Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System Workshop Summary (2009) / Chapter Skim
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6 Suggestions for Analysis Plans by Working Groups
6 Suggestions for Analysis Plans by Working Groups
Pages 81-120
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From page 81... ...
Measurement and forecasting of demand for TBI care 5. TBI care system capacity, organization, and resource allocation The committee then converted the stakeholder issues in these five categories into two or three issues for OSE analysis (i.e., analytical challenges that, if addressed effectively through OSE approaches, would answer important questions and help improve the performance of TBI care)
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From page 82... ...
• A.2. Develop an acute-to-chronic disease model of mild trau matic brain injury (mTBI)
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From page 83... ...
Each group had a chairperson who served as the technical lead, a rapporteur who was responsible for summarizing and communicating the technical aspects of the group's approach, and several experts in relevant subject matter. The group was asked to review its assigned tasks; modify them as appropriate; and develop analysis plans for a study, method, or means of data collection.
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From page 84... ...
Finally, each analysis plan included expected output, implementation actions, estimates of duration, and resource requirements. The following summaries of the suggestions for analysis plans are based on presentations by the chair and rapporteur of each group.
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From page 85... ...
Issue 1: Methods of Measuring Brain Vital Signs Issue 1 focuses on the development of methods of measuring brain vital signs in patients with blast and/or concussive injuries, that is, patients with TBI from blast, blast plus concussion, and concussion alone. The suggested technical approach includes animal and human studies using neuroimaging, neuropsychological testing, and neuropathology assessments to (1)
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From page 86... ...
Critical assumptions associated with the analysis plan described above include the capability of MRI at one echelon (at least) in theater; standardization of imaging and support of data collection at Level II through V facilities; and the availability of a technically competent staff.
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From page 87... ...
In addition, research proposals would have to be developed to support the proposed animal experiments. Expected outputs include a determination of the differences between mild blast, mild concussive, and mild blast plus concussive injuries as revealed by MRI and neuropsychological measures; the classification of characteristics of mTBI patients who need additional medical surveillance and/or treatment; and the identification of temporal characteristics of blast/concussive exposure and longitudinal outcomes.
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From page 88... ...
The overall goal is to establish a baseline frame of reference for detecting changes in the state space. Thus the approach for this analysis plan would involve enumerating the characteristics of a TBI event, comorbidities, treatment, and baseline characteristics of each victim.
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From page 89... ...
Data on the forensics of TBI events, including relative location of the blast to the soldier and the type of vehicle the soldier was in when the blast occurred, would also be necessary to define the state at the conclusion of the event. Critical assumptions for this analysis plan include (1)
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From page 90... ...
Performance, outcome, and utility metrics include identification of the characteristics of brain trauma events, primary clinical effects on humans, primary effects on brain structures and their impacts on humans, and long-term clinical effects on humans. To execute this approach, a federal program would have to be identified that would be responsible for receiving and archiving data, and a mandate or incentive system would have to be implemented to ensure that all traumatic brain events in the civilian sector were promptly reported to this agency.
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From page 91... ...
the development of systems engineering models for evaluating and improving the current TBI screening process, particularly for mTBI; and (2) the development of a predictive diagnostic model for mTBI (i.e., a means of estimating See Appendix G for names of working group members.
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From page 92... ...
Issue 1: Evaluate and Improve the Current TBI Screening Process In the first analysis plan developed by the working group, the expected outputs would be an improved understanding of how well the current screening and diagnostic processes work and mathematical models that suggest opportunities and requirements for improving them. Specifically, the models developed in the course of the proposed study would (1)
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From page 93... ...
The group identified several objectives for prescriptive optimization models. First, a model could be developed to minimize the total costs of the current screening process, including both the direct costs of screening and the costs associated with the potential harm from false positives and false negatives.
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From page 94... ...
Given our limited understanding of the sensitivity and specificity of the current screening process, one could begin by developing a simple probability model of the current process and use it to conduct "what if " analyses to get a better understanding of how well the system performs. Later, the model could be expanded into formal optimization frameworks, but typically a great deal can be learned about how to improve outcomes by using the model to conduct simple trialand-error inquiries.
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From page 95... ...
Screening m odels would require data on different kinds of screening tests and methods, their costs and risks, their false negative and positive rates, the costs of false negatives and false positives, transition probabilities, compliance rates, resource requirements, and the time required to run a test and reach a decision. Data would also be gathered on the overall screening process so that when different screening tests are integrated into a more complete screening process, the effectiveness of the whole process can be measured.
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From page 96... ...
. These requirements and constraints were drawn directly from the DVBIC Working Group on the Acute Management of Mild Traumatic Brain Injury in Military Operational Settings, Clinical Practice Guideline and Recommendations, dated December 22, 2006, which lists many key elements only some of which are called out here.
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From page 97... ...
The objective of the analysis plan is to address DOD's lack of a system-wide approach for tracking and monitoring TBI patients to e nsure the effective management of their complete care. Problems in the coordination of care have arisen between the MHS and VA and among all care providers at different levels of care and at different medical facilities (Cope et al., 2005; Sayer, 2006)
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From page 98... ...
Treatment or acute management of moderate or severe TBI is not as problematic as the long-term management of severe cases or the detection, tracking, and management of mTBI cases. The objective of the analysis plan is to improve communication and coordination of care so that all TBI patients get the right care at the right time in the right place by the right provider.
