Implications of long-term care capacity response policies for an aging population: A simulation analysis

Dentists' perspectives on structural and system barriers hindering oral healthcare provision in residential care facilities

OBJECTIVES

Oral healthcare service is not well integrated with existing healthcare policy in nursing homes (NHs) globally. This qualitative study aimed to identify dentists' perspectives on structural and system barriers that hinder oral healthcare (OHC) provision to seniors in NHs in Singapore and to understand the consequences of these barriers.

METHODS

Nineteen dentists (8 males and 11 females, 36.0 [IQR: 32.0-48.5] years old) were recruited through combination of purposive and snowball sampling. Four focus group discussions were conducted via teleconferencing, and each discussion had 4-5 anonymised participants. Sessions lasted 90-120 min and were audio-recorded and transcribed verbatim. Thematic analysis was conducted on data collected using NVivo software (Version12, QRS International).

RESULTS

Participants agreed that the current OHC system for seniors in NHs is not well developed. The challenges dentists faced were categorised in three themes: [1] general oral healthcare system level; [2] local nursing home setting level; and [3] geriatric oral healthcare education level. These challenges are complexly intertwined and have contributed to several consequences such as a shortage of dentists in NHs and their diminished motivation to serve. It has also limited the quality of dental service they are able to provide in NHs, contributing to the current poor access of dental services for seniors in NHs.

CONCLUSIONS

Dentists in Singapore face many structural and systemic barriers in providing OHC to seniors in NHs, some of which are unique to the local context. Newfound understanding of these barriers and its consequences will be helpful in developing strategic approaches to overcome these challenges.

Therapies go digital. What drives physicians' acceptance?

National healthcare systems face multiple challenges, including the increasing demand for care and decreasing availability of healthcare professionals. Digital health technologies represent opportunities that offer improved efficiency, accessibility, and patient care. In this scenario, Digital Therapeutics are technological advancements to treat or alleviate a disease and deliver a medical intervention with evidence-based therapeutic impacts and regulatory approval. Digital Therapeutics are a paradigm shift for physicians, who exercise caution in terms of trust and wide usage. Digital Therapeutics represents an opportunity and a challenge in healthcare system integration. The research investigates the factors explaining physicians' acceptance of Digital Therapeutics. A research model that combines organizational mechanisms derived from Institutional Theory and rational factors derived from the Technology Acceptance model was developed. The model was tested through 107 responses from a survey distributed to the members of the leading Italian scientific society in Diabetology. Literature-based hypotheses were empirically tested through Structural Equation Modelling. The analysis confirmed the influence of Perceived Ease of Use on Perceived Usefulness and Perceived Usefulness on the Intention To Use Digital Therapeutics. Rules and norms impact Perceived Usefulness when considering the influence of the scientific society. Culture and mindset towards innovation within the hospital positively affect Perceived Ease of Use. The readiness of hospital facilities enhances the extent to which physicians perceive the ease of employing Digital Therapeutics in their daily practice. Instead, esteemed colleagues' opinions and guidelines from the scientific society reveal to physicians the value of Digital Therapeutics in patients' care pathways. Institutions should prioritize cultural, normative, and regulative aspects to accelerate physicians' endorsement of Digital Therapeutics. Findings advance the theoretical knowledge around clinicians' adoption of innovative digital health technologies, unveiling the interaction between rational and institutional factors. The results highlight practical implications for healthcare institutions and Digital Therapeutics manufacturers willing to promote their adoption.

Projecting the burden of dental caries and periodontal diseases among the adult population in the United Kingdom using a multi-state population model

Objectives

With the aging United Kingdom population, oral diseases are expected to increase. Exploring credible projections is fundamental to understanding the likely impact of emerging population-level interventions on oral disease burden. This study aims at providing a credible, evidence-based projection of the adult population in the United Kingdom with dental caries and periodontal diseases.

Methods

We developed a multi-state population model using system dynamics that disaggregates the adult population in the United Kingdom into different oral health states. The caries population was divided into three states: no caries, treated caries, and untreated caries. The periodontal disease population was disaggregated into no periodontal disease, pocketing between 4 and < 6 mm, 6 and < 9 mm, and 9 mm or more. Data from the 2009 dental health survey in the United Kingdom was used to estimate age and gender-specific prevalence rates as input to the multi-state population model.

