Process Cost Management of Alzheimer’s Disease
Round 1
Reviewer 1 Report
Paper title: Process cost management of Alzheimer's disease
Abstract
Summary needs 1-2 more explanatory sentences
1. Introduction
One would expect a stronger motivation for the current work. Why modeling the cost is essential? Any other AD cost related approaches? what is the expected contribution? I think this section should more strongly motivate the reader.
2. Theoretical background
It is a very interesting section, but the reader is not aware why there is an overview of AD in this paper. Only in the last sentence we are informed that the activities discussed are included in the models.
The authors should re-organise the section and argue from the beginning that this section the overview of the various AD aspects serves the purpose of model understanding.
3. Methods
-Please rename to "Process Modelling Approaches" or something suitable (and more descriptive)
-I am not convinced why System dynamics is selected in the AD modeling context... please elaborate
-section 3.2...."....however, it is ideal" (!) please avoid strong wording and also provide reasons for your selection (there is no such thing as "ideal" modelling technique, only one that is suitable/appropriate, etc.)
-"by the widest range..." -> "a wide range of..."
-I am not sure that the BPMN notation needs to be described in the paper... please refer the reader to thorough material regarfing BPMN. In case he is unfamiliar the descriptions in the paper are not helpful due to their brevity, in case he is familiar they are redundant (this applies also to the elements of the stock and flow diagram).
4. Costs identification
-please rename the section e.g. Identification of the AD main costs
-why the costs in Czech Republic are considered? isn't that limiting? what other papers identify as costs worldwide? from what I see the categories of costs can be further generalised (by provided relevant sources).
-section 4 needs elaboration and a better overall narrative. It is too short and does not convince the reader of how the costs were selected.
5. Results
Inspecting the BPMN diagrams in figures 2 and 3, I am not convinced of why it needs to be modeled: (a) as a business process and, (b) with BPMN in particular. The resulting BPMN diagrams do not resemble a typical business process... either provide more convincing arguements about your choice and its benefits or consider an entirely different approach.
section 6 is "Discussion and conclusion" and section 7 is "Conclusion". Please merge the sections into a single one.
I am not sure how the two different modeling approaches compare and what's the point of the second one... I think the paper lacks a "Methodology" section that helps the reader understand how this research was designed and what are its main steps so that we can follow the results. All the decisions and the research steps should go there. Section 5 needs only to guide the reader through the various results of the two approaches and compare them... but the reader needs to know what to expect and why.
Main findings:
"The results of this study are in keeping with the conclusions made by similar studies, that is, the costs of Alzheimer’s disease increase with the severity of the disease and the decline of the patient into later stages of the disease." ...isn't that fairly obvious? what new is your research bringing?
I think the conclusion need to focus more on the work presented in this paper, how it is contributing and the next steps.
Author Response
Dear Editor, Dear Reviewer,
Thank you for your letter and constructive comments concerning our manuscript. We have studied your comments carefully and made major corrections, which we hope to meet with your approval. We highlighted any text changes in the attached document. Please kindly help us to see the following contents :
Response to Reviewer 1 Comments
Point 1 :
Abstract - Summary needs 1-2 more explanatory sentences.
Response:
Thank you very much for your comments and suggestions. The abstract has been extended according to the modifications of the whole article.
Point 2:
Introduction
One would expect a stronger motivation for the current work. Why modeling the cost is essential? Any other AD cost related approaches? what is the expected contribution? I think this section should more strongly motivate the reader.
Response:
Thank you very much for your comments and suggestions. The introduction has been significantly extended. The motivation to address the costs of neurodegenerative diseases, the need to know the cost of patient care, the reason for choosing Alzheimer's disease and the description of other approaches in the field of health and social care are presented.
Point 3:
Theoretical background
It is a very interesting section, but the reader is not aware why there is an overview of AD in this paper. Only in the last sentence we are informed that the activities discussed are included in the models.
