Secretary’s Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
Phase II –Recommendations for Implementation of the Healthy People 2020 Objectives
Via WebEx
Tenth Meeting: March 26, 2009
Committee Recommendations (Approved by Consensus and Formal Vote)
- The Committee agreed by consensus to adopt the following definitions:
- National objectives are specific, measurable, and realistic statements of intended outcomes over a stated period of time (by 2020).
- A target is the level of progress or performance expected for an objective or subobjective.
- Target-setting involves the methods used to select the value for a target.
- Members agreed by consensus that every topic area should have a brief section on health disparities.
- The Committee voted to approve the revised report of the Subcommittee on System Specifications.
Next Steps
- Dr. Fielding suggested involving Christopher Hoenig, President and CEO of State of the USA, Inc., in the work of the Subcommittee on Implementation.
- The Subcommittee on Target-setting was asked to prioritize and group discussion questions about target-setting to optimize the efficiency of their conversations on these issues.
- The Subcommittee on Topic Areas was charged with making final revisions to the list of topic areas, and then polling Committee members to word-smith topics. The selection criteria could be applied to finalize the list in advance of the Committee’s April 20th meeting.
- Dr. Fielding and Dr. Kumanyika will send a congratulatory note to HHS Secretary-designate Kathleen Sebelius, emphasizing the importance of a Web-based version of Healthy People 2020.
- Dr. Fielding and Kumanyika will work with ODPHP to identify a date for an in-person meeting.
I. Introductions and Desired Outcomes of the Meeting
Dr. Fielding welcomed Committee members and members of the public. He outlined key issues to be addressed during the meeting, including: 1) An update on the activities at the U.S. Department of Health and Human Services (HHS) and the Federal Interagency Workgroup (FIW); 2) An update on the activities of State of the USA; 3) discussion of recommendations for target setting; 4) discussion of topic areas for Healthy People 2020; and 5) an update on subcommittee work. Dr. Fielding commented that the Committee had important deadlines to meet, including a decision on topic area categories to be made that month. He suggested that the Committee develop recommendations during the meeting, and send them back to the Committee for final review to enable a vote at the April 20, 2009 meeting. Target setting methodologies would be discussed at the April Committee meeting; criteria for selecting evidence-based resources would be discussed in May; and implementation strategies would be discussed in June and July.
II. Update from the Federal Interagency Workgroup (FIW)
RADM Penelope Slade-Sawyer, Deputy Assistant Secretary for Health and Director, Office of Disease Prevention and Health Promotion (ODPHP), welcomed participants and gave an update on HHS activities. RADM Slade-Sawyer explained that the FIW, which is charged with leading the development of Healthy People 2020, had submitted its Phase One Report (a proposed framework) to the HHS Secretary. Their recommendations were substantially unchanged from the ones prepared by this Committee. Based on public input and FIW deliberations, the FIW made slight revisions to the Committee’s work. One change they made was to the first part of the mission statement, which now reads, “Healthy People 2020 strives to…” Other changes included adding the concept of “quality of life” in two different places in the overarching goals; quality of life was an important concept in Healthy People 2010. Once the changes have been approved, they will be posted online.
She said that HHS had been convening workgroups to develop Healthy People 2020 objectives. To start, these workgroups were producing recommendations for which objectives should be dropped, retained or revised. The FIW expected to have completed a draft set of objectives by this summer. At the same time, HHS staff would recommend knowledge-based resources for incorporation into Healthy People 2020. HHS would accept public comments through a variety of means, including the Internet and public meetings. She said that, as a starting point, the FIW would seek comments on Healthy People 2010 objectives until April 24, 2009. A more extensive review of Healthy People 2020 objectives would occur later in 2009. HHS plans to convene three meetings the fall of 2009 to get input on draft objectives.
RADM Slade-Sawyer noted that the FIW is working closely with non-HHS Federal partners to establish a strong understanding of their needs for Healthy People 2020; they were currently focusing on target-setting methodologies, which they would develop into a brief to present to HHS appointees as background for determining the appropriate methods for 2020. The FIW had received requests to establish new topic areas, including: Access to Quality Health Care, Adolescent Health, Global Health, Quality of Life, Social Determinants of Health Equity, Blood Diseases, Genomics, Older Americans, and Preparedness. RADM Slade-Sawyer expressed the gratitude of HHS to the Committee for their hard work and commitment.
