Secretary's Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
Phase II – Implementation, Evidence-based Actions, and Process for Choosing National Priorities
Via WebEx
Thirteenth Meeting: July 10, 2009
Committee Recommendations (Approved by Vote)
- No formal votes were taken during the meeting.
Committee Decisions (By Consensus)
- The Committee should make the following recommendations to the Secretary:
- Population-oriented interventions should be made a priority for the comparative effectiveness research efforts that are underway at HHS.
- In the development of evidence through linkages to Healthy People objectives, it is critical that gaps in the evidence-base be filled.
- The evidence paper should be amended to address the following issues:
- Clarify priority public health and clinical preventive services for research to achieve greater equity in terms of who is being looked at and who is being served.
- Emphasize that approaches are needed that fit the different circumstances of populations. The need for tailored approaches depends on the type of intervention.
- Integrate the final version of the evidence report with the final priorities document.
- Concrete recommendations are needed for the types of interventions that will have an impact on the social determinants of health.
Next Steps
- The Subcommittee on Implementation will update their draft recommendations to reflect the proposed revisions. The Committee will vote on the final recommendations at their August meeting.
- The Subcommittee on Data and IT will finalize its recommendations in time for the next public meeting, when it will seek feedback from the full Committee.
- NORC will follow-up with Committee members to schedule upcoming subcommittee and Web-based Committee meetings. A meeting of the full Committee is planned for August 14, 2009.
- NORC will provide the Committee members with key resources mentioned during the meeting, including the link to the UCLA Health Impact Assessment Web site, the Carter Center report on Closing the Gap, a paper (to be sent by Dr. Kumanyika) that explains the concept of collective risk, and the report of the RWJF Commission on Building a Healthier America.
I. Welcome and Introductions
Dr. Howard Koh, Assistant Secretary for Health, U.S. Department of Health and Human Services (HHS), welcomed the Committee and thanked them for their dedication and service. He noted that Healthy People, with its emphasis on prevention, is a critical effort for the Department and the country. As a physician, public health professor, and former state health commissioner, Dr. Koh has been familiar with the Healthy People process throughout his career. He was pleased to learn that a social determinants approach is being emphasized in Healthy People 2020, because public health needs to move in this direction. Prevention is often overlooked. Dr. Koh expressed support for renewing the Committee's charter and said he had spoken with the Secretary about this issue. Dr. Jonathan Fielding, Chair of the Secretary's Advisory Committee, thanked Dr. Koh for his support. He noted that the members had been serving in a voluntary capacity, and were delighted to hear from HHS leadership that their hard work would make a difference.
Carter Blakey, Senior Advisor, Office of Disease Prevention and Health Promotion (ODPHP), provided updates on the progress of Federal Interagency Workgroup (FIW). She explained that the FIW would begin meeting the following week to review individual proposed objectives for 2020 and noted that the process would involve lengthy, bi-weekly meetings through September 2009. The objectives would be posted for public comment in October 2009. ODPHP is planning a second round of public, regional meetings. Dates and locations for two of the meetings have been confirmed (October 22, 2009 in Kansas City, and November 7, 2009 in Philadelphia). The date for the third meeting had not been set, but would take place in Seattle, WA. ODPHP has reinvigorated the Healthy People Consortium, which has grown to almost 2,000 members. They are fleshing out the role of the Consortium to better leverage it as a resource for implementing Healthy People. Finally, she noted that they are looking into how to operationalize the Committee's recommendation to move to a Web-based format for delivering Healthy People objectives.
II. Desired Outcomes of the Meeting
Dr. Fielding, Chair of the Advisory Committee, outlined the desired outcomes of the meeting. He commented that extensive subcommittee discussions had taken place since the May 15, 2009 meeting. Today's discussion would be an opportunity to integrate this work into a cohesive whole, discuss whether refinements are needed, and prepare to approve the documents at the August 2009 meeting. Issues to be discussed included: finalization of Data & IT recommendations, criteria for identifying evidence-based strategies, implementation strategy recommendations, and the work of the Priorities Subcommittee. Dr. Fielding noted that nearly every issue that they discuss from this point forward will be one of implementation. He introduced Shiriki Kumanyika, Committee Vice-Chair, to lead that discussion.
