva R. Maps and models in system dynamics: a response to Coyle. System Dynamics Review 2001;17(4):347-355.
Richardson GP, Homer JB. System dynamics modeling: population flows, feedback loops, and health. NIH/CDC Symposia on System Science and Health; Bethesda, MD. August 30, 2007. Available at <http://obssr.od.nih.gov/news_and_events/lectures_and_seminars/systems_symposia_series/system_symposium_four/systems_symposium_four.aspx>.
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. <http://www.cdc.gov/syndemics/monograph/index.htm>
Syndemics
Prevention Network
Simulation and “Double-Loop Learning”
• Unknown structure • Dynamic complexity• Time delays• Impossible experiments
Real World
InformationFeedback
Decisions
MentalModels
Strategy, Structure,Decision Rules
• Selected• Missing• Delayed• Biased• Ambiguous
• Implementation• Game playing• Inconsistency• Short-term focus
• Misperceptions• Unscientific• Biases• Defensiveness
• Inability to infer dynamics from
mental models
• Known structure • Controlled experiments• Enhanced learning
Virtual World
Sterman JD. Learning in and about complex systems. System Dynamics Review 1994;10(2-3):291-330.
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
Syndemics
Prevention Network
A Model Is…An inexact representation of the real thing
They help us understand, explain, anticipate, and make decisions
“All models are wrong, some are useful.”
-- George Box
“All models are wrong, some are useful.”
-- George Box
Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review 2002;18(4):501-531. Available at <http://web.mit.edu/jsterman/www/All_Models.html>
Sterman J. A sketpic's guide to computer models. In: Barney GO, editor. Managing a Nation: the Microcomputer Software Catalog. Boulder, CO: Westview Press; 1991. p. 209-229. <http://web.mit.edu/jsterman/www/Skeptic%27s_Guide.html>
Syndemics
Prevention Network
Re-Directing the Course of ChangeQuestions of Social Navigation
Prevalence of Diagnosed Diabetes, United States
0
10
20
30
40
1980 1990 2000 2010 2020 2030 2040 2050
Mill
ion
pe
op
le
HistoricalData
Markov Model Constants• Incidence rates (%/yr)• Death rates (%/yr)• Diagnosed fractions(Based on year 2000 data, per demographic segment)
Honeycutt A, Boyle J, Broglio K, Thompson T, Hoerger T, Geiss L, Narayan K. A dynamic markov model for forecasting diabetes prevalence in the United States through 2050. Health Care Management Science 2003;6:155-164.
Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494.
Markov Forecasting Model
Trend is not destiny
How?
Why?
Where?
Who?
What?
Simulation Experiments
in Action Labs
Syndemics
Prevention Network
2000 2001 2002 2003 2004 2005 2006 2007 2008
Selected Examples from CDC’s Growing Portfolio of Simulation Studies for Health System Change
SD Identified as a
Promising Methodology for Health System
Change Ventures
Upstream-Downstream
Dynamics
Neighborhood Transformation
Game
National Health Economics & Reform
HealthBound Policy Simulation Game
Overall Health Protection Enterprise
Diabetes Action Labs
Obesity Overthe Lifecourse
Fetal & Infant Health
Syndemics Modeling
Local Context for Chronic Diseases
(PRISM)
Selected Health Priority Areas
Centers for Disease Control and Prevention. Dynamic models. Syndemics Prevention Network, 2009. Available at http://www2.cdc.gov/syndemics/models.htm
Syndemics
Prevention Network
Exploratory Insight Goal SettingLeadership Development
Selected CDC Models of Health System DynamicsAcross a Continuum of Purposes
Centers for Disease Control and Prevention. Dynamic models. Syndemics Prevention Network, 2009. Available at http://www2.cdc.gov/syndemics/models.htm
Diabetes Action Labs
Upstream-Downstream
Dynamics
Obesity Overthe Lifecourse
Fetal & Infant Health
Neighborhood Transformation
Game
National Health Economics & Reform
Syndemics
Local Context for Chronic Disease
(PRISM)
HealthBoundGame
Syndemics
Prevention Network
Prevention Impacts Simulation Model (PRISM)Core Contributors
System Dynamics Modelers• Jack Homer• Kris Wile
Economists• Justin Trogdon• Amanda Honeycutt
Project Coordinators• Bobby Milstein• Diane Orenstein
CDC partnered with the Austin (Travis County), Texas, Dept. of Health and Human Services. The model is calibrated to represent the overall US, but is informed by the experience and data
of the Austin team, which has been supported by the CDC’s “STEPS” program since 2004.`
CDC partnered with the Austin (Travis County), Texas, Dept. of Health and Human Services. The model is calibrated to represent the overall US, but is informed by the experience and data
of the Austin team, which has been supported by the CDC’s “STEPS” program since 2004.`
CDC & NIH Subject Matter ExpertsBishwa Adhikari, Nicole Blair, Kristen Betts, Peter Briss, David Buchner, Susan Carlson, Michele Casper, Tom Chapel, Janet Collins, Lawton Cooper, Michael Dalmat, Alyssa Easton, Joyce Essien, Roseanne Farris, Larry Fine, Janet Fulton, Deb Galuska, Kathy Gallagher, Judy Hannon, Jan Jernigan, Darwin Labarthe, Deb Lubar, Patty Mabry, Ann Malarcher, Michele Maynard, Marilyn Metzler, Rob Merritt, Latetia Moore, Barbara Park, Terry Pechacek, Catherine Rasberry, Michael Schooley, Nancy Williams, Nancy Watkins, Howell Wechsler