Dr. Fielding commented on the changes made to the mission statement in the FIW’s Phase One report. He said the change made by the FIW, while apparently small, is important. He asked why the original phrasing of the statement (“Healthy People will…”) was changed to read, “Healthy People strives to….” RADM Slade-Sawyer emphasized that Healthy People 2020 is a collaborative process, and that there was strong feeling among members of the FIW that this language should be added. Dr. Fielding acknowledged their decision, but said the change was surprising, as all elements of the mission statement that followed were achievable.
III. Presentation: State of the USA (SUSA)
Dr. Fielding introduced Christopher Hoenig, President and CEO of State of the USA, Inc. (SUSA), a new non-profit that seeks to use quality information and advanced technology to educate the American people on the status and progress of the U.S. Mr. Hoenig said he would explain the work of SUSA, and then demonstrate a prototype of its Web site. SUSA has roots in scientific and statistical communities as well as information technology (IT) and those who are building large-scale, consumer-oriented Web sites. SUSA’s view is that in order to make progress on critical issues like improving the nation’s health at lower costs, a shared factual frame of reference is needed. SUSA intends to make available a select set of data on the nation’s major issues in order to foster dialogue. They are not collecting original data or choosing policy goals, and they will leave interpretation of the facts to the media. In the health arena, SUSA will go live in late April or early May 2009 with the dissemination of 20 key national health indicators based on an Institute of Medicine (IOM) report.
Mr. Hoenig demonstrated a prototype of the Web site. He described the SUSA’s work as “a window into Healthy People.” They hope to present systematic data (e.g., the 20 health indicators) in a multi-dimensional way (e.g., by geographic region or demographic subgroup) this should permit comparisons by time, by conceptual level, or by geography. For example, they hope to be able to “drill down” to subpopulation-level data to show disparities by ethnic groups, looking at social and physical determinants of health. Mr. Hoenig said that SUSA is focused on making the Web site accessible and usable by the public.
Dr. Fielding remarked that it would be useful to drill down to local data. A Committee member suggested having Mr. Hoenig collaborate with the Subcommittee on Data and Health IT to maximize synergy between Healthy People and SUSA. Mr. Hoenig said SUSA would like to coordinate in any way possible. Dr. Ronald Manderscheid, Chair of the Subcommittee on Data and IT, said his group would be interested in collaborating with SUSA as it develops its approach; the potential to get local level data into people’s hands is important. Another Committee member commented that his organization is funded by the Robert Wood Johnson Foundation to do this type of work at the county level. He added that the framework developed by the Committee in Phase I might be helpful in connecting the SUSA and Healthy People 2020 approaches.
Addressing communication issues for the SUSA site, a member asked whether the information is being targeted to specific user groups, and what efforts they are making to promote utilization of the site. Mr. Hoenig responded that they have four target audiences: the policy community, “information intermediaries” (people who use the Web to propagate points of view), the “engaged public,” and children in the school system. Promotion will be carried out through work with strategic partners like Google. Dr. Fielding suggested involving Mr. Hoenig in the work of the Subcommittee on Implementation. He noted opportunities to link with Healthy People in terms of presenting a clear picture of how health is produced, including underlying determinants, intermediate outcomes, and disease states. Another option would be to have the SUSA key indicators link across to the Healthy People 2020 Web site.
IV. Target-Setting Recommendations
Definition of the Term, “Objective”
The Subcommittee on Target-setting, chaired by Dr. Patrick Remington, had circulated in advance of the call draft definitions for the terms “objective” and “target.” An initial, proposed definition for “objective” was:
- “Results of specific activities to be achieved over a stated time. Objectives are specific, measurable, and realistic statements of intention.”
Based on the written comments of Committee members on this definition, it was revised as follows:
- “Objectives are specific, measurable, and realistic statements of intended outcomes over a stated period of time (by 2020).”
Dr. Remington said that he has found the acronym S.M.A.R.T. (Specific, Measurable, Attainable, Realistic and Time-limited) to be helpful in his work with communities, and he argued for using that if possible. Regarding the phrase, “activities to be achieved over time,” he felt that objectives should not be limited to activities, because there are also process and outcome objectives as well. The proposed definition seemed to him to be a definition of outcome objectives. Dr. Fielding said the definition should be something everyone can understand. Dr. Remington was fine with the draft, and felt strongly that “time” should be included in it.
