Emergency and on-demand health care: modelling a large complex system

This paper describes how system dynamics was used as a central part of a whole-system review of emergency and on-demand health care in Nottingham, England. Based on interviews with 30 key individuals across health and social care, a 'conceptual map' of the system was developed, showing potential patient pathways through the system. This was used to construct a stock-flow model, populated with current activity data, in order to simulate patient flows and to identify system bottle-necks. Without intervention, assuming current trends continue, Nottingham hospitals are unlikely to reach elective admission targets or achieve the government target of 82% bed occupancy. Admissions from general practice had the greatest influence on occupancy rates. Preventing a small number of emergency admissions in elderly patients showed a substantial effect, reducing bed occupancy by 1% per annum over 5 years. Modelling indicated a range of undesirable outcomes associated with continued growth in demand for emergency care, but also considerable potential to intervene to alleviate these problems, in particular by increasing the care options available in the community

How the health-seeking behaviour of pregnant women affects neonatal outcomes: findings of system dynamics modelling in Pakistan

Background: Limited studies have explored how health-seeking behaviour during pregnancy through to delivery affect neonatal outcomes. We modelled health-seeking behaviour across urban and rural settings in Pakistan, where poor neonatal outcomes persist with wide disparities. Methods and findings: A system dynamics model was developed and parameterised. Following validation tests, the model was used to determine neonatal mortality for pregnant women considering their decisions to access, refuse and switch antenatal care services in four provider sectors: public, private, traditional and charitable. Four health-seeking scenarios were tested across different pregnancy trimesters. Health-seeking behaviour in different subgroups by geographical locations and social network effect was modelled. The largest reduction in neonatal mortality was achieved with antenatal care provided by skilled providers in public, private or charitable sectors, combined with the use of institutional delivery. Women’s social networks had strong influences on if, when and where to seek care. Interventions by Lady Health Workers had a minimal impact on health-seeking behaviour and neonatal outcomes after trimester 1. Optimal benefits were achieved for urban women when antenatal care was accessed within trimester 2, but for rural women within trimester 1. Antenatal care access delayed to trimester 3 had no protective impact on neonatal mortality. Conclusions: System dynamics modelling enables capturing the complexity of health-seeking behaviours and impact on outcomes, informing intervention design, implementation of targeted policies and uptake of services specific to urban/rural settings considering structural enablers/barriers to access, cultural contexts and strong social network influences

Population aging and pension systems : reform options for China

Using an integrated simulation model, the authors estimate the scope and speed of population-aging in China, the cost of supporting the old, and the impact of different reform options and pension arrangements. Among their conclusions: The scope and speed of population-aging in China make the present pension system financially unsustainable, even assuming that GDP grows steadily in the long term. Moving the retirement age back would provide a temporary fix for the current pay-as-you-go pension system but would be politically viable only where there is great demand for labor. Pension funds could be made more sustainable by increasing GDP growth, raising contribution rates, or gradually reducing benefit rates. But the financial costs and social obstacles of those reform options must be carefully assessed. Fully funded, privately managed pension schemes might be feasible, but require a sound regulatory framework and institutional infrastructure,including financial markets that provide adequate savings instruments and insurance options. Pension reform is a long-term, multidimensional problem involving economic, social, political, and cultural factors. Governments should not focus only on taxes and transfers to redistribute income to and among the elderly. Real income growth is needed to cope with poverty among the elderly, especially in developing countries. To establish an adequate, efficient, and equitable social security system, China must maintain long-term socioeco nomic stability and sustainable growth. China could improve the labor market by removing management rigidities, facilitating human resource development, making labor markets more competitive, improving the household registration system, improving incentives, and rewarding hard and innovative work. To reduce unemployment, China can create more job opportunities in nontraditional sectors, especially its underdeveloped service industries. To shift jobs to the nonagricultural sector, it can develop medium-size cities. And to cushion the impact of demographic shocks, China should preserve traditional values and maintain family-community support. Drawing on experience in Europe and Latin America, China should move toward a transparent and decentralized system with 1) a fully funded, portable, defined-benefit pension plan, designed to meet basic needs, and 2) occupational pension plans or personal savings accounts to satisfy demand for maintaining or improving living standards.Public Health Promotion,Health Economics&Finance,Environmental Economics&Policies,Pensions&Retirement Systems,Labor Policies,Environmental Economics&Policies,Health Economics&Finance,Governance Indicators,Pensions&Retirement Systems,Achieving Shared Growth

Towards the Holy Grail: combining system dynamics and discrete-event simulation in healthcare

The idea of combining discrete-event simulation and system dynamics has been a topic of debate in theoperations research community for over a decade. Many authors have considered the potential benefits ofsuch an approach from a methodological or practical standpoint. However, despite numerous examples ofmodels with both discrete and continuous parameters in the computer science and engineering literature,nobody in the OR field has yet succeeded in developing a genuinely hybrid approach which truly integratesthe philosophical approach and technical merits of both DES and SD in a single model. In this paperwe consider some of the reasons for this and describe two practical healthcare examples of combinedDES/SD models, which nevertheless fall short of the “holy grail” which has been so widely discussed inthe literature over the past decade

Decision makers\u27 experience of participatory dynamic simulation modelling: Methods for public health policy

Background: Systems science methods such as dynamic simulation modelling are well suited to address questions about public health policy as they consider the complexity, context and dynamic nature of system-wide behaviours. Advances in technology have led to increased accessibility and interest in systems methods to address complex health policy issues. However, the involvement of policy decision makers in health-related simulation model development has been lacking. Where end-users have been included, there has been limited examination of their experience of the participatory modelling process and their views about the utility of the findings. This paper reports the experience of end-user decision makers, including senior public health policy makers and health service providers, who participated in three participatory simulation modelling for health policy case studies (alcohol related harm, childhood obesity prevention, diabetes in pregnancy), and their perceptions of the value and efficacy of this method in an applied health sector context. Methods: Semi-structured interviews were conducted with end-user participants from three participatory simulation modelling case studies in Australian real-world policy settings. Interviewees were employees of government agencies with jurisdiction over policy and program decisions and were purposively selected to include perspectives at different stages of model development. Results: The ‘co-production’ aspect of the participatory approach was highly valued. It was reported as an essential component of building understanding of the modelling process, and thus trust in the model and its outputs as a decision-support tool. The unique benefits of simulation modelling included its capacity to explore interactions of risk factors and combined interventions, and the impact of scaling up interventions. Participants also valued simulating new interventions prior to implementation in the real world, and the comprehensive mapping of evidence and its gaps to prioritise future research. The participatory aspect of simulation modelling was time and resource intensive and therefore most suited to high priority complex topics with contested options for intervening. Conclusion: These findings highlight the value of a participatory approach to dynamic simulation modelling to support its utility in applied health policy settings