External Subject Matter ExpertsCynthia Batcher, Margaret Casey, Phil Huang, Kristen Lich, Karina Loyo, David Matchar, Ella Pugo, John Robitscher, Rick Schwertfeger, Adolpho Valadez
Syndemics
Prevention Network
Prevention Impacts Simulation Model (PRISM)• Represents multiple interacting risks and interventions for heart
disease, stroke, and related chronic diseases: medical, behavioral, social, environmental
• Begun in 2007 (now version 2i) and it remains a work-in-progress
• Engaged subject matter experts from 12 organizations (N~30), and 100s of policy officials, including a deep collaboration with local leaders in Austin, Texas
• Integrates best available information in a single testable model to support prospective planning and evaluation
• Explores the likely effects of “local interventions” (i.e., changes in local options/exposures/services that affect behavior and/or health status)
– To what extent might adverse events and costs be reduced?
– How can policymakers balance interventions for best effect with limited resources?
References: Homer J, Milstein B, Wile K, Trogdon J, Huang P, Labarthe D, Orenstein D. Simulating and evaluating local interventions to improve cardiovascular health. Preventing Chronic Disease, 2009 (in press).
Homer J, Milstein B, Wile K, Pratibhu P, Farris R, Orenstein D. Modeling the local dynamics of cardiovascular health: risk factors, context, and capacity. Preventing Chronic Disease 2008;5(2). Available at <http://www.cdc.gov/pcd/issues/2008/apr/07_0230.htm
Syndemics
Prevention Network
Tobacco
Air Pollution
Stress
Healthy Food
Sodium
Trans fat
PhysicalActivity
WeightLoss
MentalHealthServices
PrimaryCare
Emergency & Rehab Care
BloodPressure
Cholesterol
ObesityHeart Disease & Stroke
Cancer
Health CareCost
Diabetes
The Popular (and Professional) View of Chronic Disease Challenges is Largely One Headline after Another
Alcohol
Sleep Arthritis
JunkFood
Syndemics
Prevention Network
PRISM Situates Multiple Medical, Behavioral, and Environmental Factors into a Single Set of Causal Pathways
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Use of qualitypreventive care
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Heart-unhealthy diet
Physicalinactivity
Distress
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Chronic Disorders
Trans fatconsumption
Syndemics
Prevention Network
PRISM Situates Multiple Medical, Behavioral, and Environmental Factors into a Single Set of Causal Pathways
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Use of qualitypreventive care
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Heart-unhealthy diet
Physicalinactivity
Distress
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Syndemics
Prevention Network
Weight lossservices for obese
JUNK FOODTax, restrict sales/mktg,
counter-marketing
Sodium in food
Trans fatIn food
HEART-HEALTHYFOOD
Access, promotionCardiovascular
events
Air pollutionexposure(PM 2.5)
Use of qualitypreventive care
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Heart-unhealthy diet
Physicalinactivity
PHYSICAL ACTIVITYAccess, promotion,
social support,school recs, childcare recs
Distress
Help servicesfor distress
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Quality of acuteand rehab care
Quality and use ofpreventive care
Trans fatconsumption
Local Context for TobaccoLocal Context for DietLocal Context for Physical ActivityLocal Context for Air PollutionLocal Context for Health Care ServicesLocal Context for Weight Loss ServicesLocal Context for Mental Health Services
PRISM Also Includes Frontiers for Social Action
Tax, restrict sales/mktg,counter-marketing,
quit services
TOBACCOBan smoking in
public places
Syndemics
Prevention Network
Primary Information Sources• Census
– Population, deaths, births, net immigration
• American Heart Association & NIH statistical reports
– Cardiovascular events, deaths, and prevalence
• National Health and Nutrition Examination Survey (NHANES)
– Risk factor prevalence by age and sex
– Diagnosis and control of hypertension, high cholesterol, and diabetes
• Medical Examination Panel (MEPS), National Health Interview (NHIS), Behavioral Risk Factor Surveillance System (BRFSS), Youth Risk Behavior Survey (YRBS)
– Medical and productivity costs attributable to risk factors
– Prevalence of distress in non-CVD and post-CVD populations
– Primary care utilization
– Extent of physical activity
• Research literature
– CVD risk calculator (Framingham)
– Relative risks from secondhand smoke, air pollution, obesity, poor diet, inactivity, distress
– Quality of diet (USDA Healthy Eating Index)
– Medical and productivity costs of cardiovascular events
– Effect sizes of behavioral interventions
• Expert judgment
– Effect sizes of behavioral interventions
Uncertainties are assessed through sensitivity testing
Uncertainties are assessed through sensitivity testing
Syndemics
Prevention Network
Mapping Information SourcesPhysical Activity Pathway
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Syndemics
Prevention Network
Mapping Information SourcesPhysical Activity Pathway
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Syndemics
Prevention Network
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
Physical Inactivity Prevalence52% - 65% (by age)
• NHANES, BRFSS, & YRBS • Troiano RP, et al. Med Sci Sports Ex 2008;
40(1):181-188.
