Dynamics of Episodes-of-Care Lounsbury, Levine, & Ostroff 1
Episode-of-C are Analysis and Tobacco Treatment
in Primary Care Settings
David Lounsbury, Ph.D.!
Ralph Levine, Ph.D.”
Jamie Ostroff, Ph.D.?
‘Memorial Sloan-Kettering Cancer Center
Department of Psychiatry & Behavioral Sciences
641 Lexington Avenue, 7 Floor
New Y ork, NY 10022
646 888-0045/212 888-2584
Lounsbud@ mskcc.org
°Michigan State University
College of Agriculture and Natural Resources
131 Natural Resources Building
East Lansing, MI 48823
517 353-5190/517 432-3597
’Memorial Sloan-Kettering Cancer Center
Department of Psychiatry & Behavioral Sciences
641 Lexington Avenue, 7" Floor
New Y ork, NY 10022
646 888-0041/212 888-2584
Ostroffj@ mskcc.org
25" International C onference of the System Dynamics Society
July 29 - August 2, 2007
Boston, Massachusetts, USA
Dynamics of Episodes-of-Care Lounsbury, Levine, & Ostroff 2
Episode-of-Care Analysis and Tobacco Treatment in Primary Care Settings
Economists and health services researchers have long been faced with the problem of
how to effectively unitize and assess cost and quality of health care delivery across diverse
practice settings. One such approach is episode-of-care analysis, first theorized and applied by
Hombrook and his colleagues in the mid-1980s. A health care episode is defined as a series of
health-related events with a beginning, an end, and a course, all related to a given health problem
that exists over a specific time period (i.e., time horizon). In our research we have adapted an
episode- of-care framework to the topic of treating tobacco use and dependence. Further
reductions in tobacco use calls for increased readiness and capacity of primary care physicians to
treat tobacco dependence (CDC 2002). However, Primary care providers face considerable
pressure to address multiple patient care concerns during increasingly brief clinical visits
(Cabana et al. 1999). Efforts to encourage adaptation of well-established clinical practice
guidelines must address the tension between time limitations and best practices. We need
techniques and tools to support sustainable change in practice related to tobacco dependence in
diverse primary care settings, particularly those located in medically underserved communities
(Davis and Taylor-Vaisey 1995; Hellinger 1996; Stone et al. 2002; Swartz et al. 2002;
Wandersman 2003).
Our efforts are focused on how to improve dissemination and implementation of the U.S.
Public Health Service Guideline for Treating Tobacco Use and Dependence in primary care
practices (Foire et al. 1996). This line of work is especially timely, as the PHS Guidelines for
Treating Tobacco Dependence are currently under revision and innovations to support
dissemination are of especially high priority. Our system dynamics modeling will show the
interdependent process of patients and providers cycling through various stages of tobacco use
and treatment, and it will need to represent a patient’s stage of readiness to quit or likelihood to
avoid relapse.
Focus on Primary Care Practices
Brief counseling intervention by primary care providers has been shown to effectively
promote tobacco use cessation, yet many physicians do not consistently adhere to this practice
for all patients at each appointment (Davis and Taylor-Vaisey 1995; Goldstein et al. 1998; Greco
and Eisenberg 1993). Significant barriers exist that can interfere with clinicians’ assessment and
treatment of smokers. Many clinicians lack knowledge about how to identify smokers quickly
and easily, which treatments are efficacious, how treatments can be delivered, and the relative
efficacies of different treatments (Orleans 1993). Even if clinical knowledge is strong, many
physicians do not consistently use this intervention (Davis and Taylor-V aisey 1995; Goldstein et
al. 1998; Greco and Eisenberg 1993).
