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The Connector
Issue: Fall 2011

Advance Management Group and iThink® Significantly Improve Care for Dialysis Patients

Jim Rogers
Jim Rogers

In 2007, Mayo Clinic in Rochester, Minnesota, engaged Advance Management Group (AMG) to develop a reporting system that would provide timely feedback on key performance indicators (KPIs) for their 15 dialysis care facilities. One critical KPI is the percentage of dialysis patients with hemoglobin (Hgb) levels in a target range. In fact, payment for services is now largely based upon that percentage. Now completed, the project gave rise to an important system dynamics application.

Systems Thinking Engenders a New Perspective for Healthcare Providers

"Hemoglobin enables every cell in the body to breathe," explains Jim Rogers, CEO of AMG. "It's critically dependent on EPO, a hormone that controls production of red blood cells that deliver it to the body. The kidneys of dialysis patients don't produce EPO as healthy kidneys do, so physicians administer synthetic EPO exogenously to achieve and maintain adequate hemoglobin levels. The problem was existing EPO protocols did not account for the dynamics of hemoglobin production."

The first few charts produced patterns of oscillations in Hgb levels over time for individual patients that were... signatures of a causal system with feedback and delay.

AMG advises clients that measurement leads to learning. When it came to measuring Hgb, the then current management system was focused on the most recent one or two measurements. As a part of the KPI reporting project, it was second nature for a Systems Thinker to take a look at readily available historical Hgb measurements. "We wanted to chart behavior for each patient's Hgb levels and related clinical measurements for extended periods of time," explains Rogers.

The first few charts produced patterns of oscillations in Hgb levels over time for individual patients that were amazing to AMG's Systems Thinkers. The observed swings above the target range (which carry increased risks of stroke and cardiovascular problems) and back down to levels below the target range (which lead to anemia) were signatures of a causal system with feedback and delay.

"All we had to do was to ask the right questions and create a model of the underlying system structure," explains Rogers. "If we could understand that, we might be able to develop EPO protocols to eliminate undesirable oscillations in hemoglobin."

In the summer of 2008, Mayo Clinic approved AMG's proposal to develop a simulation model of red blood cell production as influenced by exogenously administered EPO.

The Map and Simulation Model

Working with Mayo's anemia manager for dialysis patients and Dr. Ed Gallaher, an expert in modeling biophysical systems, the AMG team used iThink to create a preliminary map. The map presented a plausible theory of red blood cell production under the control of exogenous EPO doses.

But Gallaher realized the project needed to cross the boundary between nephrologists (kidney specialists) and hematologists (blood specialists). That crossing was made possible by the iThink map. "Our literature reviews had served up lots of technical descriptions of the system we were modeling, usually in the form of 5-10 pages of time delayed differential equations," explains Rogers. "Our 1-page stock and flow map laid out the proposed theory we'd developed which made it easy to present and discuss."

In fact, a hematologist who had never seen an iThink map or been exposed to Systems Thinking before was able to understand AMG's stock and flow map and make critical revisions in less than 15 minutes. "He corrected our theory by moving one connector from an inflow to an outflow," says Rogers.

"Over the past four years, iThink maps and models have played a key role in creating the most interesting and fulfilling project I've ever worked on over a 30-year working career."
— Jim Rogers, Advance Management Group

With that change in place, the AMG team soon had a simulation model up and running that could replicate individual patients' Hgb patterns over time in response to EPO dosing. The model could also find individualized EPO dosing regimens that would stabilize Hgb levels in any desired target range.

The Results

Mayo Clinic uses the iThink model to generate recommended EPO doses. These, in combination with expert clinical judgment, have enabled Mayo to increase the percentage of patients with Hgb in the target range from 40% to 80 - 90%. This is an industry leading result, placing Mayo in excellent position for years to come for pay for performance regulations currently being implemented.

Overall EPO doses have decreased by 40%. Annual savings amount to more than $1M per year.

More importantly, the quality of life for these patients has significantly improved. "Three 4-hour dialysis sessions per week, week in and week out, is a challenging lifestyle, indeed," explains Rogers. "Now, the majority of these patients are feeling much better. Their increased stamina, concentration, and frankly, hope, impact many areas of their lives. We couldn't be more pleased."

EPO is an expensive drug. Overall EPO doses have decreased by 40%. Annual savings amount to more than $1M per year.

And, having eliminated the swings in a patient's Hgb levels, physicians can now see and attend to small changes that were previously lost in the noise. This has improved the quality of care they now deliver.

The Role of iThink

Could these results have been achieved without using tools like iThink and Systems Thinking? Rogers doesn't think so. "First of all, the stock and flow map enabled a rich and effective dialogue about complex dynamics that couldn't have happened any other way. And, the simulation model has actually taught practitioners a whole new way of thinking about hemoglobin and EPO."

"iThink and Systems Thinking may well be the tools we need to bring about fundamental improvements in healthcare delivery systems that we must achieve."

Practitioners will tell you, "The new way of thinking extends far beyond maintaining Hgb levels for these patients. The clinical stability we've established provides a window into other issues for our dialysis patients that we just couldn't detect before. Beyond that, the methods we applied in this project are applicable to many other systems in the body."

As the word about this project has filtered out among MDs and Systems Thinking thought leaders, Rogers sums up the feedback he has personally received, "iThink and Systems Thinking may well be the tools we need to bring about fundamental improvements in healthcare delivery systems that we must achieve."

View YouTube Video (Part 1), Controlling Anemia in Hemodialysis Patients With System Dynamics, Part 1 of 2

View YouTube Video (Part 2), Controlling Anemia in Hemodialysis Patients With System Dynamics, Part 2 of 2

About isee systems ( — isee systems is the world leader and innovator in Systems Thinking software. Founded in 1985, isee released STELLA®, the first software application to bring Systems Thinking to the desktop. In addition to STELLA which is primarily used by educators, isee offers iThink® for business simulation. Thousands of individuals and organizations in over 80 countries use isee software to gain insight and shared understanding of environmental, financial, organizational, biological, chemical, mathematical, humanistic, and other systems.

About Advance Management Group ( — Advance Management Group helps organizations surface and sustainably improve the behavior of complex systems and processes. Its group of interdisciplinary professionals assists leaders in operationalizing insights using system dynamics principles and tools like STELLA® and iThink® from isee systems in order to advance toward creating the future they want for their organizations, one step at a time.

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