Results

Of the population 16 years and older, the number with carious teeth is projected to decrease from 15.742 million in the year 2020 to 15.504 million by the year 2050, representing a decrease of 1.5%. For individuals with carious teeth, the older adult population is estimated to constitute 62.06% by 2050 and is projected to increase 89.4% from 5.079 million in 2020 to 9.623 million by 2050. The adult population with periodontal pocketing is estimated to increase from 25.751 million in 2020 to 27.980 million by 2050, while those with periodontal loss of attachment are projected to increase from 18.667 million in 2020 to 20.898 million by 2050. The burden of carious teeth and periodontal diseases is anticipated to shift from the adult population (16-59 years) to the older adult population. The older adult population with carious teeth is estimated to rise from 32.26% in 2020 to 62.06% by 2050, while that for periodontal disease is expected to increase from 42.44% in 2020 to 54.57% by 2050.

Conclusion

This model provides evidence-based plausible future demand for oral health conditions, allowing policymakers to plan for oral health capacity to address growing needs. Because of the significant delay involved in educating and training oral health personnel, such projections offer policymakers the opportunity to be proactive in planning for future capacity needs instead of being reactive.

Instability in Caregivers' Perception of Dementia as a Terminal Disease

OBJECTIVES

Family caregivers' perception that dementia is a terminal disease influence end-of-life (EoL) care of persons with severe dementia (PwSDs). Yet, this perception and the extent to which it changes over time is underexplored. We assessed PwSD caregivers' perception of dementia as a terminal disease and changes in this perception over time.

DESIGN

Prospective cohort.

SETTING AND PARTICIPANTS

Two hundred fifteen primary informal caregivers of community-dwelling PWSDs in Singapore were surveyed every 4 months over a period of 16 months.

METHODS

We assessed the proportion of caregivers who perceived that dementia is a terminal disease and the extent to which it changed between the previous time points. Using mixed effects multinomial regression models, we assessed factors associated with caregivers' perception and changes in perception between consecutive time points.

RESULTS

At baseline, only 26% of the caregivers reported correctly that dementia is a terminal disease. This changed over time, not necessarily toward a correct perception. Caregivers of PwSDs with an acute medical condition in the last 4 months (risk ratio [RR] 2.19, 95% CI 1.21, 3.97) and those with higher functional dependence (RR 1.11, 95% CI 1.01,1.22) were more likely and those of older PwSDs were less likely (RR 0.87, 95% CI 0.81, 0.93) to perceive dementia as a terminal disease. Caregivers of PwSDs who had experienced an acute medical problem in the last 4 months (RR 1.58, 95% CI 1.00, 2.49) were also more likely to shift their perception toward being correct. Caregivers of PwSDs who had more agitation behaviors were more likely to shift their perception toward being incorrect (RR 1.04, 95% CI 1.00,1.07) CONCLUSIONS AND IMPLICATIONS: Few caregivers perceived dementia as terminal, and this perception changed over time and differed according to age and the health status of PwSD. Results have implications regarding the frequency of prognostic discussions.

Scarcity in abundance? Spatial inequalities in Rheumatoid Arthritis in a health system with financial equity

BACKGROUND

This paper estimates spatial inequalities of Rheumatoid Arthritis (RA) in Colombia and explores correlates of those disparities from a health system perspective.

METHODS

We apply descriptive epidemiology to healthcare administrative records for estimation of crude and age-standardized prevalences, and health systems thinking for identification of barriers to effective access in RA diagnosis.

RESULTS

The crude and age-standardized RA prevalence for Colombia in 2018 is estimated at 0.43% and 0.36%, respectively. In the contributory regime, the binding constraint is effective access to rheumatologists in rural and sparsely populated areas; this constraint in workforce affects service delivery, and ultimately comes from the lack of a differentiated model for effective provision of healthcare in those areas (governance).