The Association of American Medical Colleges and the American Legacy Foundation
(AAMC/Legacy Foundation), working in cooperation with the Center for Health Workforce
Studies at the University of Albany, recently published an in-depth report on physician behavior
and practice patterns related to smoking cessation (2007). The report noted that physicians do not
address tobacco use and dependence among their patients as consistently and intensively as they
might, citing work by the Centers for Disease Control and Prevention (2004) that indicates that
no less than 70% of patients wanted to quit at any given time and that, although more than 80%
of physicians report asking patients about whether or not they smoke, this level falls short of
agreed upon national goals (Fiore et al. 2000; Katz et al. 2002). Moreover, far fewer physicians
Dynamics of Episodes-of-Care Lounsbury, Levine, & Ostroff 3
routinely prescribe cessation pharmacotherapies or refer patients to counseling and other
supports, as recommended in the guidelines (Thorndike et al., 1998; (Bourm 2000).
Shortage of Cessation Tools and Resources. The AA MC/Legacy Foundation (2007)
study reported that a majority of physicians across specialties and settings reported significant
limitations in the interventions they have available to help end their tobacco use. These included
having too few cessation resources and organizational supports, as well as lacking interventions
that are effective in helping them quit. Moreover, the study that access to more resources and
organizational supports was associated with more active cessation interventions on the part of
physicians.
Only half of physicians reported having any type of resource to aide in the delivery of
tobacco treatment, such as informational posters and brochures for their waiting rooms (50%) or
a tobacco user identification system (33%). When asked if they would refer patients to individual
counseling and group programs should they be available, 90% of physicians said they would.
However, only 10% of reporting physicians rated their ability to address smoking among their
patients as “very effective.” When physicians knew about the patients’ insurance coverage and
eligibility for medication and pharmacotherapy, counseling, and quitlines, they were more likely
to engage their patients in smoking interventions.
Access to resources did not vary greatly across types of medical specialties. However,
psychiatrists were found to be least likely to report that resources were available, with the
exception of individual counseling. Among primary care providers, internists were more likely to
report limited availability of resources, though they were also found to show higher levels active
participation in smoking cessation interventions for their patients (see also Meredith et al. 2005).
Other Barriers to Tobacco Treatment in Primary Care. Lack of patient motivation
and poor financing of cessation activities were both reported as large barriers to addressing
tobacco use and dependence in their patients. These results were also consistent with prior
findings (see A dsit et al. 2005; Cabana et al. 1999; Glynn and Manley 1989). Physicians
surveyed for the AAMC/Legacy Foundation (2007) report underscored that patients bear a
considerable responsibility for choosing to smoke and for quitting. The most commonly
endorsed physician-reported barrier identified by the AAMC/Legacy Foundation study was that
patients are not motivated to quit (63%). Reimbursement of coverage for cessation interventions
and limited reimbursement for office visits were key financial barriers (54% and 52%,
respectively).
In addition, there was a general perception about the overall effectiveness of smoking
cessation interventions. A majority of physicians reported that most cessation interventions have
“some” effectiveness; however, less than one-third rated any single intervention as “highly”
effective. Bupropion and nicotine replacement therapies (NRT) were assessed to be the most
efficacious interventions by physicians. No differences were found in terms of assessment of
interventions by physicians’ subspecialty, organizational setting, or gender. Y ounger physicians
and those whose medical training covered tobacco treatment were more likely to correctly assess
intervention effectiveness.
Dynamics of Episodes-of-Care Lounsbury, Levine, & Ostroff 4
Conceptual Framework for Development of the Simulation Tool
Our conceptual framework for development of the simulation tool is organized around
three general domains of interest: (1) primary care, (2) tobacco use, and (3) patient health (see
Figure 1). Tobacco use can be viewed as a mediator of patients’ health and their use of primary
care, in that everyone requires some level of primary care at some point (whether for an acute,
chronic or preventive health matter) (Fetter et al. 1984; Ritzwoller et al. 2005). Moreover, we
know that tobacco users are more likely to have respiratory, cardiovascular, gastrointestinal, and
other chronic health problems and, therefore, are more likely to require primary care services
(Rigotti 2002; Ritzwoller et al. 2005).
Figure 1 - Conceptual framework
“moked (ness
episodes *._ episodes:
Primary Tobacco Patient
Care Use Health
treatment’, quitting
Ncnisodes ATT episodes
To represent the interdependent nature of these domains, we have chosen to adopt
Hombrook’s fundamental concept of health care episodes (Hornbrook, Hurtado, and Johnson
1985). Hombrook and his colleagues are economists and health services researchers whose work
takes a theoretical approach to unitizing health care services and costs (Hornbrook et al. 2005).