Syndemics
Prevention Network
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
Effective Interventions Increase PA by 40-55%
(by age and strategy)
• Kahn EB, et al. Am J Prev Med 2002; 22:S73-102.
Syndemics
Prevention Network
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
RR for obesity onset = 2.6
• Haapanen N, et al. Intl J Obesity 1997: 21:288-296
Syndemics
Prevention Network
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
RR for distress = 1.3
• Netz Y, Wu M-J, et al. Psyh Aging 2005; 20(2):272-284. .
Syndemics
Prevention Network
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
RR of inactivity if distressed: 1.6
• Whooley MA, et al. JAMA 2008; 300(20):2379-2388.
Syndemics
Prevention Network
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
RR for High BP = 1.15RR for High Cholesterol = 1.4
RR for Diabetes = 1.4
• Ann Med 1991;23(3):319–327.• Intl J Epidemiology 1997; 26(4):739-747.
• Canadian Med Assoc J 2000;163(11):1435-1440.• Lancet 1991; 339:778-783.
• Arch Intern Med 2001; 161:1542-1548.
Syndemics
Prevention Network
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
Modification of theFramingham Risk Calculator
• Ex Rev Pharm Out Res 2006;6(4):417-24.• Am Heart J 1991;121(1 Pt 2):293-8.
• Am Heart J 2007;153(5):722-31, 31 e1-8.• JAMA 2001;286(2):180-7.
Syndemics
Prevention Network
Base Case & Illustrative Intervention Scenarios
Base Case (a simple scenario for comparison)
• Assume no further changes in the contextual factors that affect risk factor prevalences
• Any changes in prevalences after 2004 are due to “inflow/outflow” adjustment process and population aging
• Result: Past trends level off after 2004, after which results reflect only slow adjustments in risk factors
– Increasing obesity, high BP, and diabetes
– Decreasing smoking
– Increases in risk factors and population aging lead to eventual rebound in attributable deaths
Example Intervention Scenarios (max plausible effects, sustained)
• Four clusters of interventions layered to show their partial contribution and combined effects
• Services (health care, weight loss, smoking quit, distress)+ Diet & Physical Activity+ Tobacco + Air Pollution & Sodium & Trans fat
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Illustrative Intervention Scenarios: Maximum Plausible StrengthIndividual Services + Diet & PA + Tobacco + Air Pollution & Sodium & Trans
fat
Work in Progress, Please do no cite or distribute.
Smoking Prevalence (Adults) Obesity Prevalence (Adults)
Cardiovascular Events per 1000(CHD, Stroke, CHF, PAD)
Deaths from All Risk Factors per 1,000
0.4
0.3
0.2
0.1
0
1990 2000 2010 2020 2030 2040
0.4
0.3
0.2
0.1
0
1990 2000 2010 2020 2030 2040
30
22.5
15
7.5
0
1990 2000 2010 2020 2030 2040
8
6
4
2
0
1990 2000 2010 2020 2030 2040
Draft Model Output Draft Model Output
Draft Model Output Draft Model Output
**if all risk factors=0**
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Illustrative Intervention Scenarios: Maximum Plausible StrengthIndividual Services + Diet & PA + Tobacco + Air Pollution & Sodium & Trans
fat
Work in Progress, Please do no cite or distribute.
