modeling an integrated system for obesity & weight management

Modeling an Integrated

System for Obesity and

Weight Management

David Gilding

Public Health Information and Intelligence

Nottinghamshire County Council

Anne Pridgeon, Policy lead


SIMUL8 Corporation | SIMUL8.com | [email protected]

1 800 547 6024 | +44 141 552 6888

Presenters

David Gilding

Public Health Information and Intelligence


[email protected]

Claire Cordeaux

Executive Director, Healthcare

SIMUL8 Corporation

[email protected]

mailto:[email protected]



Housekeeping

• Audio

• Q and A

• Recording available on

simul8healthcare.com

Nottinghamshire County

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Population approx. 780,000 people. Some areas are very affluent, others deprived.Parts of Bassetlaw, Newark and Sherwood very rural – others ex-coalminingConurbation around Nottingham City.

The National Health Service & Public health

Background

• Prior to 2013, obesity and weight management was the responsibility of Primary Care Trusts (PCTs)

• These were NHS organisations who commissioned – not provided –care

• The local Public Health system was part of PCTs

• In April 2013, local Public Health transferred to local Government

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Changes to NHS & Public healthApril 2013

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LAP

H

Changes to NHS & Public healthWho commissions obesity and weight management?

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LAP

H

Obesity and weight management – tender and procurement process

Challenges

• Nottinghamshire has adopted a whole system approach

• one tender for prevention and all levels of intervention and

treatment for all aged over 5.

• Focus on pregnant women

• We also want an outcomes based commissioning approach

• Parts of the system are commissioned through national specialist

commissioning functions

• Each of these has implications for modelling and simulation

• As far as we know, no other LA has commissioned on this basis

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A whole system approach


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Weightwatchers, Slimming world,

Rosemary Conley etc‘We’ll help you lose

weight’

GPs‘You need to lose 7

kilos’

Who can I refer to?

Exercise referral schemes

We can help you exercise more - if you

live locally

Bariatric surgeryDemand is much

greater than capacity

Who’s going to

pay?

Specialist treatmentWho is responsible?

Who will pay?


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weight’


kilos’

Who can I refer to?



live locally



Who’s going to

pay?


Who will pay?Public HealthRising prevalence overweight and obesity

Dispersed and disjointed servicesNo system leadership

Long-term health consequences


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weight’


kilos’

Who can I refer to?



live locally



Who’s going to

pay?


Who will pay?

Commission a whole system approach

Modelling challenges

• Estimate need• Children aged 5 to 17, adults aged 18 or older, pregnant women

• Build a NICE compliant model

• How to commission affordable numbers of clients, given no precedent for this pathway

• Clients are likely to be in the system for up to 2,3,4 years;• how will this affect provider stability, payments and cashflow

(provider and commissioner)• arrangements at end of contract

• How might successful, sustained weight loss by individuals affect prevalence of overweight/ obesity in Nottinghamshire?

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Estimating need

Estimating need

• We don’t have counts of obese and overweight people

• Need to estimate from national and regional surveys and estimates

• This is even harder when talking about health need as onepart of obesity & overweight

• We need an overall idea of scale

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Estimating need – changing obesity profile in England

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Hypertensive Not hypertensive

BMI category Low High Very high BMI category Low High Very high

Under 2,121 0 0 Under 7,695 0 0

Normal 36,369 8,247 1,265 Normal 148,597 34,648 5,381

Overweight 14,523 25,574 22,918 Overweight 39,973 71,202 65,272

Obese 1 (30to35) 0 6,338 58,342 Obese 1 (30to35) 0 3,324 38,895

Obese 2 (35 to40) 0 0 23,262 Obese 2 (35 to40) 0 0 12,525

Obese 3 (40+) 0 0 11,416 Obese 3 (40+) 0 0 4,893

Waist Waist

All

Increased risk 85,725

High risk 94,171

Very high risk 178,589 of whom BMI>=40 16,309

'Pathway eligible' 358,485

Obesity and overweight vs health riskNICE ‘health risk’ categories

• Waist circumference as risk factor• Comorbidities as risk factor• 3 categories: increasing, high and very high risk

Nottinghamshire numbers:

