Secretary's Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
Data & IT, Implementation, Evidence-based Actions, Process for Choosing National Priorities
Via WebEx
Fourteenth Meeting: August 14, 2009
Committee Recommendations (Approved by Vote)
- The recommendations of the Subcommittee on Data and IT were unanimously approved. Any updates or revisions to the recommendations will be discussed at the next meeting.
- The recommendations of the Subcommittee on Implementation were unanimously approved. Any updates or revisions to the recommendations will be discussed at the next meeting.
- The Criteria for Evidence-based Strategies were unanimously approved. Any updates or revisions to the recommendations will be discussed at the next meeting.
Next Steps
- Dr. Fielding noted that the Subcommittee should work with NORC to produce a revised version of prioritization recommendations that would be discussed more extensively at the September in-person Advisory Committee meeting.
- The Charter has been officially renewed. ODPHP will individually inform Committee members once they have been officially approved.
- The Subcommittee on Data & IT Subcommittee will compile its findings about sources of data for social and physical environmental determinants of health and will send this to the Committee.
- The Subcommittees on Data & IT and Implementation will collaborate on how their activities should be integrated with Healthy People stakeholders.
- Dr. Fielding and Dr. Kumanyika will continue to develop a supplementary report on operationalizing the concept of social determinants of health.
I. Welcoming Remarks
Dr. Jonathan Fielding, Chair of the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 (the Committee), welcomed the audience and thanked participants for their contributions to the development of Healthy People 2020. He said the meeting would begin with an update on the activities of the U.S. Department of Health and Human Services (HHS) and the Federal Interagency Workgroup (FIW). He introduced RADM Penelope Slade-Sawyer, Deputy Assistant Secretary for Health and Director of the Office of Disease Prevention and Health Promotion (ODPHP).
RADM Slade-Sawyer reported that Healthy People 2020 is still scheduled to be launched in the fall of 2010. The Healthy People Topic Area Workgroups are in the process of developing specific objectives, and the FIW is reviewing them. Workgroup coordinators and subject matter experts present to the FIW a detailed explanation of and justification for each objective. This objective review process was expected to be finished by September, 2009. Three regional meetings would be held in October and November to enable the public to provide feedback on the objectives. The healthypeople.gov Web site would also be updated with the draft objectives so that visitors can review them and submit comments online. At the end of the public comment period, Workgroup Coordinators would review feedback and consider revisions to objectives.
RADM Slade-Sawyer announced that the Healthy People Consortium has grown to about 1,150 members. The profile of members has remained fairly consistent, and includes health departments, academic institutions, professional organizations, corporate organizations, community-based organizations, and nonprofit organizations. The FIW has developed a survey for Consortium members that will be fielded soon. Findings will be used to engage Consortium members through communication and outreach activities.
II. Desired Outcomes of the Meeting
Dr. Fielding said a great deal of discussion had taken place since the Committee's previous meeting in July. The Data & IT and Priorities subcommittees each met twice, and the Subcommittee on Data & IT finalized a draft report. The Subcommittee on Implementation and the Evidence Ad Hoc group both used the Committee's feedback from the July 10, 2009, meeting to revise their reports. (New versions were included in the briefing materials for this meeting.) A draft document on social determinants of health had been prepared and circulated to experts for comment. Providing an overview of issues to be addressed during the meeting, he said that the Committee would review recommendations of the Subcommittee on Data & IT, vote on the draft report on selecting evidence-based actions, and the short and long-term recommendations of the Subcommittee on Implementation. They would also discuss the recent work of the Subcommittee on Priorities. Finally, the Committee would lay groundwork for its upcoming September meeting in Washington, D.C.
III. Data and IT Subcommittee Recommendations
Dr. Ron Manderscheid, Chair of the Subcommittee on Data & IT, presented his group's draft recommendations. He explained that they had examined HHS data systems in three areas: epidemiology, services, and cost. They looked at how well those systems would be able to meet the data needs of Healthy People 2020 and also discussed systems outside of HHS (particularly those relevant to defining social and physical determinants of health). Recommendations were divided into immediate and long-term needs for HHS and non-HHS data sources, as well as health information technology (health IT). They highlight areas where work is needed, as well as current HHS efforts that are already working very well. The Subcommittee believes these recommendations can help to better position HHS in the national Health Reform process, to use developments in health IT, and to develop a stronger data infrastructure for Healthy People 2020.