CONCLUSIONS

There are opportunities for implementation of public health policies and health system interventions that would lead to a better identification of RA patients and the subsequent more precise estimation of RA prevalence, and most importantly, to reduce exposition to risk factors and accurate diagnosis and treatment of RA patients.

Caregivers' End-of-Life Care Goals for Persons with Severe Dementia Change Over Time

BACKGROUND

Family caregivers make end-of-life (EOL) decisions for persons with severe dementia (PWSDs). It is not known whether the family caregivers' goals change over time.

OBJECTIVE

Assess caregivers' EOL care goal for PWSDs and change in these goals over time.

METHODS

Using a prospective cohort of 215 caregivers of PWSDs, we assessed the proportion of caregivers whose EOL care goal for PWSDs changed between two consecutive time points. Mixed effects multinomial regression models assessed factors associated with caregivers' EOL care goals for PWSD (maximal, moderate, minimal life extension); and change in EOL care goal from previous time point.

RESULTS

At baseline, 20% of the caregivers had a goal of maximal life extension for their PWSD, and 59% changed their EOL care goal at least once over a period of 16 months. Caregivers of PWSDs with lower quality of life (RR: 1.15, CI: 1.06, 1.24), who expected shorter life expectancy for PWSDs (RR: 10.34, CI: 2.14, 49.99) and who had an advance care planning discussion (RR: 3.52, CI: 1.11, 11.18) were more likely to have a goal of minimal life extension for PWSD. Caregivers with higher anticipatory grief (RR: 0.96, CI: 0.93,1) were more likely to have a goal of maximal life extension. Change in PWSDs' quality of life and change in caregivers' anticipatory grief were associated with change in caregivers' EOL care goals.

CONCLUSION

Caregivers' EOL care goals for PWSDs change over time with change in PWSD and caregiver related factors. Findings have implications regarding how health care providers can engage with caregivers.

Research on the optimization of financing scheme of long-term care insurance in China based on system dynamics simulation

Objective

The aging population in China highlights the significance of long-term care insurance (LTCI). This study provides policy suggestions for China to establish a sustainable LTCI financing mechanism by predicting the trend of funds balance and screening the appropriate financing scheme.

Method

A system dynamics model (SDM) of LTCI funds was constructed by clarifying the current situation and its main influencing factors of revenue and expenditure of LTCI funds in China. Also, through literature research and expert consultation, we found the intervention goals and predicted the changing trend of LTCI fund balance from 2020 to 2050 under different intervention schemes.

Results

The SDM of LTCI financing passes the dimensional consistency test, structural test, and historical test. Therefore, it can objectively reflect the structure and behavior of the financing system. It is found that the factors affecting the revenue and expenditure system of LTCI funds mainly include economic factors, demographic factors, and other factors. By adjusting three intervention indicators, namely, individual payment rate, reimbursement proportion, and severe disability rate, this study produces 45 financing combination schemes. By comparing the changing trend of LTCI fund balance under different intervention schemes, according to the screening principle, five better financing schemes are finally selected. These five financing schemes have no deficit and excessive balance in the forecast period, which is in line with the principle of sustainability. It can provide a reference for the selection of financing schemes in pilot areas.

Discussion

This study has optimized the policy of the LTCI financing mechanism, determined the suitable LTCI participants, financing channels and levels, and screened out the suitable LTCI financing policy optimization scheme for China. By appropriately increasing the individual payment rate, strengthening the disability intervention of the elderly, formulating scientific and objective disability evaluation standards, and finally establishing a dynamic financing adjustment mechanism of LTCI. This study can provide a basis for the scientific formulation of the LTCI financing mechanism in China and provide a reference for developing countries to establish a sustainable LTCI.

A study on how to achieve flexibility in healthcare process: a simulation-based approach

Purpose

The paper aims to investigate the cardiology department’s operational system for improving flexibility by minimizing the patient waiting time and simultaneously maximizing the utilization of service capacity in an uncertain environment. This article also proposes a policy framework that suggests a pool of additional resources and inter-firm collaboration can boost healthcare service delivery excellence.