The concept of a health care episode is useful here because it “enables more appropriate
assessment of costs of care and, in addition, lends itself to analysis of the processes as well as the
outcomes of medical care” (Hombrook, Hurtado, and Johnson 1985)(p. 164).
The concept of a health care episode lends itself to system dynamics analysis because it is
a dynamic event, bounded by a variable length of time. A health care episode is defined as a
series of health-related events with a beginning, an end, and a course, all related to a given health
problem that exists over a specific time period. We have identified four types of episodes useful
for modeling tobacco treatment interventions, namely: (1) smoking episodes, (2) quitting
episodes, (3) illness episodes, and (4) treatment episodes (see Figure 2).
Quitting episodes and smoking episodes are the most concretely defined units in our
model: they are bounded by the moment at which the patient stops using tobacco and the
moment the patient resumes using tobacco, or relapses. Treatment episodes may be defined in
many different ways. For our purposes, a treatment episode for tobacco begins when a patient
makes his or her first office visit to physician's practice, as either a well patient or a sick one.
Likewise, the treatment episode ends when the patient leaves a physician's practice, that is, he or
she leaves the providers care or is lost to follow-up. More than 70% of those who use tobacco
will make at least one visit to a physician each year (Cromwell et al. 1997). When physicians
take this opportunity to intervene, studies have shown that patients are more likely to make a quit
attempt and more likely to sustain long-term cessation (from 7% without to 30% with; Orleans &
Alper, 2003).
Dynamics of Episodes-of-Care Lounsbury, Levine, & Ostroff 5
Figure 2 - Health care episodes for tobacco treatment in primary
care
Quitting episode
Patients quiting Patients relapsing
Smoking episode
Patients relapsing Patients quiting
Treatment episode
Patients entering practice Patients exiting practice
(G visits over a2 year period)
Illness episode
Onset of symptoms Resolution of symptoms
Anillness episode is arguably the most difficult episode to define, for it involves the
patient and the doctor recognizing that a patient is afflicted with a particular medical condition,
whether acute or chronic. For example, a common illness episode among smokers would be the
period of time someone is sick with bronchitis, from the earliest stages of coughing through to
the patient’ s full recovery.
With respect to the topic of treating tobacco use and dependence, we delineate two
general goals: (1) to motivate patients who currently use tobacco to quit and, for those who quit,
(2) to prevent their relapse. To understand how to facilitate achievement of these goals for any
given patient, providers must assess their own preparedness and resources, as well the patient's
readiness to change. The PHS Guideline presents research that describes how trained providers
can assist patients at any stage of cessation, as conceptualized by Prochaska and colleagues’
transtheoretical model, from pre-contemplation through maintenance, as well as when patients
relapse (Prochaska, Delucchi, and Hall 2004; Prochaska and DiClemente 1992). We will explore
principles of the transtheoretical model in our planned study, and we will view each treatment
episode, or each provider-patient encounter, as a potential opportunity to intervene and to prompt
quitting episode, or at least foster additional readiness to consider quitting. The experience of an
illness episode is likely to compel one or more office visits, offering the opportunity to address
their tobacco use (Easton et al. 2001; Katz et al. 2002; McBride et al. 1997; Sippel et al. 1999;
Smith et al. 2003; Thompson et al. 1988).
Sample Partial Model and Simulation Output
To help illustrate how we plan to apply our conceptual framework and the notion of
episodes-of-care to study tobacco treatment interventions in primary care settings, we present a
stock and flow diagram of our current, partial sample model, using V ensim (Ventana Systems,
Harvard, MA). A table that lists each of the 22 variables that currently comprise the model is
also provided, organized by domain (i.e., either Primary Care and Tobacco Use; Patient Health
is not yet featured in our partial model). The table shows each variable’s name, its class
(Auxilary, Flow, or Stock), type, and dimension. We provide a brief definition and/or relevant
assumption to further explain how the variable is used (see appendix).
