Combined Regional Investments Could Substantially Enhance Health System Performance And Be Financially Affordable

“Quarantined within a quarantine”

When the Australian state and lone isle of Tasmania went into coronavirus disease 2019 (COVID-19) quarantine lockdown in March, within a quarantine-imposed Australian continent, thinking it was being very prudent, unforeseen was the lurking virus. Australia across January had been watching the global northern hemisphere scenario occurring and by February was preparing to quarantine itself, echoing its existing and long-term biosecurity exclusion regime. On a much grander scale, following through on a previously trialed national pandemic training exercise, no one had factored in the Ruby Princess variable and its major consequences that would require unprecedented pandemic response. The concentrated impact of cruise ship virus dissemination and escalation has been palpable across the world, but the Ruby Princess will remain a disaster in Australia's history. For Tasmania, several elderly passengers retraveled from Sydney to Tasmania, and a minor cluster has occurred. This chapter contextualizes what has been transpiring in Australia with the pandemic, with particular attention upon Tasmania, including discussion about the new COVIDSafe.App, and then explains the potential application of a Systems Dynamics Modeling exercise of the COVID-19 spread, in collaboration with a custom-built 2D/3D geographic information system (GIS) Dynamic Scenario Planning Model to spatially visualize potential “what-if” scenarios of COVID-19 spread (and other future pandemics) to identify high-risk areas and vulnerable communities in the northern areas of Tasmania that is aiding real-time pattern mapping and preparation work and to further consider and enable the most effective emergency response and recovery scenarios.

The Association of American Medical Colleges' Local Area Physician Workforce Modeling Project

Physician workforce planning must address multiple concerns such as having sufficient numbers and adequate geographic distribution of physicians and pressures for physicians to adapt to new models of care and payment. Though there are national workforce planning tools, planning tools for local areas have been scarce. This article describes a dynamic simulation model developed as a pilot project to support physician workforce planning in 2 metropolitan areas, Cleveland and Albuquerque (February 2014-June 2016). This model serves as a prototype for planning tools that could be used by medical educators and local health systems to project the effect of different policies on physician supply and demand. System dynamics and group model building approaches were used to develop the model with the participation of local stakeholders to create the model's causal structure. The model included determinants of the demand for primary and specialty care for the local population and projected the effects of births and deaths, aging, level of chronic illness present, and migration on demand. Physician supply was disaggregated by primary versus specialty care, age, sex, and work setting and projected based on completions of local residency programs, physician migration in and out of the area, and retirements. Feedback relationships between supply and demand (e.g., adequacy of care affecting the distribution of chronic illnesses, demand for care influencing in- and out-migration of physicians) were also included and had important effects on the results produced by the model. Scenarios were simulated that projected increased demand for care (e.g., through expanded insurance coverage) and increased supply (e.g., through practice incentives to encourage in-migration) and a combination of these. An expanded advanced practice registered nurse and physician assistant capacity scenario was also simulated. In Albuquerque, the combination scenario yielded the greatest increases in local physician supply.

Dynamics of Parental Opioid Use and Children's Health and Well-Being: An Integrative Systems Mapping Approach

The seemingly intractable opioid epidemic compels researchers, the media, and families to better understand the causes and effects of this complex and evolving public health crisis. The effects of this crisis on people using opioids, maternal prenatal opioid exposure, and neonatal abstinence syndrome are well-documented, but less is known about the impact of caregivers' opioid use on children's health and well-being. One challenge to understanding the effects of parental opioid use disorder (OUD) on child and adolescent outcomes is the numerous interrelated pathways in which a child's health and well-being can be impacted. To better understand these dynamic relationships, we applied a systems mapping approach to visualize complex patterns and interactions between pathways and potential leverage points for interventions. Specifically, we developed a causal loop diagram system map to elucidate the complex and interconnected relationships between parental OUD, social determinants of health at the family and socio-environmental levels, family strengths, social supports, and possible adverse impacts on children's physical and mental health and risks for future substance misuse. The goals of this research are to (1) identify factors and dynamics that contribute to the relationship between parental OUD and children's health and well-being and (2) illustrate how systems mapping as a tool can aid in understanding the complex factors and dynamics of the system(s) that influence the well-being of children and their parents or primary caregivers.