Years of Life Lost from Attributable Deaths
Consequence Costs per Capita(medical costs + productivity)
30 M
22.5 M
15 M
7.5 M
0
1990 2000 2010 2020 2030 2040
6,000
4,500
3,000
1,500
01990 2000 2010 2020 2030 2040
**if all risk factors=0**
Draft Model Output Draft Model Output
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Example of Sensitivity TestingEstimated impacts of a 15-component intervention,
with uncertainty ranges
1990 2000 2010 2020 2030 2040
Total Consequence Costs per capita (2005 dollars per year)
3,000
2,000
0
1,000
Combined 15 interventionswith range of uncertainty
Base Case
Costs if all risk factors = 0
1990 2000 2010 2020 2030 2040
Deaths from CVD per 1000
4
2
0
Combined 15 interventionswith range of uncertainty
Base Case
Deaths if all risk factors = 0
Homer J, Milstein B, Wile K, Trogdon J, Huang P, Labarthe D, Orenstein D. Simulating and evaluating local interventions to improve cardiovascular health. Preventing Chronic Disease, 2009 (in press).
Model Output (v2008)Model Output (v2008)
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How are Practitioners Using PRISM?
A Few Local Versions
• Re-calibrate to areas with different demographics, histories, and current conditions
Planning• Engage a wider circle of stakeholders
• Situate silos within a system
• Prioritize interventions (given tradeoffs/synergies)
• Set plausible short- and long-term goals
Evaluating
• Trace intervention effects through direct, secondary, and summary measures
• Extend the time horizon for evaluative inquiry
• Establish novel referents for comparison (self-referential counter-factuals)
Users (~500)Customized Versions
• East Austin, Texas
• Mississippi Delta
• New Zealand Ministry of Health
• U.S. economic stimulus health initiative
Nat’l & State Stakeholders
• CDC Staff
• National Association of Chronic Disease Directors
• Directors of Public Health Education
• National Institutes of Health (NHLBI, OBSSR)
Users (~500)Customized Versions
• East Austin, Texas
• Mississippi Delta
• New Zealand Ministry of Health
• U.S. economic stimulus health initiative
Nat’l & State Stakeholders
• CDC Staff
• National Association of Chronic Disease Directors
• Directors of Public Health Education
• National Institutes of Health (NHLBI, OBSSR)
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Conversations Around the Model
Other health
priorities
Available information
Health inequities
Local interventionopportunities and costs
Communitythemes and strengths
Political willStakeholder
relationships
• What’s in the model does not define what’s in the room
• Simulations intentionally raise questions to spark broader thinking and judgment
• Narrower boundaries tend to be more empirically grounded
• Wider boundaries may legitimize “invisible” processes
• Boundary judgments follow from the intended purpose and users
SYSTEMDYNAMICS MODEL
STRATEGICPRIORITIES
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acute andrehab care for
cardiovascular events
Use of qualitypreventive care
Use of weightloss services
by obese
Use of help servicesfor distress
Bans on smokingin public places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk foodinterventions
(N=4)
Physical activityinterventions
(N=6)
Heart-unhealthy diet
Physicalinactivity Distress
Efforts to promoteprovision and use of
quality preventive care
Sodiumreduction
Trans fatreduction
Excesscalorie diet
Fruit &vegetable
interventions(N=3)
CVD deaths,disability,and costs
Excesssodium diet
Air pollutionreduction
Tobaccointerventions
(N=4)
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Researchagenda
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Interactive ModelingBuilds Foresight, Experience, and Motivation to Act
Experiential Learning“Wayfinding”
Expert Recommendations
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Evidence and Action Both Emerge fromBroader Philosophies of Science and Society
Shook J. The pragmatism cybrary. 2006. Available at <http://www.pragmatism.org/>.
Addams J. Democracy and social ethics. Urbana, IL: University of Illinois Press, 2002.
West C. The American evasion of philosophy: a genealogy of pragmatism. Madison, WI: University of Wisconsin Press, 1989.
Pragmatism• Begins with a response to a perplexity or injustice
in the world• Learning through action and reflection
(even simulated action can be illuminating)• Asks, “How does this make a difference?”
Positivism • Begins with a theory about the world• Learning through observation and falsification• Asks, “Is this theory true?”
These are conceptual, methodological, and moral orientations, which shape how we think, how we act, how we learn, and what we value
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Discussion
For Further Information
CDC Syndemics Prevention Network http://www.cdc.gov/syndemics
NIH Office of Behavioral and Social Sciences Research http://obssr.od.nih.gov/scientific_areas/methodology/systems_science/index.aspx
• Examples
– HealthBound
– PRISM
• Try your own scenarios
– HealthBound
– PRISM
• System Dynamics 101