Dr. Shiriki Kumanyika, Committee Vice-Chair, said that the Committee should look the definition of objectives in conjunction with the definition of targets. One could envision a broad objective that would have within it specific targets. Dr. Fielding agreed that targets and subobjectives could be for different periods of time. He said that the group should be clear about what these differences are for the sake of consistency. Dr. Kumanyika asked whether the FIW is using existing definitions of these terms, but RADM Slade-Sawyer said the FIW had not tackled this issue yet. Carter Blakey, ODPHP, noted that Healthy People has historically considered an “objective” to be a general statement, and a “target” to be an actual percentage. So an objective could be, “Increase the proportion of women who’ve received mammograms at the recommended rate,” and the target could be, “100% of women should receive mammograms at the recommended rate.”
Dr. Remington suggested the possibility that an objective would be standard nationwide, but the target would vary by community. It could be based on baseline data and take into consideration specific barriers in communities, since it’s a component of an objective. RADM Slade-Sawyer clarified that there does need to be a national target. Communities can use the national target as a starting point for setting their own targets. A Committee member noted that the use of different targets for different sub-populations had been a source of criticism for Healthy People 2010. Some interpreted that approach as a tacit approval of health disparities. However, he said it would be acceptable to have a subobjective focused on reducing disparities.
Dr. Fielding reviewed the proposed definition of objective. He noted that it does not specify that the objectives are national, and felt it was important to add this concept. Also, every state should be setting objectives that are mindful of the national objectives. He asked if anyone disagreed with this definition of “objective.” No Committee members voiced disagreement. Dr. Fielding indicated that the Committee would adopt the definition, “National objectives are specific, measurable, and realistic statements of intended outcomes over a stated period of time (by 2020).”
Definition of the Term, “Target”
Dr. Fielding then reviewed a proposed definition of the term “target.”
- A “target” is the level of progress or performance expected for an objective.
- “Target-setting” involves the methods used to select the value for a target.
He felt that the definition should be revised to state that a target is the level of progress for an objective or a subobjective. He felt that the definition of “target-setting” makes sense, and asked if anyone disagreed with either definition. No Committee members voiced disagreement. The Committee adopted the definition, “A target is the level of progress or performance expected for an objective or subobjective.”
Dr. Kumanyika indicated that many issues have been raised around target setting, as discussed in the briefing book materials. Why were Healthy People targets not met in previous decades? How can those reasons inform current target-setting efforts? Dr. Fielding agreed that this is a critical issue, adding that the methods used to set targets should be transparent. It should be clear if targets are being set by expert opinion because we don’t know which interventions would work, versus being set through application of the best evidence. Dr. Fielding added that being clear about who was involved in the target-setting process is part of transparency. A Committee member commented that there should be a role for communities in setting targets to ensure that community groups and the public have ownership of Healthy People 2020.
Dr. Fielding suggested there should be a logic model for everything that Healthy People does, an objective or a target, to clarify where Healthy People is trying to intervene in the process and what outcomes are expected. Without a logic model, the thinking can be unclear. He also suggested that in setting targets, one should look at the effects of targets on multiple outcomes. Effective interventions could be expected to affect multiple topic areas, so it is important to look at how such interventions would cut across topic areas. A Committee member agreed that logic models should be used, but said they need not be complicated. Simply showing how an objective that is focused on determinants links to outcomes, and vice-versa, would be a useful way to employ the framework. Logic models will require integration across topic areas, and topics are scattered across a continuum (i.e., from downstream to upstream).
Another member asked whether there was an underlying assumption that different methods could be brought to bear on different topic areas, depending on their content, or whether a standard set of methods should be applied. Dr. Fielding responded that this would be a good question for the Subcommittee on Target-setting to address. Dr. Kumanyika referred to a series of questions that had been posed to the Committee in the presentation slides for the meeting. She suggested that the Subcommittee on Target-setting prioritize and group these questions to make their discussions more efficient. These questions were:
- What target-setting methods have been used in the past?
- What are the pros and cons associated with each method?
- If multiple methods are used, how should one determine which method is appropriate?
- What would an ideal method of target-setting look like?
- What tools are available now that were not for 2010?
- How should past performance on targets be factored in?
- If trends are improving, how should the bar be raised?
- What compromises are acceptable…
- When there is essentially no evidence base?
- When the available evidence is weak?
- When the available evidence is strong but relevance is limited?