Importance of medicine quality in achieving universal health coverage

OBJECTIVE

To assess the importance of ensuring medicine quality in order to achieve universal health coverage (UHC).

METHODS

We developed a systems map connecting medicines quality assurance systems with UHC goals to illustrate the ensuing impact of quality-assured medicines in the implementation of UHC. The association between UHC and medicine quality was further examined in the context of essential medicines in low- and middle-income countries (LMICs) by analyzing data on reported prevalence of substandard and falsified essential medicines and established indicators for UHC. Finally, we examined the health and economic savings of improving antimalarial quality in four countries in sub-Saharan Africa: the Democratic Republic of the Congo (DRC), Nigeria, Uganda, and Zambia.

FINDINGS

A systems perspective demonstrates how quality assurance of medicines supports dimensions of UHC. Across 63 LMICs, the reported prevalence of substandard and falsified essential medicines was found to be negatively associated with both an indicator for coverage of essential services (p = 0.05) and with an indicator for government effectiveness (p = 0.04). We estimated that investing in improving the quality of antimalarials by 10% would result in annual savings of $8.3 million in Zambia, $14 million in Uganda, $79 million in two DRC regions, and $598 million in Nigeria, and was more impactful compared to other potential investments we examined. Costs of substandard and falsified antimalarials per malaria case ranged from $7 to $86, while costs per death due to poor-quality antimalarials ranged from $14,000 to $72,000.

CONCLUSION

Medicines quality assurance systems play a critical role in reaching UHC goals. By ensuring the quality of essential medicines, they help deliver effective treatments that lead to less illness and result in health care savings that can be reinvested towards UHC.

Which Priorities for Health and Well-Being Stand Out After Accounting for Tangled Threats and Costs? Simulating Potential Intervention Portfolios in Large Urban Counties

Policy Points Interventions in a regional system with intertwined threats and costs should address those threats that have the strongest, quickest, and most pervasive cross-impacts. Instead of focusing on an individual county's apparent shortcomings, a regional intervention portfolio can yield greater results when it is designed to counter those systemic threats, especially poverty and inadequate social support, that most undermine health and well-being virtually everywhere. Likewise, efforts to reduce smoking, addiction, and violent crime and to improve routine care, health insurance, and youth education are important for most counties to unlock both short- and long-term potential.

CONTEXT

Counties across the United States must contend with multiple, intertwined threats and costs that defy simple solutions. Decision makers face the necessary but difficult task of prioritizing those interventions with the greatest potential to produce equitable health and well-being.

METHODS

Using County Health Rankings data for a predefined peer group of 39 urban US counties, we performed statistical regressions to identify 37 cross-impacts among 15 threats to health and well-being. Adding appropriate time delays, we then developed a dynamic model of these cross-impacts and simulated each of the counties over 20 years to assess the likely impact of 12 potential interventions-individually and in a combined portfolio-for three outcomes: (1) years of potential life lost, (2) fraction of adults in fair or poor health, and (3) total spending on urgent services.

FINDINGS

The combined portfolio yielded improvements by year 20 that are considerably greater than those at year 5, indicating that the time delays have a major effect. Despite the wide variation in threat levels across counties, the list of top-ranked interventions is strikingly similar. Poverty reduction and social support were the most highly ranked interventions, even in the shorter term, for all outcomes in all counties. Interventions affecting smoking, addiction, routine care, health insurance, violent crime, and youth education also were important contributors to some outcomes.

CONCLUSIONS

To safeguard health and well-being in a system dominated by tangled threats and costs, the most important priorities for a county cannot be simply inferred from a profile of its relative strengths and weaknesses. Two interventions stood out as the top priorities for almost all the counties in this study, and six others also were important contributors. Interventions directed toward these priority areas are likely to yield the greatest impact, irrespective of the county's specifics. A significant concentration of resources in a regional portfolio therefore ought to go to these strongest contributors for equitable health and well-being.

Adoption of New Medical Technologies: The Case of Customized Individually Made Knee Implants

OBJECTIVES

To investigate the impact of insurance coverage on the adoption of customized individually made (CIM) knee implants and to compare patient outcomes and cost effectiveness of off-the-shelf and CIM implants.