III. Healthy People 2020 Implementation Strategies
Dr. Kumanyika noted that she would moderate the discussion after Eva Moya, Subcommittee Co-Chair, had presented introductory slides. The Implementation Subcommittee, which includes key players at the state- and local-levels and representatives of the business community, has sought to answer questions related to what Healthy People 2020 should do, and how it should ensure accountability. She noted that the subcommittee was focused on users' needs for tools, aids, and guidance.
Ms. Moya provided an overview of the Subcommittee's discussions of action-oriented implementation strategies within a social determinants-oriented framework. The Subcommittee organized their recommendations around four general themes: action orientation; infrastructure for accountability; incentives for engaging and participating in Healthy People; and investing adequate resources at the state and local levels. This last element includes providing tools, resources, and guidance for users. The Subcommittee's draft document presents recommendations for activities and actions that should be carried out within the immediate- (i.e., the first year of the decade) and the long-term (i.e., might not be initiated until later). Ms. Moya walked the members through the specific recommendations in the document. Dr. Kumanyika requested feedback from the Committee about whether or not the recommendations were complete." They discussed several revisions that pertain to "immediate-term recommendations," summarized below.
Dr. Fielding said that physical determinants should be emphasized in addition to social determinants, as the two elements are complementary and have import for health issues. An accountability infrastructure should be in place at all levels of government. Federal level efforts should be coordinated with the Office of Personnel Management, which is responsible for the Federal workforce. Dr. Fielding mentioned that, although states are the primary partners of the Federal government, local health departments should not be overlooked. Local agencies have a major role in implementation efforts.
Members of the Committee discussed the need for more hands-on technical assistance and resources (e.g. webinars, conferences, call centers, online curricula, and smart assistance) to support implementation efforts at the local level, especially for large local health departments. These resources should be linked to the interactive Web site. The interactive Web site should be a major priority for resources, because the potential exists for it to create an online community including far more people than could be reached through individual technical assistance.
The Committee also recommended revisions regarding the longer-term recommendations. For example, it would be beneficial to create a tool that helps users at the state or local level cross-walk their current activities with the Healthy People 2020 action strategies; this would enable them to see how their activities align with Healthy People, and identify areas that they are not currently addressing. It would be useful to provide a toolkit to help states develop their own objective targets and data-tracking methods. An online curriculum (e.g., distance learning) could be created to give users general understanding of Healthy People and how they can obtain technical assistance. Completion of this course could serve as a measure of competency by offering some sort of certification on the basic components of Healthy People 2020.
When using an "Health in All Policies" approach, attention should be paid to measuring how health outcomes are affected by efforts to address the social determinants of health. As an interdisciplinary body, the Federal Interagency Workgroup (FIW) can play a key role in operationalizing cross-cutting elements of Healthy People 2020 (e.g., those that relate to physical and social environments and extend beyond the field of health). FIW members are from various agencies and organizations, so this group could be valuable for implementing a "Health in All Policies" approach.
Dr Fielding said that depending on the state, more than one Healthy People State Coordinator may be needed; the number of coordinators should be scaled by population. Coordinators may also be needed to direct implementation at the local level. States are primary partners for the Federal Healthy People efforts, but local health departments—particularly large ones—are also critical. Partnerships that are leveraged in the public sector are important, but the private sector should also be mentioned. Public/private partnerships would draw a larger network of interest. Non-health related companies should be motivated to get involved in Healthy People 2020 by using arguments about economic productivity and the overall economy.
Implementation of Healthy People 2020 should be linked to the national health reform effort. The issue of health reform is extremely visible, and has a strong public health and population health focus. Implementation efforts for Healthy People 2020 would be strengthened if they were linked to something visible and well-received. At the conclusion of the discussion, Dr. Kumanyika said it seemed that additional refinements to the document were needed in the coming weeks. The Subcommittee would present its final recommendations to the full Committee for vote at the next meeting on August 14, 2009.