Dynamics of Episodes-of-Care Lounsbury, Levine, & Ostroff 6
To demonstrate the current model’s behavior, we have initialized the practice size to 400
patients (200 never smokers, 100 current smokers, and 100 former smokers). These proportions
are based on population statistics of prevalence of smoking in a typical primary care practice
(Bourm 2000; Easton et al. 2001; McBride et al. 1997; Sippel et al. 1999). For this practice
population, we assume that 7% of patients will quit without assistance (Burkhalter 2005; Lamb
et al. 2005; Webb, Simmons, and Brandon 2005). We also assume that about 7 out of 10 patients
are at a moderately high level of readiness to quit (readiness = .70; scale: 0 > 1.0) (CDC 2005).
The sample partial model is unitized in weeks and runs over a period of 100 weeks (25 months).
We chose to unitize the model in weeks because we assume that most patients would not require
more than one primary care office visit per week. Also, a week’s time is short enough to allow
reliable estimates of patient flow, staffing, and other important variables in the model (see
Sample Partial Model in appendix).
We generated results of three possible intervention scenarios, namely that the counseling
intervention delivered to a patient lasted 3 minutes (minimal), 7 minutes (brief), or 15 minutes
(full), per the PHS Guideline and as summarized by Cromwell et al. 1997; Table 1). Results of
this baseline scenario run indicate that, as expected more intervention time per patient yields
Table 1 - Resource untilization assumptoins (Cromwell et al., 1997)!
Intervention time (minutes)
Min Brief Full
counseling counseling counseling
Interventions for primary care
physicians
Screening for tobacco use
Registerd nurses 1 ail 1
Advice to quit
Physician alone 1. al 1
Initial cessation counseling
Physician alone 3 vi 15
Physician with patch or gum 6 10 18
Follow-up counseling
First follow-up physician visit 3-6 10 10
Second follow-up physician visit - : 10
Intensive interventions for Intervention time (minutes)
Z 4 em Individual Group
smoking cessation specialists . 3 . oP of
intensive’ intensive
Screening for tobacco use
Registered nurse 1 1
Advice to quit
Physician 1 1,
Cessation counseling sessions
Physician 10 20
Registered nurse 80 400
Psychologist 60 400
‘Data from Fiore et al.
?Patients referred to a smoking cessation specialist are first screened in an
office and advised to qite by a primary care provider.
3Counseling time for ‘Individual intensive’ patients are distributed over five
30-minute sessions.
‘Counseling time for 'Group intensive' patients are distributed over 7
1-hour sessions.
Dynamics of Episodes-of-Care Lounsbury, Levine, & Ostroff 7
higher quit rates. However, in this practice, the model shows that more patients are relapsing
thatquitting, on a weekly basis, over the specified time period (see sample output in appendix).
In our planned study (currently under review by the NIH), we will continue developing
our sample partial model in collaboration with an expert advisory group and a sample of
community-based primary care practices. The participating practices will aide our formative
assessment the system dynamics model. The formative assessment will examine: (1) feasibility
and acceptability of using the simulation tool in an academic detailing intervention, (2) changes
in individual provider attitudes about and practices in tobacco treatment, (3) and implementation
of new or improved office systems to improve tobacco treatment at the practice level. We
hypothesize that system dynamics modeling of the practice environment will promote deeper
understanding of and greater impetus to implement the PHS Guideline.
Our planned study will be nested within Queens Quits!, a larger, on-going statewide
initiative to disseminate and implement the PHS Guideline into clinical practice via a network of
19 Tobacco Cessation Centers, funded by the New Y ork State Department of Health
(NY SDOH). Memorial Sloan-Kettering Cancer Center (MSKCC) colleagues (Ostroff and
Lounsbury) provide expertise in tobacco cessation treatment and program evaluation to Queens
Quits!
