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RRP 09-146 – HSR&D Study

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RRP 09-146
Using System Dynamics Tools to Integrate Evidence into VA Stroke Care
Hayden B Bosworth PhD
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: March 2010 - February 2011

BACKGROUND/RATIONALE:
The prevalence, morbidity, impact, and cost of stroke make it a critical health problem in the United States. For the VA, there are major opportunities to reduce the burden of stroke through prevention, acute treatment, and rehabilitation.

OBJECTIVE(S):
The aim of this study was to use System Dynamics tools to engage system stakeholders to achieve a deeper understanding of the complex systems involved in stroke prevention and treatment in the VA to develop a stroke strategic agenda.

METHODS:
We recruited a set of system VA stakeholders to address the following aims: Aim 1 was to improve prior simulation model assumptions. Aim 2 was to use the model to simulate and compare possible interventions and determine strategic policy recommendations for the Stroke QUERI. Aim 3 was to facilitate discussions about the use of System Dynamics more broadly in the VA by facilitating a series of meetings with relevant VA representatives.

FINDINGS/RESULTS:
In Aim 1 we predicted a base case scenario for the stroke QUERI, shaped a set of 15 intervention scenarios, and estimated the anticipated reduction in the following outcomes for intervention scenarios individually and in combination: Disabililty-Adjusted Life Years (DALYs), strokes, and stroke related deaths in a 5, 10, and 20 year time horizon. Combining all intervention scenarios, we estimate an upper bound of 12-15% reduction in the negative consequences of stroke among VA users. At five years, across outcomes, the top five interventions included broad hypertension management, targeted management of hypertension and atrial fibrillation among veterans with a history of diabetes, hyptertension management among diabetics. If DALYs are the priority, rehabilitation and improving DVT care in the acute setting post stroke are most powerful. However, if the focus changes to preventing strokes and stroke fatalities, enhanced prevention efforts post TIA and Stroke are among the top interventions considered.

IMPACT:
The model helped the team identify important synergies and to discuss tradeoffs between the cost and benefits of alternate strategic priorities. For example, targeting hypertension and atrial fibrillation management to veterans with a history of cardiovascular disease, TIA, and stroke is more powerful than broad expansion of hypertension and atrial fibrillation management across the VA.

PUBLICATIONS:
None at this time.


DRA: Health Systems, Other Conditions
DRE: Technology Development and Assessment, Prevention
Keywords: Hypertension, QUERI Implementation
MeSH Terms: none

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