- To account for the influence of secular trends?
V. Healthy People 2020 Topic Areas
Dr. Remington, Chair of the Subcommittee on Topic Areas, reviewed the Subcommittee’s proposed definitions for the terms, “vision,” “goal,” and “focus area/topic area.” For Healthy People 2020, the term “topic area” would be used instead of the term “focus area” that was used for Healthy People 2010. He explained that, in trying to map the topic areas to the broad categories of the framework, his subcommittee found that some topics mapped well, but others didn’t because they are addressed across the continuum from interventions to determinants to outcomes. Another potential approach to organizing topic areas is a matrix that shows how topic areas flow across the different elements of the framework. The rationale for this approach was to help the FIW work across topic areas. Topic areas would be developed independently of objectives, and there would be many similar objectives.
He suggested that Healthy People 2020 would be likely to have more topic areas than the 28 that were in 2010, perhaps 30 or more. If a grid was used to organize topic areas in relation to the framework, users could enter the grid through an interest (e.g., social and economic determinants) or through a specific topic area. (e.g., specific diseases) or vice-versa. He warned that “the devil is in the details” in selecting topic areas, but based on written feedback from Committee members, there seemed to be consensus that the Healthy People 2010 topics would continue with some modifications, and six to eight new topic areas would also be added.
Dr. Fielding asked the Committee for feedback on the function of topic areas, and, secondly, what specific topic areas should be proposed. He noted the key functions of Healthy People 2010 focus areas, were: organizational, managerial, and communications-related. Dr. Fielding asked if an expanded number of topic areas would change their overall function, especially considering that each topic area is assigned to a Federal agency that is responsible for those objectives. Would that system need to change with an increased number of topic areas? Dr. Fielding then said the Committee does not necessarily need to answer all of these questions, since they are up to the FIW. Yet he said that the Committee should ensure that the topic areas are more than a point of entry.
Dr. Fielding reviewed proposed selection criteria for topic areas, and asked the Committee members for comments. The proposed criteria were:
- A logic model to clarify pathways of intervention
- Coherence of content; clarity of boundaries between Topic Areas:
- Reflects a body of available literature that can be accessed to promote health and prevent disease and injury;
- Reflects our understanding of the pathophysiology and multiple underlying determinants of health;
- Relates to a schema or logic model that links back to the HP2020 framework;
- Can be “owned” by a group of individuals with complementary expertise to adequately address the issue;
- Allows sufficient focus (e.g., a manageable number of objectives).
A couple of members commented that these selection criteria for Healthy People 2020 topic areas seemed fine, before moving on to comment directly on the topic area categories themselves. Dr. Fielding later said that there seemed to be general agreement on the selection criteria for topic areas.
In written feedback, Committee members had voted to retain all of the 28 Healthy People 2010 focus areas, to add 8 new topic areas that were proposed by the Subcommittee, and to create additional new topic areas or split Healthy People 2010 focus areas. That would lead a total of 52 topic areas for Healthy People 2020. One Committee member said the traditional Healthy People focus area categories map well to the organization of state and Federal agencies, but new areas dealing with issues like social and economic disparities and child development might not map as well to the organization of agency divisions and bureaus. He felt it was even more important to make sure that cross-cutting issues would be addressed since there would not be specific divisions to take ownership of them. Another member commented that the proposed topic areas are fine for content, but the Committee should also address infrastructure issues such as data, IT, staff and other issues.
Dr. Kumanyika said topic areas that do not neatly fit into current organizational structure could present opportunities to stimulate cross-fertilization and integrative approaches that are consistent with the framework. This might create certain economies, since some of the same determinants lead to several risk factors and diseases. Another member strongly agreed and said it would be a shame if the Committee did not push for ways to get determinants integrated across each of the topic areas. Dr. Fielding proposed that every topic area should have a brief section on disparities. This would not necessarily negate the need for a separate topic area specifically devoted to disparities. He asked if any members disagreed with that idea. No Committee members voiced disagreement. Dr. Fielding said this would be one of their recommendations.
Dr. Fielding said that disability, infrastructure, and some other issues have not gotten enough attention. Some of the topic areas could be split, such as nutrition and overweight, substance abuse, and injury (unintentional vs. intentional). Access to services could be split between access and quality. He clarified that these were the areas that the Committee previously voted to retain, but additional categories were also recommended by participants. He said that the Committee may need to go back to knowledgeable groups to discuss these. Dr. Fielding suggested that the Subcommittee on Topic Areas should do a final revision of the list. They could then poll Committee members for word-smithing, apply the selection criteria to the list, and finalize it before the April 20th meeting. Ms. Blakey said this proposed timeline would work well.
