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Syndemics
Prevention Network
Finding the Foresight and Strength to Transform Health Systems
Queensland GovernmentBrisbane
October 7, 2009
Bobby MilsteinSyndemics Prevention Network
U.S. Centers for Disease Control and Preventionbmilstein@cdc.gov
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
Wickelgren I. How the brain 'sees' borders. Science 1992;256(5063):1520-1521.
How Many Triangles Do You See?
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The Weight of Boundary Judgments
Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.
Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999. Available at <http://www.sustainabilityinstitute.org/pubs/Leverage_Points.pdf>.
Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
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Implications for Policy Planning and Evaluation
Insights from the Overview Effect
• Maintain a particular analytic distance
• Not too close to the details, but not too far as be insensitive to internal pressures
• Potential to anticipate temporal patterns (e.g., better before worse)
• Structure determines behavior
• Potential to avoid scapegoating or lionizing
Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
Richmond B. Systems thinking: critical thinking skills for the 1990s and beyond. System Dynamics Review 1993;9(2):113-134. Available at <http://www.clexchange.org/ftp/documents/whyk12sd/Y_1993-05STCriticalThinking.pdf>.
White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.
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
“Public health [work] is what we, as a society, do collectively to assure the conditions in which
[all] people can be healthy.”
-- Institute of Medicine
Institute of Medicine. The future of public health. Washington, D.C.: National Academy Press, 1988.
Institute of Medicine. The future of the public's health in the 21th century. Washington D.C.: National Academy Press, 2002.
Syndemics
Prevention Network
What does it mean to organize science and society around the goal of assuring more healthful and equitable conditions?
• Constantly in flux
• Politically contested
Syndemics
Prevention Network
Crafting a Place-based View
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>.
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006.
Where we want to go?
How do we prepare to get there?
Where do you want your children to live?
Where you do want to live?
Syndemics
Prevention Network
Cultivating a Place-based View
"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.
It was the most uncomfortable moment of silence that I
can remember…That was the defining moment for me.
I recognized that I have to participate in answering that
question otherwise I am not taking responsibility for
the place I love and the people I love.”
-- 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>.
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006.
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."
-- The Builder Magazine
Broad Street, One Year Later
Syndemics
Prevention Network
A Complementary Science of Relationships
• Efforts to Reduce Population Health ProblemsProblem, problem solver, response
• Efforts to Organize a System that Assures Healthful Conditions for All Dynamic interaction among multiple problems, problem solvers, and responses
Institute of Medicine. The future of public health. Washington, DC: National Academy Press, 1988.
Institute of Medicine. The future of the public's health in the 21th century. Washington, DC: National Academy Press, 2002.
Bammer G. Integration and implementation sciences: building a new specialisation. Cambridge, MA: The Hauser Center for Nonprofit Organizations, Harvard University 2003.
True innovation occurs when things are put together for the first time that had been separate.
– Arthur Koestler
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.
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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>
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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
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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
HealthBound Get in the Game to Re-direct the U.S. Health System
…In support of Healthiest Nation
Bobby Milstein, PhD, MPHCenters for Disease Control
and PreventionBMilstein@cdc.gov
Jack Homer, PhDHomer Consulting
JHomer@comcast.net
Gary Hirsch, MSIndependent ConsultantGBHirsch@comcast.net
The name “HealthBound” is used courtesy of Associates & Wilson, Inc.
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Prevention Network
Poised for Transformation…
• America has a national health shortage: we pay the most for health care, yet suffer comparatively poor health, especially among the disadvantaged
• High cost of poor health drives personal bankruptcy and business failure
• Over 75% think the current system needs fundamental change
• Analyses that focus narrowly on parts of the system, without examining connections, often miss the potential for policy resistance
Commission to Build a Healthier America. America is not getting good value for its health dollar. Princeton, NJ: Robert Wood Johnson Foundation 2008. Nolte E, McKee CM. Measuring the health of nations: updating an earlier analysis. Health Affairs 2008; 27(1):58-71.Blendon RJ, Altman DE, Deane C, Benson JM, Brodie M, Buhr T. Health care in the 2008 presidential primaries. NEJM 2008;358(4):414-422. White House. Americans speak on health reform: report on health care community discussions. Washington, DC: HealthReform.gov; March, 2009. <http://www.healthreform.gov/reports/hccd/>Altman DE, Levitt L. The sad history of health care cost containment as told in one chart. Health Affairs 2002;Web Exclusive:hlthaff.w2.83.