Design/methodology/approach

A discrete event simulation (DES) approach is followed for modeling patient flow and determining the service capacity to respond to demand variability and uncertainty. The model's outputs are used to minimize patient waiting time, maximize the utilization of the resources and match the service capacity with the patient demand.

Findings

This research has tested two hypotheses and proved that an increase in waiting time decimates the throughput rate, and additional resources deployment in bottleneck activity positively impacts the throughput rate. The simulated scenarios prescribe an enhanced service capacity with quality care and further contribute to operational performance in reduced waiting time and cost. The results indicate that flexibility reduces the patient waiting time and maximizes the throughput rate.

Practical implications

The study guides the healthcare policymakers to develop flexible competence and facilitate service mechanisms that are adaptive and robust while operating under a volatile environment. The article contributes to the healthcare literature that conjoins flexibility through simulation and resource utilization.

Originality/value

This research is based on real-life primary data collected from healthcare providers. This study adds value to the healthcare systems to adopt strategic decisions to build flexibility through resource allocation, sharing and coordinated care.

Biomedical IoT: Enabling Technologies, Architectural Elements, Challenges, and Future Directions

This paper provides a comprehensive literature review of various technologies and protocols used for medical Internet of Things (IoT) with a thorough examination of current enabling technologies, use cases, applications, and challenges. Despite recent advances, medical IoT is still not considered a routine practice. Due to regulation, ethical, and technological challenges of biomedical hardware, the growth of medical IoT is inhibited. Medical IoT continues to advance in terms of biomedical hardware, and monitoring figures like vital signs, temperature, electrical signals, oxygen levels, cancer indicators, glucose levels, and other bodily levels. In the upcoming years, medical IoT is expected replace old healthcare systems. In comparison to other survey papers on this topic, our paper provides a thorough summary of the most relevant protocols and technologies specifically for medical IoT as well as the challenges. Our paper also contains several proposed frameworks and use cases of medical IoT in hospital settings as well as a comprehensive overview of previous architectures of IoT regarding the strengths and weaknesses. We hope to enable researchers of multiple disciplines, developers, and biomedical engineers to quickly become knowledgeable on how various technologies cooperate and how current frameworks can be modified for new use cases, thus inspiring more growth in medical IoT.

Research on Financing Mechanism of Long-Term Care Insurance in Xiamen, China: A System Dynamics Simulation

Objective: This study aimed to predict the changing trend of long-term care insurance (LTCI) funds by clarifying the linkage between revenue and expenditure and its influencing factors and to provide evidence for the establishment of a sustainable LTCI financing mechanism in China.

Method: We have taken Xiamen as an example, based on the data from Xiamen Special Economic Zone Yearbook and field survey. The changing trend of LTCI funds is predicted from 2020 to 2030 based on the system dynamics model (SDM) of the LTCI financing system. Also, through literature research and expert consultation, we found the intervention goals and analyzed their impact on the balance of LTCI funds.

Results: In the current situation, according to the forecast, the revenue and the expenditure of the LTCI funds will increase year by year from 2020 to 2030 in Xiamen, an increase of about 3.7 times and 8.8 times, respectively. After 2029, the expenditure will exceed the revenue of the LTCI funds and the balance will turn into a deficit. From the perspective of fund revenue, by adjusting the individual payment rate, government financial subsidies, and enterprise payment rate, the proportion of LTCI funds can be increased to alleviate the balance deficit under the original forecast. On the contrary, from the perspective of fund expenditure, increasing the proportion of reimbursement and the rate of severe disability will lead to an increase in fund expenditure. In this case, the balance of the funds will turn into a deficit, 7 years in advance. In addition, it was found that the severe disability rate has the greatest impact on the balance of funds.

Discussion: The SDM can objectively reflect the structure and the behavior of the LTCI financing system and has good applicability. By increasing the individual payment rate, government financial subsidies, and enterprise contribution rate, reasonable setting of the reimbursement ratio of nursing services, especially for the prevention of disability among the elderly, to maintain the sustainability of the funds. This study provides strong evidence for policymakers to establish a sustainable LTCI system in China.