The authors should re-organise the section and argue from the beginning that this section the overview of the various AD aspects serves the purpose of model understanding.
Response:
Thank you very much for your comments and suggestions. Thank you for finding this section interesting. The whole section was reorganized. In the beginning, is a brief general introduction into the topic and then the introduction to Alzheimer's disease. The last part of this section discusses cost management approaches.
The key to specifying BPMN processes and identifying costs is a detailed specification of the activities, activities, and closure that need to be ensured in the treatment and care of people with dementia. Their specification is made in relation to the stage of the disease, which fundamentally influences the list of activities requiring assistance and the amount of medical care. Specification reflects the basic cost classification given in the method chapter. These two classifications (activities and costs) must correspond in the resulting models. This will prevent redundancies in calculations, or in future data collection as part of the use of the model.
Point 3:
Methods
-Please rename to "Process Modelling Approaches" or something suitable (and more descriptive)
Response:
Thank you very much for your comments and suggestions. The Methodology section was created, where the research proposal is described in the beginning. Modeling approaches (BPMN and SD) and Activity-Based Costing Method were also included. And in the last part, we talk about Identifying the main costs of Alzheimer's disease.
Point 4:
Methods : I am not convinced why System dynamics is selected in the AD modeling context... please elaborate
Response:
Thank you very much for your comments and suggestions. System dynamics was chosen as a suitable representative of a simulation approach based on mathematical modeling. This approach verified the values simulated by the BPMN model, which are then further implemented in the ABC method, which provides an overall view of the costs of Alzheimer's disease. More is elaborated in the attached text.
Point 5:
Methods: section 3.2...."....however, it is ideal" (!) please avoid strong wording and also provide reasons for your selection (there is no such thing as "ideal" modelling technique, only one that is suitable/appropriate, etc.)
Response:
Thank you very much for your comments and suggestions. We read the whole article and reformulate strong wording.
Point 6:
Methods: "by the widest range..." -> "a wide range of..."
Response:
Thank you very much for your comments and suggestions. We modified as required.
Point 7:
Methods: I am not sure that the BPMN notation needs to be described in the paper... please refer the reader to thorough material regarfing BPMN. In case he is unfamiliar the descriptions in the paper are not helpful due to their brevity, in case he is familiar they are redundant (this applies also to the elements of the stock and flow diagram).
Response:
Thank you very much for your comments and suggestions. We applied the comments to the text and reformulated the affected parts of the text.
Point 8:
Costs identification: please rename the section e.g. Identification of the AD main costs
Response:
Thank you very much for your comments and suggestions. This section has been renamed, extended and incorporated into the new Methodology section as its subsection.
Point 9:
Costs identification: why the costs in Czech Republic are considered? isn't that limiting? what other papers identify as costs worldwide? from what I see the categories of costs can be further generalised (by provided relevant sources).
Response:
Thank you very much for your comments and suggestions. The use of costs per country is not restrictive given that their categorization (and hence the groups entering the model) was generally recognized. The classification of costs was newly explained in the theoretical background chapter as well as in the methodology. The values from the Czech Republic were collected to show up-to-date and original data whose collection is very complicated in each country so far.
Point 10:
section 4 needs elaboration and a better overall narrative. It is too short and does not convince the reader of how the costs were selected.
Response:
Thank you very much for your comments and suggestions. The text now includes, among others, a subchapter on "Approaches to cost measurement" and "Identification of the AD main costs". The costs involved in the model were selected under the supervision of a neurologist on the basis of current Czech legislation, approaches of Czech health insurance companies, available databases such as SUKL and the Statistical Office and analysis of publications on Alzheimer's disease costs in the Czech Republic.
Point 11:
Results: Inspecting the BPMN diagrams in figures 2 and 3, I am not convinced of why it needs to be modeled: (a) as a business process and, (b) with BPMN in particular. The resulting BPMN diagrams do not resemble a typical business process... either provide more convincing arguements about your choice and its benefits or consider an entirely different approach.
