Post on 13-Jan-2016
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The Dynamics of Upstream and Downstream
CDC Futures Health Systems Workgroup
December 3, 2003
Bobby MilsteinSyndemics Prevention Network, CDC
Bmilstein@cdc.gov
http://www.cdc.gov/syndemics
Jack HomerHomer Consulting
Jhomer@comcast.net
http://www.homerconsulting.com
Why is it so hard for the public health system to work upstream, and what can be done about it?
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Public Health Effort Across the Chain
Upstream Prevention and Protection-----------------------------------Total 3%
Downstream Care and Management--------------------------------Total 97%
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The Simple Physics of Upstream and Downstream
Safer, Healthier
Population Becomingvulnerable
Becoming no longervulnerable
VulnerablePopulation
BecomingAfflicted
Afflictedwithout
Complications DevelopingComplications
Afflicted withComplications
Dying fromComplications
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Why focus on “affliction”?
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Focusing on disease prevention and control
has led to major achievements
600
500
400
200
100
501950 1960 1970 1980 1990 1995
Rate if trend continued
Peak Rate
Actual Rate
Age-a
dju
sted D
eath
Rate
per
10
0,0
00
Popula
tion
1955 1965 1975 1985
300
700
Year
Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998
Marks JS. The burden of chronic disease and the future of public health. CDC Information Sharing Meeting. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion; 2003.
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Source: Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. National Center for Chronic Disease Prevention and Health Promotion, 2003. Accessed March 21 at <http://apps.nccd.cdc.gov/HRQOL/>.
But the pictures look different when we examine people’s overall state of health or affliction
14% increase
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Why Do We Do Public Health Work?What is the System Organized to Do?
CDC Vision & Mission
Healthy people, in a healthy world, through prevention
To promote health and quality of life by preventing and controlling
disease, injury, and disability
CDC Vision & Mission
Healthy people, in a healthy world, through prevention
To promote health and quality of life by preventing and controlling
disease, injury, and disability
Institute of Medicine
The purpose of public health is to fulfill society’s interest in
assuring the conditions in which people can be healthy
Institute of Medicine
The purpose of public health is to fulfill society’s interest in
assuring the conditions in which people can be healthy
How we reconcile these two frames of reference will shape the possibilities for what we can accomplish in leading health system change.
A systems approach understands that both perspectives exist in a dynamic relationship with each other.
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“When we attribute behavior to people rather than system structure the focus of management becomes
scapegoating and blame rather than the design of organizations in which ordinary people can achieve
extraordinary results.”
-- John Sterman
Sterman J. System dynamics modeling: tools for learning in a complex world. California Management Review 2001;43(4):8-25.
Why Has it Been So Hardto Correct the Imbalance?
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more inter-organizationally complex, slower rate of improvement
organizationally complex, faster rate of improvement
What Kinds of Work Must the Public Health System Perform?
Public Work (organizing, governance, citizenship, mutual accountability)
Professional Work (customers, products, services)
FOR SELF INTEREST FOR OTHERS IN NEED
Safer,Healthier
Population BecomingVulnerable
Becoming nolonger vulnerable
VulnerablePopulation Becoming
Afflicted
Afflictedwithout
Complications DevelopingComplications
Afflicted withComplications
Targetedprotection
Primaryprevention
Secondaryprevention
Dying fromComplications
Tertiaryprevention
Society's HealthResponse
Generalprotection
Adverse LivingConditions
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“Let me assure you, we will survive any crisis that involves funding, political support, popularity, or
cyclic trends, but we can't survive the internal crisis, if we become provincial, focus totally on the short term,
or if we lose our philosophy of social justice.”
-- Bill Foege
Foege WH. Public health: moving from debt to legacy. American Journal of Public Health 1987;77(10):1276-8.
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Beyond the Obvious Morality of it, Why Place So Much Emphasis on Social Justice?
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What Drives Change Across the Chain?