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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
Homer J, Hirsch G, Milstein B. Chronic illness in a complex health economy: the perils and promises of downstream and upstream reforms. System Dynamics Review 2007;23(2/3):313–343.
Causal diagrams with practical definitions of states, rates, and
interventions
Inflationary trends and self-sustaining tendencies of the
downstream healthcare industry
Diabetes Action Labs
Upstream-Downstream
Dynamics
Obesity Overthe Lifecourse
Fetal & Infant Health
Neighborhood Transformation
Game
National Health Economics & Reform
Syndemics
Local Context of Chronic Disease Prevention and
Control
HealthBoundGame
Important Structures
EmpiricalData
Creative policies for moving out of an entrenched and unhealthy state
Experiential learning to devise strategies, interpret dynamics, and weigh tradeoffs
Syndemics
Prevention Network
• Cognitive and experiential learning for health leaders• Four simultaneous goals: save lives, improve health,
achieve health equity, and lower health care cost• Intervene without expense, risk, or delay• Not a prediction, but a way for diverse stakeholders
to explore how the health system can change
HealthBound
HealthBound is a Simplified Health System to be Explored Through Game-based Learning
Milstein B, Homer J, Hirsch G. The "HealthBound" policy simulation game: an adventure in US health reform. International System Dynamics Conference; Albuquerque, NM; July 26-30, 2009.
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Prevention Network
HealthBound Presents a Navigational ChallengeGet Out of a Deadly, Unhealthy, Inequitable, and Costly Predicament
Starting Values for Mortality, Morbidity, Inequity, Cost (~2003)
Death rate per thousand
Unhealthy days per capitaHealth inequity indexHealthcare spend per capita
8 6
0.2 7,000
4 3
0.1 5,000
0 0 0
3,000
-5 0 5 10 15 20 25
How far can you move
the system?
Deaths
Unhealthy Days
Health Inequity
Healthcare costs
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Prevention Network
The U.S. health system is dense
with diverse issues and opportunities
Healthier behaviorsHealthier behaviors
Adherence to care guidelines Adherence to
care guidelines
Insurance coverageInsurance coverage
Insurance overheadInsurance overhead
Socioeconomic disadvantage
Socioeconomic disadvantage
Provider capacityProvider capacity
Reimbursement rates
Reimbursement rates
Extent of care
Extent of care
Provider income
Provider income
Provider efficiencyProvider efficiency
Access to careAccess to care
ER useER use
Safer environments
Safer environments
CitizenInvolvement
CitizenInvolvement
Syndemics
Prevention Network
Major Causal Pathways
Syndemics
Prevention Network
Intervention OptionsA Short Menu of Major Policy Proposals
Improve quality of care
Expand primary care supply
Simplify insurance
Change self pay fraction
Change reimbursement ratesExpand insurance coverage
Enable healthier behaviors
Build safer environments
Create pathways to advantage
Strengthen civic muscle
Improve primary care efficiency
Coordinate care
Syndemics
Prevention Network
Science Behind the Game
Integrating prior findings and estimates• On costs, prevalence, risk factors, inequity,
utilization, insurance, quality of care, etc. (8 databases and large professional literatures)
Using sound methodology• Reflecting real-world accumulations, resource
constraints, delays, behavioral feedback
Simplifying as appropriate• Three states of health:
Healthy, Asymptomatic disorder, Disease/injury
• Two SES categories: Advantaged, Disadvantaged (allowing study of disparities and equity)
• Some complicating trends not included in simplified game (e.g., aging, technology, economy); an extended model incorporates such factors
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Concept Proxy Initial Values (~2003) Sources
Advantaged & Disadvantaged
Prevalence Household income (< or ≥ $25,000)
Advantaged = 78.5% Disadvantaged = 21.5%
Census
Some key concepts and measures
• CDC/SD study of cardiovascular risk in Austin/Travis County, TX. See Homer J, Milstein B, Wile K, et al. Modeling the local dynamics of cardiovascular health. Preventing Chronic Disease 2008;5(2).