An International Comparison of the Management of Gastrointestinal Surgical Emergencies in Octogenarians-England Versus United States: A National Population-based Cohort Study

OBJECTIVE

To compare the United States and England for the utilization of surgical intervention and in-hospital mortality from 5 gastrointestinal emergencies in octogenarians.

BACKGROUND

The proportion of older adults is growing and will represent a substantial challenge to clinicians in the next decade.

METHODS

Between 2006 and 2012, the rate of surgical intervention and in-hospital mortality for 5 index conditions for octogenarians were compared between the United States and England: appendicitis, incarcerated/strangulated abdominal hernia, perforation of esophagus, small or large bowel, and peptic ulcer. Univariate and multivariate analyses were performed to adjust for underlying differences in patient demographics.

RESULTS

Thirty-two thousand one hundred fifty-one admissions of octogenarians in England for 5 index surgical emergencies were compared with 162,142 admissions in the USA.Surgical intervention was significantly more common in the USA than in England for all 5 conditions: appendicitis [odds ratio (OR) 4.63, 95% confidence interval (95% CI) 4.21-5.09], abdominal hernia (OR 2.06, 95% CI 1.97-2.15), perforated esophagus (OR 1.71, 95% CI 1.31-2.24), small and large bowel perforation (OR 4.33, 95% CI 4.12-4.56), and peptic ulcer perforation (OR 4.63, 95% CI 4.27-5.02). In-hospital mortality was significantly more common in England than in the USA for all 5 conditions: appendicitis (OR 3.22, 95% CI 2.73-3.78), abdominal hernia (OR 3.49, 95% CI 3.29-3.70), perforated esophagus (OR 4.06, 95% CI 3.03-5.44), small and large bowel perforation (OR 6.97, 95% CI 6.60-7.37), and peptic ulcer perforation (OR 3.67, 95% CI 3.40-3.96).

CONCLUSION

Surgery is used less commonly in England for emergency gastrointestinal conditions in octogenarians, which may be associated with a high rate of in-hospital mortality from these conditions compared with the USA.

Integration of health services for the elderly in Asia: A scoping review of Hong Kong, Singapore, Malaysia, Indonesia

Against the backdrop of rapid ageing populations, there is an increasing recognition of the need to integrate various health services for the elderly, not only to provide more coordinated care, but also to contain the rapid cost inflation driven primarily by the curative sector. Funded by the Asia-Pacific Observatory on Health Systems and Policies, this scoping review seeks to synthesize the received knowledge on care integration for the elderly in four Asian societies representing varying socioeconomic and health-system characteristics: Singapore, Hong Kong, Malaysia, and Indonesia. The search for English-language literature published between 2009 and 2019 yielded 67 publications in the final sample. The review finds that both research and practice regarding health service integration are at a preliminary stage of development. It notes a marked trend in seeking to integrate long-term elderly care with curative and preventive care, especially in community settings. Many distinctive models proliferated. Integration is demonstrated not only horizontally but also vertically, transcending public-private boundaries. The central role of primary care is highly prominent in almost all the integration models. However, these models are associated with a variety of drawbacks in relation to capacity, perception, and operation that necessitate further scholarly and policy scrutiny, indicating the robustness and persistence of siloed healthcare practices.

The Impact of Long-Term Care Policy on the Percentage of Older Adults With Disabilities Cared for by Family Members in China: A System Dynamics Simulation

This study examined the impact of current and future long-term care (LTC) policies on the family caregiving burden in China. System dynamics (SD) methodology was used to construct an LTC delivery system model that simulates the demand of LTC, living options, and LTC service use for disabled older adults. The model was based on three policy variables including the proportion of payment from LTC insurance, the growth rate of beds in LTC institutions, and the time to adjusting the capacity of community-based care. Results showed that the percentage of older adults with disabilities cared for by family members was projected to increase from 92.6% in 2015 to 97.8% in 2035, assuming no policy changes; under the mixed policy scenario, this percentage would reduce significantly to 63.8% in 2035. These findings illustrate that changes in LTC policy and delivery system have a significant impact on family care.