VulnerablePopulation
BecomingAfflicted
Afflictedwithout
Complications DevelopingComplications
Afflicted withComplications
Dying fromComplications
Safer, Healthier
Population Becomingvulnerable
Becoming no longervulnerable
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Upstream and Downstream Work
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Downstream/Professional work
Professionalconcern
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Upstream and Downstream Work
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onprogression
-
Effect oncomplications
-
TertiaryPrevention
SecondaryPrevention
Downstream/Professional work
Professionalconcern
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Upstream and Downstream Work
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onprogression
-
Effect oncomplications
-
TertiaryPrevention
SecondaryPrevention
Vulnerable andAfflicted Popn
Upstream/Public work
Downstream/Professional work
Professionalconcern
Publicconcern
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Upstream and Downstream Work
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onincidence
-
Effect onprogression
-
Effect oncomplications
-
Effect onvulnerabilityreduction
TargetedProtection
TertiaryPrevention
SecondaryPrevention
PrimaryPrevention
Vulnerable andAfflicted Popn
Upstream/Public work
Downstream/Professional work
Professionalconcern
Publicconcern
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Upstream and Downstream Work
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onincidence
-
Effect onprogression
-
Effect oncomplications
-
Effect on livingconditions
Effect onvulnerabilityreduction
GeneralProtection
TargetedProtection
TertiaryPrevention
SecondaryPrevention
PrimaryPrevention
Vulnerable andAfflicted Popn
Upstream/Public work
Downstream/Professional work
Professionalconcern
Publicconcern
AdverseLiving
Conditions
-
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Upstream and Downstream Work
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onincidence
-
Effect onprogression
-
Effect oncomplications
-
Effect on livingconditions
Effect onvulnerabilityreduction
GeneralProtection
TargetedProtection
TertiaryPrevention
SecondaryPrevention
PrimaryPrevention
Vulnerable andAfflicted Popn
Upstream/Public work
Downstream/Professional work
Professionalconcern
Publicconcern
AdverseLiving
Conditions
-
PublicStrength
Citizen Involvementand Organizing
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Upstream and Downstream Work
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onincidence
-
Effect onprogression
-
Effect oncomplications
-
Effect on livingconditions
Effect onvulnerabilityreduction
GeneralProtection
TargetedProtection
TertiaryPrevention
SecondaryPrevention
PrimaryPrevention
Vulnerable andAfflicted Popn
Upstream/Public work
Downstream/Professional work
Professionalconcern
Publicconcern
AdverseLiving
Conditions
-
PublicStrength
SocialDisparity
-
Citizen Involvementand Organizing
SocialDivision
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Upstream and Downstream Work
Downstream lock-in: Delay in upstream effort guarantees continued growth in affliction, need for downstream effort and, hence, dependency on professionals, which further undermines upstream effort, as does mounting social disparity.
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onincidence
-
Effect onprogression
-
Effect oncomplications
-
Effect on livingconditions
Effect onvulnerabilityreduction
GeneralProtection
TargetedProtection
TertiaryPrevention
SecondaryPrevention
PrimaryPrevention
Vulnerable andAfflicted Popn
Upstream/Public work
Downstream/Professional work
Professionalconcern
Publicconcern
AdverseLiving
Conditions
-
PublicStrength
SocialDisparity
-
Citizen Involvementand Organizing
SocialDivision
-
Dependency onProfessionals
Citizen exclusionand complacency
-
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Dynamic Models Let Us Search for Policies That Leverage Public Work
• Computer technology makes it feasible to put system maps in motion, to learn how health patterns change under different conditions, and to seriously evaluate or rehearse the long-term effects of response options: they provide added foresight
• Such models open new avenues for domestic and global problem solving, systems research, knowledge integration, game-based learning, as well as richer dialogue among stakeholders
Prototype of a health system simulation model
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CDC’s Strength Lies in Leading Public Work
• CDC’s credibility and effectiveness rest on more than scientific excellence
• The agency’s reputation also stems from the widespread perception that CDC is an organization of talented people working to protect us all: a people’s institution
• If CDC comes to be viewed primarily as a provider of products/services to customers in need, it could erode leadership potential for upstream action
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SummaryWhy is it So Hard to Work Across the Whole System?