IV. Healthy People 2020 Criteria for Selecting Evidence-based Strategies
Dr. Fielding started the discussion of evidence by thanking several individuals who provided input through one of the Advisory Committee's subcommittees on this issue, including Steven Teutsch (Los Angeles County Public Health Department), Ned Calonge (Colorado Department of Public Health and Environment), Tracy Orleans (Robert Wood Johnson Foundation), and Michael McGinnis (Institute of Medicine). He offered an overview of issues discussed by the group, which were summarized in a draft report by Dr. Fielding and Dr. Teutsch. (This document was included in the meeting briefing books.) Questions included how decisions should be made with regard to linking Healthy People objectives to evidence-based interventions, what to do when there is insufficient evidence to identify effective interventions, and what guidance should be provided to users about what really needs to be done.
Dr. Fielding provided an overview of challenges in this area. It is important to make available the best evidence as has been accumulated through systematic reviews and graded of levels of evidence. The clinical paradigm cannot always be used when addressing population health issues, because randomized clinical trials aren't always available. In community settings, interventions are context-sensitive. Thus, an intervention may be effective in one place but not another; it may need to be adapted.
Examining the term, "evidence-based" Dr. Fielding asked how one can evaluate accepted current practices that aren't supported by evidence and how should the findings of Health Impact Assessments be included to promote an inter-sectoral approach to evidence reviews? He noted that when evidence is not available, there are two alternative view points about how to proceed: 1) Recognize interventions that are accepted, but may be supported by weaker forms of evidence (e.g., expert opinion), or 2) Prioritize the interventions that one knows will work over those that are unproven.
The draft report, Evaluating Sources of Knowledge for Evidence-based Actions adopts the second approach. There are often gaps between what we know can work and what is currently being done to achieve the same objectives. A "hierarchy of evidence" can be used to organize different levels of evidence. At the top level of the hierarchy, the Community Guide and Clinical Guide can be used as references, but other sources are of interest as well. Systematic analyses are needed of all available studies using standardized methodologies and conducted by persons free of conflicts of interest (e.g., Cochrane reviews). Other types of evidence are designated at the next level of the hierarchy, and include best available methods (e.g., Health Impact Assessments). Translation tables can be used to weigh the evidence. Examples from the U.S. Preventive Services Task Force and the Guide to Community Preventive Services are included in the report.
Priorities should be informed by the best available evidence. Policies affecting a large number of individuals (i.e., through the physical and social environment) may have greater impact overall than programs that target individuals. The FIW should explore ways to produce rapid syntheses of what is being learned from evaluations of all types, including support for more practice-based evidence. Web 2.0 applications can be used to learn what stakeholders want to know.
Dr. Fielding said criteria for selecting evidence-based practices should be developed with the view that this information will be used for priority-setting, because that is where Healthy People users will be making systematic decisions. The issues should be framed in a positive way. He noted that there are more than 200 high priority topics that the Preventive Services Task Force has not been able to review due to its limited staff and resources. He hoped that this need would be redressed through the Federal budget process.
A Committee member recommended integrating efforts that are being proposed for Healthy People 2020 with the Agency for Healthcare Research and Quality (AHRQ)'s comparative effectiveness research. He suggested looking at the report of the Federal Task Force on Comparative Effectiveness, which was due to Congress at the end of June. Comparative effectiveness research is needed for population- and clinical-level interventions. Dr. Fielding said decisions on priorities are likely to be made on a short timeline. He suggested that the Committee recommend to the Secretary that population-oriented interventions be made a priority for the comparative effectiveness research efforts underway at HHS. The other Committee Members concurred.
Another Committee member pointed out that people with disabilities are systematically excluded from clinical trials. People with multiple chronic conditions or sometimes any chronic conditions are also excluded from the trials that produce the grade A level of evidence; thus, these two populations have no clinical evidence to guide therapeutic decision-making. She asked whether there are also certain select populations that are excluded in public health initiatives research.
