ADA, Kaiser using modeling in DM efforts

Web site will recommend customized treatments

A new web site designed by the American Diabetes Association (ADA) in Alexandria, VA, and Kaiser Permanente in Oakland, CA, will recommend customized treatment plans for diabetes patients. The plan uses a complex software program called Archimedes to model health care outcomes.

ADA officials say physicians with a patient, or the patient alone, could go to the web site, enter health information, and get back an optimized program of steps for treatment within 10 minutes.

Archimedes is a complex model of the American health care system that medical researchers use to study questions about costs and best-treatment recommendations. The Gateway computer company will help run the massive program, which can take hundreds of hours on a single computer, by donating the use of "idle" computers in its retail stores.

The advantages of modeling

Medical modeling is a superior approach to disease management, says Richard Kahn, PhD, the ADA’s chief scientific and medical officer.

"Modeling in general means being able to simulate the real world so we can predict events to come," notes Kahn. "In the medical arena, that means medical events, particularly outcomes like heart attacks, strokes, and other untoward events." Much human thinking is actually a form of modeling, he explains. "Thinking about a trip to the drug store, considering how much time you have and whether you can make it back home by a certain time — that’s a way of modeling," Kahn says.

What are the benefits of medical modeling? "For many reasons, individual physicians and patients present with unique circumstances, conditions or situations; they do not neatly fit into [broad conclusions reached in] clinical trials that have been done. If they did, one could say these are the exact odds of things happening to you if you do X, Y, or Z."

For example, he notes, there have never been clinical trials on smoking that randomized people to different smoking habits and then examined the outcomes. "From a lot of different studies, people have pulled together predictive’ information," he says.

"The question is the degree to which you can accurately predict what will happen given the known variables," Kahn continues. "When you have a half-hour to get to the drug store, you may consider what the weather is like and the type of transportation are you taking, but you might discount whether you could have an accident, if there’s enough gasoline, if the hoses and fan belts are in good shape, whether there will be a line, or even whether the store will have your product."

Modeling, math, and computers, says Kahn, allow medical researchers to take into account a much larger number of such variables than a single human mind can and factor them into the equation to give a much more accurate picture.

Kaiser Permanente uses other methods of modeling in addition to Archimedes, says Jed Weissberg, MD, associate executive director for quality at Kaiser Permanente.

"We have access to a number of tools, such as DxCG [Diagnostic Care Groups]," he notes. "As opposed to just being controlled for age and sex, which can predict only 5% of subsequent utilization, this can boost it to 20%-30%."

He says since Kaiser Permanente already has a wealth of information about individuals, this type of modeling is being used instead to help determine risk-adjusted premiums for groups. "Since we are an integrated delivery system, we already know who’s not doing well and who needs more intensive work," he explains.

Not there yet

Modeling is still in its infancy, Kahn concedes, and much of it leaves a lot to be desired.

"When modeling takes into account as many factors as it does, the person who wants the information wants to know if you are right and wants to see some testing that shows you have been right in the past," he observes. "Unfortunately, all models up to now don’t have independent validation that they have weighed all the relevant factors."

Archimedes, however, does all of that, and it weighs more factors than any other model by far, says Kahn.

"Equally important, we see that it is really accurately predictive," he says.

"Archimedes uses bio-mathematical simulation employing differential equations and complex mathematics to project a virtual population based on evidence from clinical trials," adds Weissberg. "Its great strength has been starting with that information and then prospectively predicting outcomes of trials that have not yet been input."

Weissberg calls this "quite a remarkable test" of such a program.

A program like Archimedes can contribute to improved outcomes in two ways, says Kahn. "First, we can use it to design our clinical practice recommendations, because we can confidently predict the right results. Clinicians have been asking for this type of information, but up till now, our recommendations have come from a bunch of people sitting around a table and modeling."

The second thing Archimedes does is to allow users to enter a patient’s individual circumstances, conditions, and history and then to obtain predictions of likely health outcomes, both with and without possible interventions.

"Archimedes is used primarily for up-front information for clinicians trying to weigh interventions," Weissberg explains. "It helps give a richness to our clinical practice guidelines. It can also be a very powerful motivator for behavior change."

The seed money for the initial efforts on Archimedes was provided by Kaiser, says Kahn. "More recently, the money to enhance it and make it more robust was provided by Bristol-Myers Squibb."

"At present, Archimedes has been mostly developed for diabetes, but we are working on other modules for cardiovascular disease," Weissberg notes. "Our intent is to develop it to the point where it covers the bulk of chronic illnesses."

While Kaiser Permanente’s primary goal is naturally to benefit the health of its patients, it also has more far-ranging goals. "This information will be in the public domain," Weissberg says. "Our intent is to really advance scientific modeling and chronic care management."

The ADA hopes the Archimedes web site will start offering the free customized service during the first half of 2004.

Need More Information?

For more information, contact:

• Richard Kahn, PhD, Chief Scientific and Medical Officer, American Diabetes Association, 1701 North Beauregard St., Alexandria, VA 22311. Telephone: (703) 299-2065.

• Jed Weissberg, MD, Associate Executive Director for Quality, Kaiser Permanente, Oakland, CA. Telephone: (510) 271-6432.