METHODS

A system dynamics simulation model was developed to study adoption dynamics of CIM and meet the research objectives. The model reproduced the historical data on primary and revision knee replacement implants obtained from the literature and the Nationwide Inpatient Sample. Then the dynamics of adoption of CIM implants were simulated from 2018 to 2026. The rate of 90-day readmission, 3-year revision surgery, recovery period, time savings in operating rooms, and the associated cost within 3 years of primary knee replacement implants were used as performance metrics.

RESULTS

The simulation results indicate that by 2026, an adoption rate of 90% for CIM implants can reduce the number of readmissions and revision surgeries by 62% and 39%, respectively, and can save hospitals and surgeons 6% on procedure time and cut down cumulative healthcare costs by approximately $38 billion.

CONCLUSIONS

CIM implants have the potential to deliver high-quality care while decreasing overall healthcare costs, but their adoption requires the expansion of current insurance coverage. This work presents the first systematic study to understand the dynamics of adoption of CIM knee implants and instrumentation. More broadly, the current modeling approach and systems thinking perspective could be used to consider the adoption of any emerging customized therapies for personalized medicine.

Exploring challenges, threats and innovations in global health promotion

Global health faces a broad spectrum of old and new challenges. Besides epidemiological problems, political conflicts, economic crisis and austerity policies are jeopardizing progress towards Universal Health Coverage (UHC), affecting the most vulnerable populations. During the 22nd International Union for Health Promotion and Education (IUHPE) World Conference on Health Promotion held in Curitiba, Brazil, in 2016, challenges and threats for global health, in addition to a wide range of innovative experiences in health promotion, were discussed with participants from 65 countries. At the end of the conference, a public statement was approved claiming for Democracy and Human Rights in all countries around the world as essential conditions for the promotion of health and equity. In this paper, we explore challenges, threats and innovations in global health promotion. We use scientific literature, analysis of the current situation of the Brazilian health system, and material presented during the 22nd IUHPE World Conference. Also, we discuss strategies to strengthen health systems, policies and practices through the approach of STI and illustrative local experiences presented at the congress mentioned above, including examples developed in the city of Curitiba. We conclude that STI is crucial to support strengthening local health systems, design effective intersectoral public policies, scaling up innovative initiates, and skilling staff in addressing the contemporary challenges. Finally, the Declaration of the 22nd World Conference on Health Promotion of the IUHPE is a fundamental policy statement based on the prioritization of democracy and human rights as essential conditions for the promotion of health and equity.

A Balanced Investment Portfolio For Equitable Health And Well-Being Is An Imperative, And Within Reach

Health investments, defined as formal expenditures to either produce or care for health, in the US are extremely inefficient and have yet to unlock the country's full potential for equitable health and well-being. A major reason for such poor performance is that the US health investment portfolio is out of balance, with too much spent on certain aspects of health care and not enough spent to ensure social, economic, and environmental conditions that are vital to maintaining health and well-being. This commentary summarizes the evidence for this assertion, along with the opportunities and challenges involved in rebalancing investments in ways that would improve overall population health, reduce health gaps, and help build a culture of health for all Americans.

Multisector Partnerships Need Further Development To Fulfill Aspirations For Transforming Regional Health And Well-Being

Regional multisector partnerships involving stakeholders in areas such as public health, health care, education, housing, and others are growing in number. These partnerships are pursuing increasingly comprehensive strategies to transform health and well-being in their communities. Most analyses of these groups rely on self-reports and case studies. These have led many in the field to form optimistic expectations about how well prepared the groups are to lead transformative efforts-that is, how "mature" they are. Few studies have systematically combined data from multiple perspectives to assess partnership characteristics against specific developmental criteria. In 2015-16 we gathered 145 nominations of regions (places) and partnerships with reputations for being relatively mature. Using a three-step assessment procedure, informed by eighty-five interviews with close observers and ten site visits, we found that most of these groups lacked certain characteristics that seem necessary to transform regional health systems. Even the more mature groups were not as well poised for transformation as their reputations implied. Our findings can help correct misperceptions and clarify ways to best support further partnership development.