Syndemics
Prevention Network
Concept Proxy Initial Values (~2003) Sources
Advantaged & Disadvantaged
Prevalence Household income (< or ≥ $25,000)
Advantaged = 78.5% Disadvantaged = 21.5%
Census
Disease & InjuryPrevalence
Adults: 22 specific conditions Kids: 12 specific conditions
Overall = 38% D/A Ratio = 1.60 (= 53.6%/33.5%)
NHIS JAMA
Asymptomatic Disorder Prevalence
High blood pressure High cholesterol Pre-diabetes
Overall = 51.5% D/A Ratio = 1.15
NHANES JAMA
Mortality Deaths per 1,000 Overall = 7.5 D/A Ratio = 1.80
Vital Statistics AJPH
Morbidity Unhealthy days per month per capita
Overall = 5.26 D/A Ratio = 1.78
BRFSS
Health Inequity Fraction of unhealthy days attributable to disadvantage
Attributable fraction = 14.3% (calculated)
Health Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82
Census
Sufficiency of Primary Care Providers
Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.76
AMA PCD
Unhealthy Behavior Prevalence
Smoking Physical inactivity
Overall = 34% D/A Ratio = 1.67
BRFSS JAMA PCD
Unsafe Environment Prevalence
Survey response: “My neighborhood is not safe”
Overall = 26% D/A Ratio = 2.5
BRFSS PCD
Some key concepts and measures
Syndemics
Prevention Network
Three Intervention ScenariosExpand Insurance CoverageReduces the uninsured fraction by 90%
Improve Quality of Care Raises provider adherence to guidelines for preventive, chronic and urgent care (eliminating non-adherence by 50%)Implementation Cost = $10k/MD/yr.; $500k/hospital/yr. Expand Primary Care SupplyRaises the number of primary care providers per capita to the Disadvantaged by 60% over 15 yearsImplementation Cost = $300k/additional MD Improve Primary Care EfficiencyRaises the fraction of primary care offices that run efficiently (eliminating inefficiency by 90%)Implementation Cost = $10k/MD/yr. Enable Healthier BehaviorsIncreases the fraction with healthier behavior (eliminating unhealthy behavior by 40% over 15 years)Implementation Cost = $2,000 per person helped Build Safer EnvironmentsIncreases the fraction living in safer environments(eliminating unsafe environments by 50% over 15 years)Implementation Cost = $500 per person helped
Capacity
Protection
Coverage & Quality
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Prevention Network
Some Policy InsightsValue Tradeoffs Come to the Foreground
• Expanded coverage and higher quality of care may improve health but, if done alone, would likely raise costs and worsen equity
• Additional primary care supply and greater efficiency could eliminate current shortages (esp. for the poor), reducing costs and improving equity
• Upstream health protection (behavioral + environmental remedies) could reduce costs, elevate health, and improve equity, with an initial investment and a time delay, but the benefits would grow over time
Milstein B, Homer J, Hirsch G. Are coverage and quality enough? A dynamic systems approach to health policy. AJPH (under review).
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“Winning” Involves Not Just Posting High Scores, But Understanding How and Why You Got Them
Scorecard
ProgressReport
Results in Context
CompareScenarios
HealthBound
HealthBound
HealthBound
HealthBound
Syndemics
Prevention Network
Why a Game?To Build Foresight, Experience, and Motivation to Act
Experiential Learning“Wayfinding”
Expert Recommendations
Who Has Been Playing? (N~500)
• Federal, state, local health officials
• Public health leadership institutes
• Citizen organizations
• Labor unions
• University faculty and students
• Think tanks
• Philanthropists
Who Has Been Playing? (N~500)
• Federal, state, local health officials
• Public health leadership institutes
• Citizen organizations
• Labor unions
• University faculty and students
• Think tanks
• Philanthropists
Syndemics
Prevention Network
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
Researchagenda
Healthcare costs
Sufficiency ofprimary care
providers
PCP netincome
Reimbursementrates
Disease& injury
Morbidity &mortality
Receipt of qualityhealth care
- -
Health careaccess
Primary careefficiency
Insurancecoverage
-Health
inequity
Behavioralrisks
Quality ofcare delivered
- -
Number ofprimary care
providers
-
Socioeconomicdisadvantage
-
Environmentalhazards
PCP training& placement
programs
Insurancecomplexity
Use of specialists& hospitals for
non-urgent care-
-
-
-
Self-pay fractionfor the insured
-
Asymptomaticdisorders
Carecoordination
-
Health careprice inflation
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Prevention Network
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
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
Syndemics
Prevention Network
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**
Syndemics
Prevention Network
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
Syndemics
Prevention Network
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)
Syndemics
Prevention Network
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)
Syndemics
Prevention Network
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
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