Mathematical modelling for health systems research: a systematic review of system dynamics and agent-based models

BACKGROUND

Mathematical modelling has been a vital research tool for exploring complex systems, most recently to aid understanding of health system functioning and optimisation. System dynamics models (SDM) and agent-based models (ABM) are two popular complementary methods, used to simulate macro- and micro-level health system behaviour. This systematic review aims to collate, compare and summarise the application of both methods in this field and to identify common healthcare settings and problems that have been modelled using SDM and ABM.

METHODS

We searched MEDLINE, EMBASE, Cochrane Library, MathSciNet, ACM Digital Library, HMIC, Econlit and Global Health databases to identify literature for this review. We described papers meeting the inclusion criteria using descriptive statistics and narrative synthesis, and made comparisons between the identified SDM and ABM literature.

RESULTS

We identified 28 papers using SDM methods and 11 papers using ABM methods, one of which used hybrid SDM-ABM to simulate health system behaviour. The majority of SDM, ABM and hybrid modelling papers simulated health systems based in high income countries. Emergency and acute care, and elderly care and long-term care services were the most frequently simulated health system settings, modelling the impact of health policies and interventions such as those targeting stretched and under resourced healthcare services, patient length of stay in healthcare facilities and undesirable patient outcomes.

CONCLUSIONS

Future work should now turn to modelling health systems in low- and middle-income countries to aid our understanding of health system functioning in these settings and allow stakeholders and researchers to assess the impact of policies or interventions before implementation. Hybrid modelling of health systems is still relatively novel but with increasing software developments and a growing demand to account for both complex system feedback and heterogeneous behaviour exhibited by those who access or deliver healthcare, we expect a boost in their use to model health systems.

The 2019 WACEM Expert Document on Hybrid Simulation for Transforming Health-care Simulation Through "Mixing and Matching"

With the multitude of options available under the umbrella of "simulation" today, we have a larger repertoire of choices in our educational journey and outreach. These provide a platform for us to really transform health-care simulation from the traditional, unimodality simulation, to more complex, high fidelity, integrated, and engaging multimodality techniques. The main thrust must be to enhance clinical decision-making in patient care, to solve real-world clinical problems. Hybrid simulation (HS) utilizes at least two different simulation modalities, whereby combining them will enable one type of simulation modality to enhance the other, with the proper alignment, coordination, and interfacing between the modalities. Although the term is often used interchangeably, HS is slightly different from multimodality simulation. The latter refers to the use of multiple types of simulation in the same scenario or place. The main objectives for using HS have to be as follows: (1) for the acquisition of knowledge and skills by the best combination of methodologies, (2) for clinical performance improvement at all levels of care through the creation of as close as possible to real-world situation and problems, (3) to be able to sustain motivation and passion of our spectrum learners in their educational continuum, and (4) to provide a rich, exciting, and stimulating learning platform and environment, which can trigger deep learning and understanding. This article will also share some examples and cases utilizing HS in transforming health-care simulation.

[Development and Analysis of System Dynamics Model for Predicting on the Effect of Patient Transfer Counseling with Nurses]

PURPOSE

This study aimed to construct a management model for patient transfer in a multilevel healthcare system and to predict the effect of counseling with nurses on the patient transfer process.

METHODS

Data were collected from the electronic medical records of 20,400 patients using the referral system in a tertiary hospital in Seoul from May 2015 to April 2017. The data were analyzed using system dynamics methodology.

RESULTS

The rates of patients who were referred to a tertiary hospital, continued treatment, and were terminated treatment at a tertiary hospital were affected by the management fee and nursing staffing in a referral center that provided patient transfer counseling. Nursing staffing in a referral center had direct influence on the range of increase or decrease in the rates, whereas the management fee had direct influence on time. They were nonlinear relations that converged the value within a certain period.

CONCLUSION

The management fee and nursing staffing in a referral center affect patient transfer counseling, and can improve the patient transfer process. Our findings suggest that nurses play an important role in ensuring smooth transitions between clinics and hospitals.