Planned A pplication of the Model: Academic Detailing to Change Provider Practices
Academic detailing interventions typically involved multiple components, including
provision of written materials and sample supplies, didactic training, auditing (with feedback),
‘reminder’ systems, and one or more office-based consultations (Gandjour and Lauterbach 2005;
Goldstein et al. 2003; Soumerai and Avorn 1990). A recent Cochrane review by O’Brien and
colleagues (O'Brien et al. 2005) examined the effectiveness of educational outreach visits, or
academic detailing, to promote changes in medical and health care provider practices. In 13 of 18
randomized trials examined, the targeted provider behavior was prescribing practices. Three
studies addressed preventive practices, including brief counseling for smoking cessation (Avorn
et al. 1992; Berings, Blondeel, and Harbraken 1994). Collectively, these efforts help detailers
establish a rapport with providers that, in turn, can generate effective change in practices.
Although positive outcomes were observed in all studies in the review, interventions that
provided one or more of the following, including individual instruction, used audit and feedback
strategies, incorporated review by peers, and that successfully integrated ‘reminder’ systems,
were among the most effective for medical professionals (Dietrich et al. 1992; Steele et al. 1989)
(Andrews et al. 2001; Kiefe et al. 2001; Weissman et al. 1999; Wensing and Grol 1994; Y ano et
al. 1995). Results did not reveal a clear relationship between the number of office visits by
detailers and impact on the provider, although it was noted that interventions with as few as one
or two visits had positive effects. Overall, academic detailing appears to be a promising way to
change provider behaviors, especially when the behavior was prescribing medications. However,
additional research on interventions intended to change preventive practices, including tobacco
treatment practices (Goldstein et al. 2003), is needed. Although dissemination-only strategies
(e.g., conferences and mailings) always demonstrated smaller effects than interventions
involving outreach visits or peer review, such interventions had varying levels of effective
impact (Oxman et al. 1995).
We believe that the system dynamics modeling approach has the potential to transform
how clinical guidelines and scientific reviews are disseminated to busy professionals. A well-
Dynamics of Episodes-of-Care Lounsbury, Levine, & Ostroff 8
designed simulation tool could greatly accelerate the rapport- building process between detailers
and providers. We hypothesize that the capability to automatically simulate the dynamics of
implementing practice changes during the course of either a didactic training session and/or an
office-based consultation would help an academic detailer quickly learn about a provider's
practice environment and help providers make practice-specific, cost-effective decisions about
how to most efficiently and rapidly attain (and/or sustain) evidence-based standards of tobacco
treatment for their patients. A tool with this capability would allow for quick comparison of
alternative ways of changing office procedures by generating scenarios that simulate different
combinations of role-sharing or resource exchange.
The system dynamics simulation tool we envision would be able to generate customized
output, on the spot, in the form of easy-to-read behavior-over-time charts and data tables. Results
would give a dynamic picture of demand on providers as well as patient outcomes over a
specified period of time. It could show how, for example, adding tobacco treatment time during
office visits will impact wait times over the course of a single day, or how combination NRT
impacts relapse rates for heavy smokers over a three year period. More generally, our completed
simulation tool would help providers answer critical questions such as: Which staff members
should (and can) be involved in the practice’ s tobacco treatment strategies? How effective are
minimal interventions, such as clinician advice to stop smoking, for our patients, or are more
intensive interventions required? How does the duration of an intervention in number of
treatment sessions or in total face-to-face contact time substantially influence efficacy for our
patients? How much counseling time can we allocate during an office visit? What are the short-
term and long-term costs of not effectively treating tobacco use, to the practice and to our
patients? Which pharmacologic interventions will be easiest for our patients to adhere to and
may lead to greater patient contact? How many times do patients relapse before they quit for
good?
We expect that the capacity to address these types of questions with the simulation tool
will help primary care providers visualize the implementation of various features of the tobacco
treatment guidelines. In turn, we expect that providers will more quickly identify the
mechanisms that will drive effective tobacco treatment in their own practices.
Summary
Our sample partial model is a starting point for a planned study with primary care
physicians in New Y ork City. Episode-of-care analysis has proven central to conceptualization
and application of system dynamics to the problem of tobacco dependence and treatment in
primary care. We will use the conceptual framework presented here as a theoretical blueprint to
develop the simulation tool, integrating both professional knowledge and knowledge for
improvement over the course of the model-building process.