Response:
Thank you very much for your comments and suggestions. The arguments supporting our selection have been added to the text, starting with the Introduction.
Point 12:
section 6 is "Discussion and conclusion" and section 7 is "Conclusion". Please merge the sections into a single one.
Response:
Thank you very much for your comments and suggestions. Both sections have been extended.
Point 13:
I am not sure how the two different modeling approaches compare and what's the point of the second one... I think the paper lacks a "Methodology" section that helps the reader understand how this research was designed and what are its main steps so that we can follow the results. All the decisions and the research steps should go there. Section 5 needs only to guide the reader through the various results of the two approaches and compare them... but the reader needs to know what to expect and why.
Response:
Thank you very much for your comments and suggestions. The Methodology section was created, where the research proposal is described in the beginning. Modeling approaches (BPMN and SD) and Activity-Based Costing Method were also included. And in the last part, we talk about Identifying the main costs of Alzheimer's disease. Furthermore, the text explains that to calculate the complex cost of treatment, we need the cost of activities that a BPMN simulation can provide us in the case of a variable disease such as AD. Comparable values were verified by a different simulation approach based on mathematical modeling.
Point 12:
"The results of this study are in keeping with the conclusions made by similar studies, that is, the costs of Alzheimer’s disease increase with the severity of the disease and the decline of the patient into later stages of the disease." ...isn't that fairly obvious? what new is your research bringing?
I think the conclusion need to focus more on the work presented in this paper, how it is contributing and the next steps.
Response:
Thank you very much for your comments and suggestions. The conclusion was reworked and focused more on the results presented and, above all, their consequences
Author Response File: 
Author Response.pdf
Reviewer 2 Report
The authors conduct a very interesting study about how to measure the cost of a process of management of Alzheimer's disease by using BPMN and system dynamics processes. The authors introduce the problem and provide a good background to the problem. However, my feedback is going to be only in the process part perspective.
Some aspects should be considered to improve the paper:
- I cannot see the relation between the process in system dynamics and the Alzheimer's disease process. The explanation given in section 3.1 is general and it is unrelated to the disease process further I don't see which part of the paper the system dynamic process is used and simulated to obtain data to analyse the costs, please clarify that.
- Inline 241, the authors state "... the length of each phase of the disease was fixed ...". What do the authors mean when talks about the length of the phases are fixed? They established a time for each phase for simulation. The authors must clarify that in the paper.
- In section 5.1, the authors merely describe the BPMN process and some restrictions of the models. It will be interesting to see the system dynamic used to the same purpose, isn't it?
- Looking at the costs calculations, analysing the subprocesses and the activities involved and the cost/time required, in my opinion, it is not difficult to obtain an estimation without processes. The authors must clarify what is the use of the model and how cost data are obtained and if those costs are obtained by simulation or not.
- In general, after reading the paper, my great concern is about how the authors have used the two process models to simulate the processes because I have the feeling that the processes have been used only for a mere descripción of the process but they do not show anything about the simulations. If the contribution is only based on the description of the processes using two different models the contribution, in my opinion, the contribution is very poor.
- It is more interesting that the authors focus on the simulation of the process to obtain that an compare with real data (if they have). Moreover, the authors can simulate both models and compare them. I recommend at least to simulate both model design and compare with real data shown in the paper.
Minor issues:
- Include the references to the tools used to design process models. For instance, include the Stella and BPMN editor used.
- The font size inside the activities of the processes must be increased.
Author Response
RESPONSE LETTER
Dear Editor, Dear Reviewer,
Thank you for your letter and constructive comments concerning our manuscript. We have studied your comments carefully and made major corrections, which we hope to meet with your approval. We highlighted any text changes in the attached document. Please kindly help us to see the following contents :
Response to Reviewer 2 Comments
Point 1 :
I cannot see the relation between the process in system dynamics and the Alzheimer's disease process. The explanation given in section 3.1 is general and it is unrelated to the disease process further I don't see which part of the paper the system dynamic process is used and simulated to obtain data to analyse the costs, please clarify that.