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From page 99... ...
The structure would have portals for access by multiple users, such as TBI patients, families, providers, MHS managers, and the general public. It would also have to be accessible from remote locations via portable wireless devices.
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From page 100... ...
Any plan designed to improve communication and coordination in the comprehensive delivery of TBI care for military personnel would be subject to major constraints. Cultural differences among the Army, Navy, Marines, Air Force, VA, and the private health care systems, reflecting mainly differences in tradition and mission, are barriers to transparent interoperability.
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From page 101... ...
Execution of this plan would require eight major tasks. The first, fundamental step is mapping the care process for TBI to identify and organize time, place, person, data requirements, and decision points.
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From page 102... ...
The director of the new Center for Psychological Health and Traumatic Brain Injury could play a leading role in implementing this plan. Clinical expertise could be drawn from the DVBIC staff, and engineering expertise would be available from sources internal to and external to DOD to facilitate process mapping and to provide advice on information technologies and OSE.
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From page 103... ...
Three specific analysis objectives were assigned to Working Group D First, based on historical data on mTBI, develop a statistical estimate of the number of mTBI cases in the population of military personnel who participated in OIF/OEF; second, develop a methodology for forecasting future mTBI cases in the military population, including new and previously undiagnosed cases; and third, develop the elements of, and a process for assessing the value of measures to prevent the occurrence of TBIs.
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From page 104... ...
have different levels of training and may be assigned different missions, which in turn may affect potential exposures to TBI events. 11 That is, is this the first time this unit has been there?
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From page 105... ...
model, which can be used not only to project future demands on health and benefits systems, but also to predict the possible effect of various protective measures. These may include advancements in technology (e.g., more protective helmets)
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From page 106... ...
military experience in a combat environment Answers to any of these questions could be incorporated into the models to refine the estimates. The third objective -- to develop elements of and a process for assess ing the value of preventing TBI -- is necessarily more complex than the first two, because prevention and injury mitigation can mean preventing TBI-causing events and/or providing better protective measures for mitigating injuries or keeping the health status of injured personnel from deteriorating by using best practices and new medical and other therapeutic technologies.
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From page 107... ...
, and resources. The purpose of the description is to inform the design of an approach to the development of a stand-alone model of the TBI care system or to enrich an existing enterprise-level health care delivery model that would include TBI system elements, care processes, and resources.
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From page 108... ...
are properly structured, it might point the way to the prospective design of a TBI system of care. However, much of the work of Group E was predicated on the output of models or analysis plans developed by Groups A through D
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From page 109... ...
Resource allocation would also be assessed for all levels of TBI severity, and process measures related to outcome metrics would be analyzed. Process characterizations in this analysis plan range from prevention to reintegration and include screening, diagnosis, treatment, and rehabilitation.
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From page 110... ...
The technical approach to this analysis plan involves the development of a description of elements, processes, and activities to represent the dynamics of a complete episode of mTBI care for use in modeling a TBI care system at the enterprise level. This includes an outline of the structure of a model or methodology to assist in planning for the allocation of scarce TBI care providers in theater and in CONUS.
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From page 111... ...
3. Give an educational sheet to all positive No mild TBI patients.
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From page 112... ...
Sensitivity analysis with early versions of the model can be used to help prioritize the need for additional information. In addition, standard modeling or computational engines involving standard representations must be used, and required data in existing information systems must be "capturable." Critical constraints of modeling for this analysis plan include the lack of knowledge about care paths and results, the lack of baseline comparison data, and problems with determining the sample size because of the large number of care paths.
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From page 113... ...
A necessary task for the execution of this analysis plan is a valuestream analysis for chronic mTBI. Currently, hundreds of soldiers per month "screen" positive for self-reported blast injuries and symptoms, with roughly 50 percent of these diagnosed as symptoms related to mTBI.
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The expected outputs for the proposed model include (1) the identification of processes that need improvement and suggestions for improving them; (2)
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Working Group C suggested an approach to the development of an information system for tracking, monitoring, and cueing care delivery for all TBI patients. The approach focuses on combining the integration and augmentation of existing databases and a communication system that would ensure access to information and the dissemination of information to appropriate parties; the system architecture would be compatible with the care delivery system.
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From page 116... ...
Information on effects of treatment Improved treatment processes and associated resource requirements FIGURE 6-2 Interrelationships among suggestions for analysis plans developed by participants in Working Groups A through E Figure S-1.eps landscape
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From page 117... ...
The analysis of data through data mining and the execution of surveys would be essential to the development of these models. Markov decision theory, Bayesian networks, influence diagrams, and simulation were cited as viable candidates for evaluating and designing TBI diagnostic and screening processes (see Appendix H)
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From page 118... ...
Particular quantitative methods and models could provide insights into the design of diagnostic and screening processes, the delivery of care, the sizing of facilities, and the design of the overall health care delivery complex to meet current and future demands. As depicted in Figure 6-2, the challenges addressed by the OSE analysis plans are interrelated with the outputs of each analysis plan potentially providing important inputs to the development of one or more of the other plans.
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From page 119... ...
. Presentation at the Workshop on Harnessing Operational Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System, National Academies, Washington, D.C.
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