Dynamics of Episodes-of-Care
Lounsbury, Levine, & Ostroff 9
Appendix
Sample Partial Model Stock and Flow Diagram
Number of minutes
: devoted to
ibtervention, per office ‘Average number
of office visits for .
sikets OQ Average time for
A smokers to leave
; Time devoted to a Smokers leaving pmcine
intervention per smoker the practice
Smokers
Proportion of aa entering
smokers who are practice | seo 7
' to quit'
Tend, to quit Fraction of smokers
[Setto 70%] 7 who make unaided
it attempts
effectiveness o! . cape ,
F i Patients Patients
( intervention ——s1\ Patients quitting relapaing
Effect of time devoted to
intervention on quitters Patient's relapse
time
oS Former
Smokers
Saari Average time for
former smokers to
practice Former smokers <¢——— Lave the practice
leaving practice
Average time for never
smokers to leave the
Never Practice
Never smokers Smokers Never smokers
entering the practice leaving the practice
Dynamics of Episodes-of-Care Lounsbury, Levine, & Ostroff 10
Sample Partial Model Output
Former Smokers
100 If we start with 100 Smokers and 100 Former Smokers in the practice, then
we see that implementing counseling (5As) is effective, and that more time
spent per visit generate more Former Smokers. However, we also see that it
90 takes time to expose all of the Smokers to the treatment. Only so many.
Smokers make an office visit each week. Over time, we see that consistent
implementation of the counseling intervention increases the number of
Former Smokers.
80
15 min
70 7 min
3 min
60
0 10 20 30 40 50 60 70 80 90 100
Time (Week)
Former Smokers : 15 min visit People
Former Smokers : 7 min visit People
Former Smokers : 3 min visit People
Quitting and Relapsing
20 This figure shows quit rates and relapse rates over time. Note how
implementation of the treatment immediately reduces relapse rates and
increases quit rates, as patients switch from a smoking episode to a quitting
episode. Over time, as Smokers are seen at the office, and thereby recieve the
I? counseling intervention, the rate of relasping and quitting approach the each
other. However, note that quit rates never surpass relapse rates. This implies
that, although the treatment is having the expected effect, more needs to be
done to lengthen the quitting episode.
14
Relapsing
11 Quitting
8
0 10 20 30 40 50 60 70 80 90 100
Time (Week)
Patients quitting: 15 min visit People/W eek
Patients relapsing : 15 min visit People/W eek
Dynamics of Episodes-of-Care Lounsbury, Levine, & Ostroff 11
Sample Partial Model Variable Definitions
Primary Care [Average number of office |Auxilary Constant |Setto 3. Constitutes an average _|Office visits
visits for smokers lreatment epidsode. Assumes no
more than 1 session per week.
Primary Care |Average time for never lAuxilary [Constant |96 weeks (nearly 2 years) Weeks
Ismokers to leave the practice
Primary Care Average time for former fAuxilary [Constant |72 weeks (nearly 1.5 years) Weeks
|smokers to leave the practice
Primary Care [Average time for smokers to Auxiliary [Constant _|48 weeks (nearly 1 year) Weeks
leave practice
Primary Care |Effect of time devoted to lAuxilary _|Variable |More time devoted, stronger effect. |1/Week
intervention on former (lookup
lsmokers able)
Primary Care |Never smokers entering the _ [Flow Constant [Rate at which new patients jon the |People/Week
practice practice.
Primary Care [Never smokers leaving the __|Flow Draining |Rate at which patients leave one __|People/Week
practice process _|practice for another, move away, die,
jetc.
Primary Care [Number of minutes devoted to [Auxilary [Constant |Setto either 3 minutes (minimal), 7 |Minutes/Smoker/
intervention per office visit minutes (moderate), or 15 minutes Office visit
(full) of tobacco counseling time
(5s)
Primary Care [Overall effectiveness of lAuxiary — |Mulupic- |The number of smokers seen bya |People/Week
intervention ative primary care physician X the
leffectiveness of the intervention X
Ithe patient's readiness to quit.
Primary Care [Patients relapsing Flow Draining |Rate at which patients patients who |People/Week
process _|had quit start smoking again
Beginning of smoking episode. End
lof quitting episode.