Response:
Thank you very much for your comments and suggestions. System dynamics was chosen as a different simulation approach (mathematical modeling) suitable for this type of problem. Of course, the SD outputs are not the same as the BPMN model outputs, but some key values of both models can be compared to verify the results obtained.
Point 2 :
Inline 241, the authors state "... the length of each phase of the disease was fixed ...". What do the authors mean when talks about the length of the phases are fixed? They established a time for each phase for simulation. The authors must clarify that in the paper.
Response:
Thank you very much for your comments and suggestions. This is now more elaborated in the text. We could solve it using fuzzy approaches, which we would like to use in the future, but it is not part of this publication.
Point 3 :
In section 5.1, the authors merely describe the BPMN process and some restrictions of the models. It will be interesting to see the system dynamic used to the same purpose, isn't it?
Response:
Thank you very much for your comments and suggestions. For the purposes of this work, SD is used to verify the results. A comprehensive SD model will be the content of further research.
Point 4 :
Looking at the costs calculations, analysing the subprocesses and the activities involved and the cost/time required, in my opinion, it is not difficult to obtain an estimation without processes. The authors must clarify what is the use of the model and how cost data are obtained and if those costs are obtained by simulation or not.
Response:
Thank you very much for your comments and suggestions The authors justify already in the Introduction of the rewritten text the motivation to use BPMN, which is used in the health sector, and how it is beneficial, especially in this case.
Point 5 :
In general, after reading the paper, my great concern is about how the authors have used the two process models to simulate the processes because I have the feeling that the processes have been used only for a mere descripción of the process but they do not show anything about the simulations. If the contribution is only based on the description of the processes using two different models the contribution, in my opinion, the contribution is very poor.
Response:
Thank you very much for your comments and suggestions. First, the whole process of treatment and care of patients with Alzheimer's disease was analyzed. This analysis was illustrated using a BPMN model that allows activities to be interconnected with costs. This model was subjected to simulations and the simulation results were verified by a mathematical model through the Stock and Flow diagram of Stella. Subsequently, the values were processed by the Activity-Based Costing Method. It is therefore not only a process description, but a proposal for the possible use of BPMN to express the cost of activities/processes. BPM is a suitable tool for presenting processes in healthcare and social services thanks to its transparency. The problem of determining costs in these areas is currently very acute, not only for the Czech Republic.
Point 6 :
It is more interesting that the authors focus on the simulation of the process to obtain that an compare with real data (if they have). Moreover, the authors can simulate both models and compare them. I recommend at least to simulate both model design and compare with real data shown in the paper.
Response:
Thank you very much for your comments and suggestions BPMN and SD are compared in Table 8; unfortunately, it is not possible to compare with reality, there are only other estimates based on the sample, in the Czech Republic it is for example: https://www.ncbi.nlm.nih.gov/pubmed/27785577.
In comparison with this study, the BPMN value of direct costs in mild dementia shows closer to this study (In Holmer 1241.2 (1437.3) - in our BMPN study it shows 1331.26 Euros, SD shows 1627.72 Euros. It is not possible to deduce the accuracy of BPMN and SD approaches.
Point 7 :
Include the references to the tools used to design process models. For instance, include the Stella and BPMN editor used.
Response:
Thank you very much for your comments and suggestionsIn the references, links to the Enterprise architect website as a platform for BPMN modeling are used for our model and the Isee systems website as the company responsible for STELLA.
Point 8 :
The font size inside the activities of the processes must be increased.
Response:
Thank you very much for your comments and suggestions. Text labels in all figures have been enlarged.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
In my opinion the paper has significantly improved its quality.
All my comments have been adequately addressed.
Reviewer 2 Report
The authors have provided and solved all the requested questions in the correct way. In my opinion, the paper has enough quality to be published.