Spatial dynamics of access to primary care for the medicaid population

Primary care (PC) has always been underestimated and underinvested by the United States health system. Our goal was to investigate the effect of Medicaid expansion and the Affordable Care Act (ACA) provisions on PC access in Broome County, NY, a county that includes both rural and urban areas, and can serve as a benchmark for other regions. We developed a spatial system dynamics model to capture different stages of PC access for the Medicaid population by using the health belief model constructs and simulate the effect of several hypothetical interventions on PC utilisation. The government data portals used as data sources for calibrating our model include the New York State Department of Health, the Medicaid Delivery System Reform Incentive Payment (DSRIP) dashboards, and the US census. In our unique approach, we integrated the simulation results within Geographical Information System (GIS) maps, to assess the influence of geospatial factors on PC access. Our results identify hot spot demographic areas that have poor access to PC service facilities due to transportation constraints and a shortage in PC providers. Our decision support tool informs policymakers about programmes with the strongest impact on improving access to care, considering spatial and temporal characteristics of a region.

Timely, Granular, and Actionable: Informatics in the Public Health 3.0 Era

Ensuring the conditions for all people to be healthy, though always the core mission of public health, has evolved in approaches in response to the changing epidemiology and challenges. In the Public Health 3.0 era, multisectorial efforts are essential in addressing not only infectious or noncommunicable diseases but also upstream social determinants of health. In this article, we argue that actionable, geographically granular, and timely intelligence is an essential infrastructure for the protection of our health today. Even though local and state efforts are key, there are substantial federal roles in accelerating data access, connecting existing data systems, providing guidance, incentivizing nonproprietary analytic tools, and coordinating measures that matter most.

A Balanced Portfolio Model For Improving Health: Concept And Vermont's Experience

A successful strategy for improving population health requires acting in several sectors by implementing a portfolio of interventions. The mix of interventions should be both tailored to meet the community's needs and balanced in several dimensions-for example, time frame, level of risk, and target population. One obstacle is finding sustainable financing for both the interventions and the community infrastructure needed. This article first summarizes Vermont's experience as a laboratory for health reform. It then presents a conceptual model for a community-based population health strategy, using a balanced portfolio and diversified funding approaches. The article then reviews Vermont's population health initiative, including an example of a balanced portfolio and lessons learned from the state's experience.

Using cognitive and causal modelling to develop a theoretical framework for implementing innovative practices in primary healthcare management in New Zealand

The continuing rise in chronic health conditions requires major changes in how healthcare is managed and delivered. While research has identified a number of factors key to bringing this about, implementing these changes requires an understanding of how the factors interact over time in different contexts. In this research study, seven senior health experts in New Zealand were interviewed, using cognitive mapping, to ascertain their thinking about major implementation challenges to enhance primary healthcare systems. The resulting cognitive maps were then consolidated and developed into a causal loop diagram, which describes a set of interlinked feedback loops representing the processes involved in implementing changes. It is concluded that these systems methods are very effective in better understanding the contextual and behavioural factors necessary for the development of a theoretical framework to support the successful implementation of innovative primary healthcare programmes.

Public health and the economy could be served by reallocating medical expenditures to social programs

As much as 30% of US health care spending in the United States does not improve individual or population health. To a large extent this excess spending results from prices that are too high and from administrative waste. In the public sector, and particularly at the state level, where budget constraints are severe and reluctance to raise taxes high, this spending crowds out social, educational, and public-health investments. Over time, as spending on medical care increases, spending on improvements to the social determinants of health are starved. In California the fraction of General Fund expenditures spent on public health and social programs fell from 34.8% in fiscal year 1990 to 21.4% in fiscal year 2014, while health care increased from 14.1% to 21.3%. In spending more on healthcare and less on other efforts to improve health and health determinants, the state is missing important opportunities for health-promoting interventions with a strong financial return. Reallocating ineffective medical expenditures to proven and cost-effective public health and social programs would not be easy, but recognizing its potential for improving the public's health while saving taxpayers billions of dollars might provide political cover to those willing to engage in genuine reform. National estimates of the percent of medical spending that does not improve health suggest that approximately $5 billion of California's public budget for medical spending has no positive effect on health. Up to 10,500 premature deaths could be prevented annually by reallocating this portion of medical spending to public health. Alternatively, the same expenditure could help an additional 418,000 high school students to graduate.

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Medical spending in California rose in 25 years from 14% to 21% of the State budget.

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In this period spending on public health fell by a similar percentage.

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California spends $6 billion annually on healthcare that does not improve health.

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Redirecting this money to tobacco prevention would prevent 12,300 deaths annually.

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Redirecting it to education would help an additional 418,000 students graduate.