Primary Care |Former smokers entering the |Flow Constant [2 per week. Rate at which new PeopleyWeek
practice patients join the practice.
Primary Care |Former smokers leaving Flow Draining |Rate at which patients leave one |People/Week
practice process practice for another, move away, die,
jetc.
Primary Care [Smokers entering practice __|Flow Constant [2 per week. Rate at which new People/Week
patients join the practice.
Primary Care [Smokers leaving the practice |Flow Draining |Rate at which patients leave one |People/Week
process practice for another, move away, die,
letc.
Primary Care |Time devoted to intervention [Auxilary _ |Multiplic- [The number of session per reatment|Minutes/Smoker
lper smoker ative lepidsode X the average time
allocated to tobacco counseling,
[Tobacco Use |Fraction of smokers who make|Auxilary Fraction |The proporation of current smokers dimensionless
fan unaided quit attempt lwho quit without assistance from
their provider.
Tobacco Use |Never Smokers Stock Initial value [Number of patients in practice who [People
have never used tobacco.
Tobacco Use |Patients quitting Flow Draining |Rate at which patients are quitting, _|People/Week
process _ once they are a patient at the
practice. Beginning of quitting
lepisode. End of smoking episode.
Tobacco Use [Patient's relapse tme lAuxilary [Constant _|6 weeks. Expected time before a _ Week
patient would relapse.
Tobacco Use |Former Smokers Stock _|Inifial value [Number of patients in practice who [People
have quit smoking.
Tobacco Use [Proportion of patients ready to|Auxilary [Fraction _ [Patient's readiness level, ona scale [dimensionless
quit from 0 (lowest) to 1.0 (highest).
Tobacco Use |Smokers Stock Initial value [Number of patients in practice who [People
currently smoke
Note: Patient Health domain is not shown here.
Dynamics of Episodes-of-Care Lounsbury, Levine, & Ostroff 12
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Sample Partial Model: Primary Care Practice Dynamics
Stock and Flow Diagram:
Number of minutes
. devoted to
intervention per office Average number
visil ce
of office visits for .
smokers oo Average time for
A smokers to leave
__ Time devoted to a” Smokers leaving practice
intervention per smoker: the practice
Smokers
Proportion of Smokers entering
smokers who are practice [set 7% |
' to anit
Teadly to qu Fraction of smokers
i who make unaided
quit attempts
ffe eee \f Pe
effectiveness 0 : sis :
intervention ——»-Dx Patients quitting ee
Effect of time devoted to
intervention on quitters Patient's relapse
time
2 Former
Former smokers Smokers
entering the Average ome for
former smokers
practice Former smokers <¢—— eave the practice
leaving practice
Average time for never
smokers to leave the
© nee ii es practice
Never smokers Smokers Never smokers
entering the practice leaving the practice
1 of 3
Sample Simulation Output:
Former Smokers
100 If we start with 100 Former Smokers in the practice, then we see that
implementing counseling (5As) is effective, and that more time spent per
visit generate more Former Smokers. However, we also see that it takes
90 time to expose all of the Smokers to the treatment. Only so many Smokers.
make an office visit each week. Over time, we see that consistent
implementation of the counseling intervention increases the number of
Former Smokers.
80
15 min
70 7min
3 min
60
0 10 20 30 40 50 60 70 80 90 100
Time (Week)
Former Smokers : 15 min visit People
Former Smokers : 7 min visit People
Former Smokers : 3 min visit People
Quitting and Relapsing
20 This figure shows quit rates and relapse rates over time. Note how
implementation of the treatment immediately reduces relapse rates and
increases quit rates, as patients switch from a smoking episode to a quitting
episode. Over time, as Smokers are seen at the office, and thereby recieve the
17 counseling intervention, the rate of relasping and quitting approach the each
other. However, note that quit rates never surpass relapse rates. This implies
that, although the treatment is having the expected effect, more needs to be
done to lengthen the quitting episode, Alternatively, it means that our assumed
14 parameters in the current model are, somehow, invalid (NOTE: this is a
sample partial model, and not yet validated).