Dr. Fielding agreed that some communities may be excluded or have less data available to demonstrate the effectiveness of community-based interventions. He said the Committee should make the point that in the development of the evidence through linkage to objectives, it is critical that such gaps be filled. The evidence should address priority public health and clinical preventive that could expand the evidence base and increase equity in terms of who is being looked at and who is being served. Another Committee member commented that community-based participatory research could be used to close gaps in the evidence base.
Dr. Kumanyika said the Committee should push back against the idea that "uniformity of evidence" is the goal for data collection. The push for diversity in clinical trials was due to the fact that people realized that studying homogenous populations did not provide answers for all population groups. It is important to emphasize that approaches are needed that fit the different circumstances of populations. Generally, the need for tailored approaches depends on the type of intervention. For instance, inventions to encourage seat-belt usage would be fairly uniform, while interventions related to increasing the amount of park space would not. Dr. Fielding recommended adding this point to the evidence paper.
The Committee agreed that the final version of the evidence report should be integrated with the final priorities document. Evidence could inadvertently drive priorities if it is not integrated in the priority-setting schema. For instance, the Carter Center report entitled, Closing the Gap, examined the issue of preventable burden in trying to identify opportunities. Yet the fact that one asks the question doesn't mean there is a sufficient evidence-base available to clearly define criteria like preventable burden. Dr. Fielding said the issues raised during this discussion should be incorporated into the final version of the Committee's evidence recommendations.
V. Healthy People 2020 Priorities
Dr. Abby King, Co-chair of the Subcommittee on Priorities, provided a summary of the Subcommittee's recent work. In its first phase, the Subcommittee had presented general recommendations for priority setting at different levels (e.g., Federal, state, and local). Now, members had been charged with thinking about national priorities. They decided to explore some fundamental questions. First they asked, "Why create national priorities?" Their discussions led them to conclude that national priorities are needed because they can be used across broad numbers of people and government agencies and can also enable cross-agency collaboration. They discussed key characteristics of national priority objectives (e.g., supported by a compelling rationale and relevant to agencies with a broad range of mandates).
Dr. King differentiated between national priorities and leading health indicators (LHIs). Healthy People 2010's LHIs were originally created to provide a broad picture of our nation's health. Yet over the decade, there was confusion about the function of LHIs. It was thought that, because they were a small and manageable set, LHIs were priorities; yet they were simply intended to serve as a means of gauging the nation's health. National priorities are issues of national urgency; they are important enough that every level of government should monitor and undertake efforts to improve them. Dr. King noted that Healthy People 2020 should separately and clearly define LHIs and national priorities to ensure the terms are not used interchangeably.
Dr. King said the Committee had previously concluded that they would not be the correct body to develop national priorities, as they are not broad-based. However, they could recommend a process that the FIW—comprising HHS and other participating Federal agencies—could use to identify those priorities. This would ensure a priority-setting process that is not exclusionary, but includes diverse constituencies and areas of health. The Subcommittee was working on a suggested set of criteria for the FIW to use to make these choices. It would combine quantitative and qualitative approaches, and would include input from public health experts and experts from other fields (e.g., housing, transportation, agriculture). They are preparing recommendations for priority-setting methods that are practical and not overly academic. Dr. King opened the floor for discussion.
A Committee member commented that priority-setting processes can be fairly straightforward, or can quickly become complex. He mentioned the 3-four-50 initiative of the Oxford Health Alliance (http://www.3four50.com/  ), which is based on the idea that three risk factors lead to four chronic diseases, causing fifty percent of preventable mortality. In earlier conversations, the Committee had discussed an approach as simple as identifying the three risk factors that could be connected to the LHIs. He said this Committee should recommend that somebody does need to set national priorities, and that the process for doing so must be well-defined, but not overly complex.
An inherent complication in setting priorities is that, if you make it too simple, you will exclude somebody. For example, Dr. Fielding was concerned that someone who has devoted their life to the issue of hearing would feel disenfranchised if the national priorities are, for example, set as obesity, physical activity, and nutrition. Within topics, it is important to look for the gap between what the evidence says is possible, and where we are today; that will help to define what the priorities are in getting from here to there. This guidance can be used to help to set priorities within every topic.
