Objective
To practice identifying dynamic complexity in a patient careexperience.
Instructions
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Read the case study.
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Review the system characteristics that contribute to dynamic
complexity:
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– Change
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– Trade-offs
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– History dependency
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– Tight coupling
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– Nonlinearity
For further explanation on these system characteristics, pleaserefer to J.D. Sterman, 2006, “Learning from Evidence in a ComplexWorld,” American Journal of Public Health 96 (3): 505–14.
3. Explain how these system characteristics are expressed in thecase study.
Case Study
This case is adapted from D. L. Kelly and S. L. Pestotnik’s 1998unpublished manuscript “Using Causal Loop Diagrams to FacilitateDouble Loop Learning in the Healthcare Delivery Setting.”
Mrs. B was a 66-year-old widow living on a fixed income. She hadbeen diagnosed with high blood pressure and osteoporosis. Herprivate doctor knew her well. When he selected the medication withwhich to treat her high blood pressure, he took into account herage, the fact that she had osteoporosis, and other issues. He chosea drug that had proven beneficial for patients such as Mrs. B andhad minimum side effects. Mrs. B did well on the medication for tenyears. Her insurance covered the cost of her medication, except fora small out-of-pocket copayment.
The last time Mrs. B went to her local pharmacy to refill herprescription, the pharmacist informed her that her insurancecompany had contracted with a pharmacy benefits management (PBM)company. (The role of a PBM company is to perform a variety ofcost-cutting services for health insurance plans. One of theseservices is to decide which drugs an insurance company will payfor; the PBM company’s preferred-product list is known as aformulary.) If Mrs. B wanted to continue to take the samemedication, it would cost her five times her usual copayment. Shewas quite disturbed because she could not afford this priceincrease and did not fully understand her insurance company’s newpolicy. The pharmacist offered to call Mrs. B’s doctor, explain thesituation, and ask him whether he would change her prescription tothe PBM-preferred brand. When the physician was contacted, he wasnot aware of the PBM company’s action and was not completelyfamiliar with the preferred product. The pharmacist discussed Mrs.B’s predicament with the physician and described the financialconsequences of continuing to receive her original prescription.After this discussion with the pharmacist, the physician concludedthat his only option was to approve the switch, which he did.
Mrs. B began taking the new brand of high blood pressuremedicine. One week after starting on the new drug, she developed apersistent cough that aggravated her osteoporosis and caused herrib pain. When the cough and pain continued for another week, Mrs.B began to take over-the-counter medicines for the pain. Sheunknowingly opened herself to a reaction between her blood pressuremedication and the pain medication: orthostatic hypotension(lightheadedness when rising from a lying to an upright position).One morning on her way to the bathroom, she fainted, fell, andbroke her hip. She was admitted to the hospital for surgery, whereshe developed a urinary tract infection. The infection spread toher repaired hip, which resulted in a bloodstream infection thateventually led to her death.
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