Relapsing
11 Quitting
8
0 10 20 30 40 50 60 70 80 90 100
Time (Week)
Patients quitting: 15 min visit People/Week
Patients relapsing : 15 min visit People/W eek
2 of 3
Former Smokers
40 Shows the accumulation (stock) of patients who quit as a function of the
intervention (minimal, brief, of full counseling). Unaided quitters are
subtracted and the initial value for Former Smokers was set to zero before
30 simulation.
15 min
20 7 min
3 min
10
0
0 10 20 30 40 50 60 70 80 90 100
Time (Week)
Former Smokers : 15 min visit People
Former Smokers : 7 min visit People
Former Smokers : 3 min visit People
3 of 3
Sample Partial Model
Variable Definitions
Primary Care |Average number of office Auxilary |Constant Set to 3. Constitutes an average Office visits
visits for smokers treatment epidsode. Assumes no
more than 1 session per week.
Primary Care |Average time for never Auxilary |Constant |96 weeks (nearly 2 years). Weeks
smokers to leave the practice
Primary Care |Average time for former Auxilary [Constant |72 weeks (nearly 1.5 years). Weeks
smokers to leave the practice
Primary Care |Average time forsmokers to |Auxilary |Constant |48 weeks (nearly 1 year). Weeks
leave practice
Primary Care |Effect of time devoted to Auxilary —|Variable More time devoted, stronger effect. |1/Week
intervention on former (lookup
smokers table)
Primary Care |Never smokers entering the Flow ‘Constant [Rate at which new patients join the |People/Week
practice practice.
Primary Care |Never smokers leaving the Flow Draining Rate at which patients leave one People/Week
practice process practice for another, move away, die,
etc.
Primary Care |Number of minutes devoted to |Auxilary |Constant Set to either 3 minutes (minimal), 7 |Minutes/S moker/
intervention per office visit minutes (moderate), or 15 minutes Office visit
(full) of tobacco counseling time
(5As).
Primary Care |Overall effectiveness of Auxilary |Multiplic- |The number of smokers seen bya __|People/Week
intervention ative primary care physician X the
effectiveness of the intervention X
the patient's readiness to quit.
Primary Care |Patients relapsing Flow Draining Rate at which patients patients who |People/Week
process had quit start smoking again.
Beginning of smoking episode. End
of quitting episode.
Primary Care |Former smokers entering the |Flow Constant |2 per week. Rate at which new People/Week
practice patients join the practice.
Primary Care |Former smokers leaving Flow Draining Rate at which patients leave one People/Week
practice process practice for another, move away, die,
etc.
Primary Care |Smokers entering practice Flow ‘Constant [2 per week. Rate at which new People/Week
patients join the practice.
Primary Care |Smokers leaving the practice [Flow Draining Rate at which patients leave one People/Week
process practice for another, move away, die,
etc.
Primary Care |Time devoted to intervention |Auxilary |Multiplic- [The number of session per treatment|M inutes/S moker
per smoker ative epidsode X the average time
allocated to tobacco counseling.
1of2
Sample Partial Model
Variable Definitions
Tobacco Use |Fraction of smokers who make|Auxilary —_ [Fraction The proporation of current smokers |dimensionless
an unaided quit attempt who quit without assistance from
their provider.
Tobacco Use |Never Smokers Stock Initial = 100 |Number of patients in practice who |People
have never used tobacco.
Tobacco Use |Patients quitting Flow Draining Rate at which patients are quitting, |People/Week
process once they are a patient at the
practice. Beginning of quitting
episode. End of smoking episode.
Tobacco Use |Patient's relapse time Auxilary [Constant |6 weeks. Expected time before a Week
patient would relapse.
Tobacco Use |Former Smokers Stock Initial =10 |Number of patients in practice who |People
have quit smoking.
Tobacco Use |Proportion of patients ready to |Auxilary —|Fraction Patient's readiness level, on a scale |dimensionless
quit from 0 (lowest) to 1.0 (highest).
Tobacco Use |Smokers Stock Initial =40 |Number of patients in practice who |People
currently smoke
2 of 2