Dr. Fielding said that the Committee should probably not suggest a separate workgroup be convened for each topic area, since some topics are closely aligned. A single workgroup could address multiple topic areas. He noted that this would ultimately be a managerial decision. Dr. Kumanyika pointed out that, as the Committee finalizes its proposed topic areas, members should look at whether prevention approaches are isolated from secondary and tertiary prevention. She said that a lot of the diseases have objectives that start with the disease, and the user would have to go to a completely different section to look at how to prevent it.
VI. Other Subcommittee Efforts
Subcommittee on System Specifications
Dr. Manderscheid, Chair of the Subcommittee on System Specifications, explained revisions that his group made to its final report after presenting it at the last meeting. These included: 1) adding an example of an intervention that has an impact on health determinants, and 2) adding an overall cost estimate. Dr. Kumanyika asked if there were any questions or comments. None were raised. She called for a vote to approve the final report. All Committee members who were present voted in favor of approving the document.
Formal vote:
The revised report of the Subcommittee on System Specifications is approved.
Subcommittee on Implementation
Dr. Kumanyika asked for an update on the activities of this subcommittee. Since Eva Moya, Subcommittee Co-Chair, was not on the call, she asked Adewale Troutman, Subcommittee Co-Chair, to provide an update. He explained that he had had to leave the first call early, and the second call was rescheduled. NORC staff explained that the work of this subcommittee is a very early stage. They have been discussing which external members should be invited to participate and have been defining whether the term “implementation” focuses on programs and policies, or processes. The next step for the subcommittee would be to discuss implementation tools.
Subcommittee on Priorities
Dr. King, Subcommittee Co-Chair, reported that the members held a conference call. She said that they are seeking to describe a system of priority-setting at all levels of government, adding that a process for national priority setting needs to be built up from state- and local-levels. Dr. King also said that there was strong support for using preventable burden as a criterion for prioritization.
Subcommittee on Data and IT
Dr. Manderscheid, Subcommittee Chair, said that the subcommittee had their first meeting a week ago. They focused on support for data and how to coordinate with other agencies to obtain data on determinants. The subcommittee organized data into three categories: epidemiological data, services data, and encounter costs data. The group plans to produce high-level recommendations for things that need to be done to strengthen the relevant Federal data systems.
VII. Next Steps
Dr. Fielding commented that the Committee was hopeful and awaiting the confirmation of Governor Sebelius, HHS Secretary Designate. He asked if ODPHP would authorize the Committee Chair and Vice-Chair to send Governor Sebelius a letter to congratulate her on her appointment. He asked if there were any objections among members of the Committee to this approach. No Committee members voiced objections to this idea. RADM Slade-Sawyer thanked the Committee for their productive discussion.
Dr. Fielding asked whether expanding the number of topic areas to almost double what it was would be feasible from a Federal perspective. RADM Slade-Sawyer was not able to provide an answer this question, but explained that Federal personnel who will manage the Healthy People 2020 topic areas will take on this responsibility in addition to their other duties. Therefore, it is critical to have strong buy-in from them.
Dr. Fielding asked if there are logical groups within HHS that can take responsibility for cross-cutting topic areas such as social determinants. Ms. Blakey replied that the Centers for Disease Control and Prevention (CDC) had previously suggested social determinants as a topic area and is taking the lead in reaching out to other agencies to co-lead that topic area. Dr. Fielding suggested that people outside of government be involved as well, and Ms. Blakey responded that the Healthy People Consortium could be helpful in that respect. She suggested that interested organizations that were listening to the meeting on the telephone contact ODPHP directly about becoming involved.
ODPHP staff asked if the Committee was interested in holding an in-person meeting in June. Dr. Fielding said that the Committee should have an in-person meeting, but that his schedule for June was full. He and Dr. Kumanyika agreed to work with ODPHP to identify appropriate dates for an in-person meeting. After a brief discussion of the timing of the meeting in relation the potential for progress on health reform in the fall, Dr. Fielding said that the group will look for opportunities. He asked that NORC provide help in developing talking points on the relevance of Healthy People 2020 to health reform. |