Initial Observations
• Upstream work requires more public concern, which is less a reaction to the prevalence of disease as to the spread of vulnerability and affliction that over many years threaten everybody (think of economic decline, inadequate education, unsafe housing, sprawl, racism, environmental decay, etc.)
• Long before upstream threats become widely apparent, money and other resources have focused downstream (where professional expertise and the weight of scientific evidence lie)
• Because of their role as providers of downstream services, health professionals do not respond to vulnerability and social disparity FOR ITS OWN SAKE, in the WAY that ordinary citizens often do
• Upstream health action involves broad-based organizing; it is political—but non-partisan—and cannot be done by professionals alone.
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"The people's health...is a concern of the people themselves. They
must want health. They must struggle for it and plan for it.
Physicians are merely experts whose advice is sought in drawing up
plans and whose cooperation is needed in carrying them out. No
plan, however well devised and well intentioned, will succeed if it is
imposed on the people. The war against disease and for health
cannot be fought by physicians alone. It is a people's war in which
the entire population must be mobilized permanently."
Sigerist, HE. Health. Journal of Public Health Policy., 1996 17(2): 204-234.
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Prototype of a Dynamic Simulation Model
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Steps For Putting the Map in Motion
• Start with an explicit dynamic hypothesis (i.e., what causal forces are at work?)
• Convert that hypothesis into a formal computer model (i.e., by writing a system of differential equations; and calibrating it based on all available data; areas of uncertainty are noted and become the focus for sensitivity analysis)
• Use the computer model to conduct controlled simulation studies, with the goal of learning how the system behaves and how to govern its evolution over time
• Iteratively repeat the process, creating better hypotheses, better models, and better policy insight
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Building a Dynamic Hypothesis
GeneralPopulation Vulnerability
onset
Vulnerabilityreduction
VulnerablePopulation Affliction
incidence
Afflictedwithout
Complications Afflictionprogression
afflicted percent of
Public healthresponse
Complicated
popn
-
General protectioneffect on vulnerability
onset
B General Protection
Targeted protectioneffect on vulnerability
reduction
B Targeted Protection
Afflicted withComplications
Death fromComplications
-
Secondary preventioneffect on progression
B
SecondaryPrevention
Primary preventioneffect on incidence
-
B
Primary Prevention
Tertiary preventioneffect on
complications
-
B
Treatment
Note: for this initial model, the system being modeled includes only a subset of the dynamics that were identified in the conceptual map.
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Could the behavior of this system be modeled using conventional epidemoiological methods (e.g., logistic or multi-level regression)?