Another issue raised is where additional Federal investments in overarching issues be made? This could point to two levels of priority setting, with one being relatively simple, and the other being more politically and logistically complex. On the one hand, there is the utility of ensuring that every person can find an entry point and have a voice; on the other hand, there is the opportunity for collective movement when people focus on common issues. It's not necessarily an either/or choice. Another aspect is the social determinants, which would likely have the greatest impact on disparities and inequalities, and should therefore be factored into priority-setting.
Dr. King approved of the idea of two levels of priority-setting, and suggested two foci for the process: 1) the gap between evidence and practice for each topic area, and 2) the overarching Federal investment in areas that will have a pervasive effect. She said the Ad Hoc group on Evidence may need to grapple with how to operationalize social determinants from a public health perspective so that the Committee can make concrete recommendations for the types of interventions that will have an impact. If the recommendations are too nebulous, there is a risk that nothing will happen on this.
Dr. Fielding agreed that examples are needed, but this can become tricky. At the margin, one could say that more investment is needed in education than in health care. But there is not a one-to-one relationship between investment and results. Some states spend more on education and still have worse outcomes than those that spend less. Each social determinant requires specification about what interventions would make a difference, but this is a challenge because the knowledge base is not solid yet. Concrete examples should be given of the type of programs that seem to have an impact.
Dr. Kumanyika introduced several ideas into the discussion. First, she recommended incorporating the concept of "collective risk" that is being used in relation to climate change to advance the social determinants approach. The concept explains how to assess investments that are of benefit to the population, but not necessarily the individual. Second, the Health in all Policies approach falls in line with the Committee's recommendation to address social and physical environmental determinants. In cases where the points of intervention do not fall under the purview of HHS, health-relevant social and physical environmental determinants may be better addressed in policy areas pertaining to other key non-health domains (e.g., housing, agriculture, transportation) as well as the health care system domains.
Dr. Fielding noted that the intent of Health Impact Assessment (HIA) is to look at some of the longer-term, indirect effects of changes in other sectors on health. He suggested that members review the materials on HIA that have been compiled at UCLA (http://www.ph.ucla.edu/hs/health-impact/ ), which summarize the HIAs that have been done in this country. Another member recommended that the World Health Organization's Commission on Social Determinants report should serve as a key reference for the Healthy People 2020 recommendations once they have been finalized. The report of the Robert Wood Johnson Foundation's Commission to Build a Healthier America was also mentioned as a resource. Dr. King requested that NORC distribute the resources mentioned during this discussion to the Committee.
V. Recommendations of the Subcommittee on Data and IT
Dr. Ronald Manderscheid, Chair of the Subcommittee on Data and IT, provided a brief update on the subcommittee's progress. He acknowledged the contributions of the subcommittee members, including Lisa Iezonni as well as representatives from the National Center for Health Statistics (NCHS), SAHMSA, HRSA, and AHRQ. There are three main issues being explored by this subcommittee: 1) How HHS' epidemiology services and services cost data can be used as part of Healthy People 2020; 2) how key Federal data sources on the social and physical determinants of health can be utilized to meet the data needs of Healthy People 2020; and 3) how information technology can be used to develop the public health infrastructure of the nation.
Dr. Manderscheid said the Subcommittee is interested in setting in motion efforts to create an online Healthy People community that all Americans can use to improve their health. It could be used to compare Healthy People 2020 indicators across counties or states, or to compare national data to local benchmark data. The Subcommittee will present its recommendations in time for the Advisory Committee's next public meeting. The two foci for this presentation will pertain to building the public health IT infrastructure and enhancing the capacity to share data.
VI. Wrap-Up and Next Steps
Dr. Fielding addressed the question of whether the Committee's charter would be renewed and when the Department would make a final decision on that issue. Ms. Blakey explained that they were seeking this information and that a decision about the timing of an in-person meeting would need to be made by early August, so that it could be announced in the Federal Register. She added that the Committee's feedback on issues related to both implementation strategies and priority-setting were extremely valuable. Dr. Fielding expressed his sincere thanks to Howard Koh for his leadership and also thanked the members of the public who had signed into the meeting for their interest and engagement in Healthy People 2020.
|