High feeding dependence prevalence in residents living in Italian nursing homes requires new policies: Findings from a regionally based cross-sectional study

OBJECTIVES

An increased amount of functional dependence has been reported among residents living in nursing homes. Among others, feeding dependence is one of the most complex needs to satisfy: behind the attempt to personalise meals with individual preferences and clinical regimens, all residents require help at the same moment and for long periods of time, three or more times a day. With the intent of debating policy implications, the aims of this study were to advance the knowledge in the field of feeding dependence prevalence and predictors in Italy, a country where life expectancy is among the highest in the World.

METHOD

A large retrospective regionally-based study approaching all nursing homes (n = 105) was performed in 2014; all residents (n = 10,900) were eligible and those with a completed assessment recorded in the regional database and aged >65 years (n = 8875) were included.

RESULTS

1839 residents (20.7%) were in total need of help in feeding on a daily basis. At the multilevel analysis, predictors were moderate/severe dementia (OR 4.044, CI 95% 3.213-5.090); dysphagia (OR 4.003 CI 95% 3.155-5.079); pressure sores (OR 2.317 CI 95% 1.803-2.978); unintentional weigh loss (OR 2.197 CI 95% 1.493-3.233); unsociability (OR 1.561 CI 95% 1.060-2.299); and clinical instability (OR 1.363 CI 95% 1.109-1.677).

CONCLUSIONS

The feeding dependence prevalence emerged seem to be unique compared to that documented at the international levels. Modifiable and unmodifiable predictors found require new policies regarding workforce skills-mix and shifts schedules; as well as alliances with families, associations and communities' stakeholders. According to the complexity of the resident profile emerged, staff education and training is also recommended.

Policy choices in dementia care-An exploratory analysis of the Alberta continuing care system (ACCS) using system dynamics

BACKGROUND

The increase in the incidence of dementia in the aging population and the decrease in the availability of informal caregivers put pressure on continuing care systems to care for a growing number of people with disabilities. Policy changes in the continuing care system need to address this shift in the population structure. One of the most effective tools for assessing policies in complex systems is system dynamics. Nevertheless, this method is underused in continuing care capacity planning.

METHODS

A system dynamics model of the Alberta Continuing Care System was developed using stylized data. Sensitivity analyses and policy evaluations were conducted to demonstrate the use of system dynamics modelling in this area of public health planning. We focused our policy exploration on introducing staff/resident benchmarks in both supportive living and long-term care (LTC).

RESULTS

The sensitivity analyses presented in this paper help identify leverage points in the system that need to be acknowledged when policy decisions are made. Our policy explorations showed that the deficits of staff increase dramatically when benchmarks are introduced, as expected, but at the end of the simulation period, the difference in deficits of both nurses and health care aids are similar between the 2 scenarios tested. Modifying the benchmarks in LTC only versus in both supportive living and LTC has similar effects on staff deficits in long term, under the assumptions of this particular model.

CONCLUSION

The continuing care system dynamics model can be used to test various policy scenarios, allowing decision makers to visualize the effect of a certain policy choice on different system variables and to compare different policy options. Our exploration illustrates the use of system dynamics models for policy making in complex health care systems.

Caregiving-related needs of family caregivers of older Singaporeans

OBJECTIVE

To describe the extent and correlates of caregiving-related needs among family caregivers of Singaporeans aged 75+ with ≥1 activity of daily living limitations (care-recipients).

METHODS

National survey data of 1181 care-recipient/caregiver dyads were used. Caregiver's report (yes/no) of 16 needs was assessed. Care-recipient and caregiver correlates of each need were determined through logistic regression analysis.

RESULTS

Caregiving-related needs were expressed by 42.3% caregivers. The most commonly reported need was keeping care-recipient safe at home (24.5%). Needs concerned with caring for care-recipients were more frequent than those concerned with the caregiver's own needs. The most frequent correlate was care-recipient's extent of mood impairment (associated with 13 needs).

CONCLUSION

Caregivers should not neglect themselves when engaging in care provision. Families and service providers should explore whether reported lack of needs reflects limited awareness and/or under-reporting.