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Active Equations (01) Afflicted = Afflicted without Complications + Afflicted with Complications
(02) Afflicted with Complications = INTEG( Affliction progression - Death from Complications , 0)
(03) Afflicted without Complications = INTEG( Affliction incidence - Affliction progression , 0)
(04) Affliction incidence = Vulnerable Popn * Affliction incidence rate baseline * Primary prevention effect on incidence
(05) Affliction incidence rate baseline = 0.05
(06) Affliction progression = Afflicted without Complications * Affliction progression rate baseline * Secondary prevention effect on progression
(07) Affliction progression rate baseline = 0.1
(08) Complicated afflicted percent of popn = 100 * Afflicted with Complications / Total popn
(09) Complicated afflicted percent required to elicit maximum PH response = 20
(10) Complicated percent of afflicted = 100 * ZIDZ ( Afflicted with Complications , Afflicted )
(11) Complications death rate baseline = 0.1
Writing Differential Equations
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(12) Death from Complications = Afflicted with Complications * Complications death rate baseline * Tertiary prevention effect on complications
(13) General Popn = INTEG( Net increase in genl popn + Vulnerability reduction - Vulnerability onset , Total popn initial * ( 100 - Vulnerable percent initial ) / 100)
(14) General protection effect from max PHR = 0.5
(15) General protection effect on vulnerability onset = 1 - ( 1 - General protection effect from max PHR ) * Public health response / 100
(16) Net increase in genl popn = Death from Complications * ( 1 - Vulnerable percent of nonafflicted / 100)
(17) Net increase in vulnerable popn = Death from Complications * Vulnerable percent of nonafflicted / 100
(18) Nonafflicted = General Popn + Vulnerable Popn
(19) Primary prevention effect from max PHR = 0.5
(20) Primary prevention effect on incidence = 1 - ( 1 - Primary prevention effect from max PHR ) * Public health response / 100
(21) Public health response = DELAY1I ( 100 * MIN ( 1, Complicated afflicted percent of popn / Complicated afflicted percent required to elicit maximum PH response ) , Time for public health to respond to affliction prevalence , 0)
Writing Differential Equations
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(22) Secondary prevention effect from max PHR = 0.5
(23) Secondary prevention effect on progression = 1 - ( 1 - Secondary prevention effect from max PHR ) * Public health response / 100
(24) Targeted protection effect from max PHR = 2
(25) Targeted protection effect on vulnerability reduction = 1 + ( Targeted protection effect from max PHR - 1) * Public health response / 100
(26) Tertiary prevention effect from max PHR = 0.5
(27) Tertiary prevention effect on complications = 1 - ( 1 - Tertiary prevention effect from max PHR ) * Public health response / 100
(28) Time for public health to respond to affliction prevalence = 2
(29) Total popn = Nonafflicted + Afflicted
(30) Total popn initial = 100000
(31) Vulnerability onset = General Popn * Vulnerability onset rate baseline * General protection effect on vulnerability onset
(32) Vulnerability onset rate baseline = 0.05
Writing Differential Equations
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(33) Vulnerability reduction = Vulnerable Popn * Vulnerability reduction rate baseline * Targeted protection effect on vulnerability reduction
(34) Vulnerability reduction rate baseline = 0.07
(35) Vulnerable percent initial = 10
(36) Vulnerable percent of nonafflicted = 100 * Vulnerable Popn / Nonafflicted
(37) Vulnerable Popn = INTEG( Net increase in vulnerable popn + Vulnerability onset - Affliction incidence - Vulnerability reduction , Total popn initial * Vulnerable percent initial / 100)
Writing Differential Equations
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Parameter Assumption
Population Characteristics
• Total population initially 100,000
• Percent afflicted initially 0%
• Percent vulnerable initially 10%
Developing Assumptions For Response Scenarios
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Parameter Assumption
Baseline Epidemiological Characteristics
• Vulnerability onset rate (% per year among general pop) 5%
• Vulnerability reduction rate (% per year among vulnerable) 7%
• Affliction incidence rate (% per year among vulnerable) 5%
• Affliction progression rate (% per year among afflicted without complications)
10%
• Complications death rate (% per year among afflicted with complications)
10%
Developing Assumptions For Response Scenarios
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Parameter Assumption
Public Health System Characteristics
• Complicated affliction prevalence required to elicit maximum public health response (lower prevalence elicits proportionally smaller response)
20%
• Time for organizing a public health response to complicated affliction prevalence
2 years
Developing Assumptions For Response Scenarios
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Parameter Assumption
Effect of Public Health Responses
• Tertiary prevention effect on deaths from complications ?
• Secondary prevention effect on affliction progression ?
• Primary prevention effect on affliction incidence ?
• Targeted protection effect on vulnerability reduction ?
• General protection effect on vulnerability onset ?