Hypertensive Not hypertensive

BMI category Low High Very high BMI category Low High Very high

Under 2,121 0 0 Under 7,695 0 0

Normal 36,369 8,247 1,265 Normal 148,597 34,648 5,381

Overweight 14,523 25,574 22,918 Overweight 39,973 71,202 65,272

Obese 1 (30to35) 0 6,338 58,342 Obese 1 (30to35) 0 3,324 38,895

Obese 2 (35 to40) 0 0 23,262 Obese 2 (35 to40) 0 0 12,525

Obese 3 (40+) 0 0 11,416 Obese 3 (40+) 0 0 4,893

Waist Waist

All

Increased risk 85,725

High risk 94,171

Very high risk 178,589 of whom BMI>=40 16,309

'Pathway eligible' 358,485

Obesity and overweight vs health riskNICE ‘health risk’ categories

• Waist circumference as risk factor• Comorbidities (especially diabetes, high blood

pressure) as risk factor• 3 categories: increasing, high and very high risk

Nottinghamshire numbers:


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Modellinghypothetical pathway (s)

Obesity and weight management – modelling challenges

• Build conceptual models based on NICE guidance

• One for children aged 5 to 17

• Another for adults of any age

• Pregnancy

• These need to identify ‘successes’ in terms of successful outcomes

(to facilitate an outcomes based approach)

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Success for individual clients means:• Improved dietary intake• Improved physical activity• Improved mental health and wellbeing• Sustained weight loss (adults, not pregnant)• Appropriate weight maintenance or loss for

children & young people

LWM: lifestyle weight management

Assess Tier 2

Assess Tier 3

LWMSuccess

LWMSuccess

LWM

Not success

Specialist team

Orlistat

Not Orlistat

Success

Follow-up

Not success

Discharge

Bariatric assessment

Not eligibleor decline

Follow-up

Surgery

2-year follow-up

LA follow-up

Bar

iatr

ic a

sses

smen

t, s

urg

ery

& 2

-yea

r fo

llow

up

no

t in

sco

pe

Service entry

In scope Out of scope

Schematic of adult pathway used for modelling

This is a hypothetical, NICE compliant pathway that Nottinghamshire County Council has developed;your pathway may differ

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Simulation of the pathway

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Decided to use Scenario Generator

• Previous experience

• Good tool for modelling strategic pathways

• Includes ‘time-in-step’ and ‘time-in-system’ measures

• Can ‘loop’ pathways – cyclic systems

• Discrete event methodology matches individuals moving through

a system

• Access to ‘raw’ results data

• Graphical approach; easy communication

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Scenario Generator model

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Start

Veryhigh need

Highneed

Increasedneed

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Modelling long time-scalesFollow up after bariatric surgery• 2 years NHS provider• Then on to LAPH responsibility

Time in system

These are results of Nottinghamshire County Council modelling a NICE compliant pathway 28

Multiple ‘success’ pointsover several months years:Hard to estimate numbersin any one month/ year

Time in system

These are results of Nottinghamshire County Council modelling a NICE compliant pathway 29

Time in system

Because it’s a complicated system, with some elements taking months to complete, the time each client spends in the system can vary considerably.

To show this, if 1,000 adults and 1,000 children start tiers 2/3 in month 1,we estimate that they will exit the system as follows:

Adults:• 60% exit by end Y1• 90% by end Y2• A few into Y4• Tiers 2 and 3 only

CYP:• 71% exit by end Y1• 100% by end Y2• Tiers 2 and 3 only

These are results of Nottinghamshire County Council modelling a NICE compliant pathway

Nu

mb

er o

f ex

its

Nu

mb

er o

f ex

its

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Patients in system – different pathways

If we assume a constant number of adults and CYP starting each month,then the estimated profile of patients in the system each month is as follows

These are results of Nottinghamshire County Council modelling a NICE compliant pathway; your pathway may differ 31

Patients in system – all pathways

Estimated profile of patient / service user numbers: adults and CYP in tiers 2/3, maternity and post-bariatric support

These are results of Nottinghamshire County Council modelling a NICE compliant pathway

Our modelling suggests that patient numbers - and provider activity – will peak in Y4 of contract

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Conclusions

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• Successful tender awarded in December

• Service live from April 2015

• Assurance for commissioners

• Provider appreciates the detailed modelling

• Volumes flow over long-term

• Anticipate end-of-contract effects

• Shared risk: ‘all models are useful, no models are right’

• Scenario Generator was a useful tool in the modelling process

• But we expect available resources far outstripped by demand…


QUESTIONS

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