Emergency department crowding in Singapore: Insights from a systems thinking approach

Objectives:

Emergency Department crowding is a serious and international health care problem that seems to be resistant to most well intended but often reductionist policy approaches. In this study, we examine Emergency Department crowding in Singapore from a systems thinking perspective using causal loop diagramming to visualize the systemic structure underlying this complex phenomenon. Furthermore, we evaluate the relative impact of three different policies in reducing Emergency Department crowding in Singapore: introduction of geriatric emergency medicine, expansion of emergency medicine training, and implementation of enhanced primary care.

Methods:

The construction of the qualitative causal loop diagram is based on consultations with Emergency Department experts, direct observation, and a thorough literature review. For the purpose of policy analysis, a novel approach, the path analysis, is applied.

Results:

The path analysis revealed that both the introduction of geriatric emergency medicine and the expansion of emergency medicine training may be associated with undesirable consequences contributing to Emergency Department crowding. In contrast, enhancing primary care was found to be germane in reducing Emergency Department crowding; in addition, it has apparently no negative side effects, considering the boundary of the model created.

Conclusion:

Causal loop diagramming was a powerful tool for eliciting the systemic structure of Emergency Department crowding in Singapore. Additionally, the developed model was valuable in testing different policy options.

System Dynamics Modeling Can be Leveraged to Predict Critical Care Pathways and Costs for End Stage Renal Disease: US Population to 2020

Background: End Stage Renal Disease (ESRD) accounts for 9% of Medicare spending, with the beneficiaries suffering from ESRD costing 7-9 times more than the average. This population is expected to continue to grow as a portion of Medicare beneficiaries. To provide clinicians and administrators with a greater understanding of the combined costs associated with the multiple critical care pathways for End Stage Renal Disease we have developed a model to predict ESRD populations through 2020. Methods: A system dynamics model was designed to project the prevalence and total costs of ESRD treatment for the United States through 2020. Incidence, transplant and mortality rates were modeled for 35 age and primary diagnosis subgroups coursing through different ESRD critical care pathways. Using a web interface that allows users to alter certain combinations of parameters, several demonstration analysis were run to predict the impact of three policy interventions on the future of ESRD care Results: The model was successfully calibrated against the output of United States Renal Data System's (USRDS) prior predictions and tested by comparing the output to historical data. Our model predicts that the ESRD patient population will continue to rise, with total prevalence increasing to 829,000 by 2020. This would be a 30% increase from the reported 2010 prevalence. Conclusions: Findings suggest that clinical care and policy changes can be leveraged to more effectively and efficiently manage the inevitable growth of ESRD patient populations. Patients can be shifted to more effective treatments, while planning integrating systems thinking can save Medicare's ESRD program billions over the next decade.

Applying dynamic simulation modeling methods in health care delivery research-the SIMULATE checklist: report of the ISPOR simulation modeling emerging good practices task force

Health care delivery systems are inherently complex, consisting of multiple tiers of interdependent subsystems and processes that are adaptive to changes in the environment and behave in a nonlinear fashion. Traditional health technology assessment and modeling methods often neglect the wider health system impacts that can be critical for achieving desired health system goals and are often of limited usefulness when applied to complex health systems. Researchers and health care decision makers can either underestimate or fail to consider the interactions among the people, processes, technology, and facility designs. Health care delivery system interventions need to incorporate the dynamics and complexities of the health care system context in which the intervention is delivered. This report provides an overview of common dynamic simulation modeling methods and examples of health care system interventions in which such methods could be useful. Three dynamic simulation modeling methods are presented to evaluate system interventions for health care delivery: system dynamics, discrete event simulation, and agent-based modeling. In contrast to conventional evaluations, a dynamic systems approach incorporates the complexity of the system and anticipates the upstream and downstream consequences of changes in complex health care delivery systems. This report assists researchers and decision makers in deciding whether these simulation methods are appropriate to address specific health system problems through an eight-point checklist referred to as the SIMULATE (System, Interactions, Multilevel, Understanding, Loops, Agents, Time, Emergence) tool. It is a primer for researchers and decision makers working in health care delivery and implementation sciences who face complex challenges in delivering effective and efficient care that can be addressed with system interventions. On reviewing this report, the readers should be able to identify whether these simulation modeling methods are appropriate to answer the problem they are addressing and to recognize the differences of these methods from other modeling approaches used typically in health technology assessment applications.