Making Decisions About How to Respond
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Response Scenario
Effect of Public Health Response on…
40-Year Simulation Results
DeathsAfflictio
n Progress
Affliction Incidence
Vulnerable Reduction
Vulnerable Onset
Percent
Afflicted w/ Complication
(T0 = 0%)
Percent Vulnerable
(T0 = 10%)
PH Response
(T0 = 0%)
No Response 1 1 1 1 1
Prev 3 0.5 1 1 1 1
Prev 2+3 0.5 0.5 1 1 1
Prev 1+2+3 0.5 0.5 0.5 1 1
Prev 1+2+3
Prot 20.5 0.5 0.5 2 1
Prev 1+2+3 +
Prot 1+20.5 0.5 0.5 2 0.5
Developing a Scenario-based Research Design
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Putting the System in Motion
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Afflicted with Complications
20,000
10,000
0
0 4 8 12 16 20 24 28 32 36 40Time
Afflicted with Complications : NoRespAfflicted with Complications : Prev3Afflicted with Complications : Prev23Afflicted with Complications : Prev123Afflicted with Complications : Prev123Prot2Afflicted with Complications : Prev123Prot12
Interpreting Behavior Over Time
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Effect of Public Health Response on…
40-Year Simulation Results
DeathsAfflictio
n Progress
Affliction Incidence
Vulnerable Reduction
Vulnerable Onset
Percent
Afflicted w/ Complication
(T0 = 0%)
Percent Vulnerable
(T0 = 10%)
PH Response
(T0 = 0%)
No Response 1 1 1 1 1 11%
Prev 3 0.5 1 1 1 1 14%
Prev 2+3 0.5 0.5 1 1 1 12%
Prev 1+2+3 0.5 0.5 0.5 1 1 11%
Prev 1+2+3
Prot 20.5 0.5 0.5 2 1 10%
Prev 1+2+3 +
Prot 1+20.5 0.5 0.5 2 0.5 9%
Interpreting Behavior Over Time
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Vulnerable Popn
40,000
32,000
24,000
16,000
8,000
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40Time
Vulnerable Popn : NoRespVulnerable Popn : Prev3Vulnerable Popn : Prev23Vulnerable Popn : Prev123Vulnerable Popn : Prev123Prot2Vulnerable Popn : Prev123Prot12
Interpreting Behavior Over Time
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Effect of Public Health Response on…
40-Year Simulation Results
DeathsAfflictio
n Progress
Affliction Incidence
Vulnerable Reduction
Vulnerable Onset
Percent
Afflicted w/ Complication
(T0 = 0%)
Percent Vulnerable
(T0 = 10%)
PH Response
(T0 = 0%)
No Response 1 1 1 1 1 11% 25%
Prev 3 0.5 1 1 1 1 14% 24%
Prev 2+3 0.5 0.5 1 1 1 12% 24%
Prev 1+2+3 0.5 0.5 0.5 1 1 11% 26%
Prev 1+2+3
Prot 20.5 0.5 0.5 2 1 10% 22%
Prev 1+2+3 +
Prot 1+20.5 0.5 0.5 2 0.5 9% 19%
Interpreting Behavior Over Time
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Public health response
80
64
48
32
16
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40Time
Public health response : NoRespPublic health response : Prev3Public health response : Prev23Public health response : Prev123Public health response : Prev123Prot2Public health response : Prev123Prot12
Interpreting Behavior Over Time
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Effect of Public Health Response on…
40-Year Simulation Results
DeathsAfflictio
n Progress
Affliction Incidence
Vulnerable Reduction
Vulnerable Onset
Percent
Afflicted w/ Complication
(T0 = 0%)
Percent Vulnerable
(T0 = 10%)
PH Response
(T0 = 0%)
No Response 1 1 1 1 1 11% 25% 0%
Prev 3 0.5 1 1 1 1 14% 24% 69%
Prev 2+3 0.5 0.5 1 1 1 12% 24% 60%
Prev 1+2+3 0.5 0.5 0.5 1 1 11% 26% 53%
Prev 1+2+3
Prot 20.5 0.5 0.5 2 1 10% 22% 50%
Prev 1+2+3 +
Prot 1+20.5 0.5 0.5 2 0.5 9% 19% 47%
Interpreting Behavior Over Time