The first set of recommendations pertains to HHS Data Systems. The most immediate and fundamental of these is that HHS should continue to perform existing major epidemiological and health services surveys and vital statistics operations as planned, restore full sample sizes where needed, and avoid further reductions in sample sizes/scope of coverage. If this step is not accomplished, it could greatly diminish the efficacy of the rest of the recommendations in the subcommittee's report. Other recommendations called upon HHS to do more with the data it currently has. For example, there are inadequate data for some special populations (e.g., American Indians) and additional analyses needed for data that are collected. Some surveys are not conducted often enough (e.g., the National Survey of Ambulatory Surgery; the National Survey of Assisted Living Facilities; and the Medical Expenditure Panel Survey). Some key recommendations included:
- Make better use of encounter data and administrative data;
- Create a core set of key health outcome measures for HHS;
- Create a core set of indicators for health determinants;
- Produce a standardized database that enables the use of outcome measures at the federal, state, and local levels;
- Document data in a standard manner;
- Have the HHS Data Council coordinate planning for HHS data systems, look at issues of survey periodicity, eliminate duplication, and seek methodological innovations;
- Expand the collection of functional status information beyond public health surveillance so it becomes part of routine healthcare delivery and administrative data; and
- Strengthen the information infrastructure to facilitate creation of an online Healthy People Community.
Dr. Manderscheid elaborated on the list of recommendations (available in the Subcommittee's written report) before opening the floor for Committee discussion and feedback. Dr. Fielding commented that these recommendations were very comprehensive, reflected an extraordinary amount of work, and were ready for a vote of approval. He encouraged the members to provide feedback.
A member praised the functional status recommendation. She noted that all of the subcommittees should strive for consistency in their terminology (e.g., social and physical environmental determinants of health). Another said the recommendation about an online Healthy People Community would be critical to the cost-effective dissemination of Healthy People. Something as simple as a Healthy People group on Facebook would help to raise awareness of the initiative. It was suggested that this recommendation should be examined in greater depth, as it would require a great deal of work.
Another member suggested that the Committee use the WHO report for content related to strengthening the base of data available to show relationships among social determinants and health outcomes. He asked whether the subcommittee had identified data sources for this information. Dr. Manderscheid said the Subcommittee had reviewed and identified several data sources and tools that elaborate on the social, physical, and environmental determinants of health, as well as new systems that are beginning to measure them. He offered to have the Subcommittee compile this information and distribute it to the Committee. This work should be coordinated by HHS so that the data are more accessible to health professionals who do not interact with departments outside of the health sector.
A member asked how the work of the Subcommittee on Data & IT could be integrated with that of the Subcommittee on Implementation, especially with regard to strengthening the role of the Healthy People Community. Dr. Manderscheid said the two subcommittees should collaborate to provide more structure to that recommendation before delivering the recommendations to the Secretary of HHS. At the end of the discussion, Dr. Fielding suggested the Committee consider approving recommendations, as discussed.
- Dr. Fielding requested a motion to approve the recommendations of the Subcommittee on Data & IT. All members who were present voted to approve; none were opposed.
IV. Next Steps Healthy People 2020 Implementation Strategies
Ms. Eva Moya, Co-Chair of the Subcommittee on Implementation explained the work that her group had done to address the Committee's feedback from the July 10, 2009, meeting. After revising the Subcommittee's short- and long-term recommendations based on comments, the subcommittee members revisited their report. Changes were made to highlight the social and physical determinants of health. In an effort to move towards a Health in All Policies approach, non-health related entities and activities are important. Ms. Moya read through the revised language for all of the recommendations that had been prepared by the Subcommittee. (These had been discussed in detail during the July meeting and are presented in the Subcommittee's written report.) She then invited Dr. Shiriki Kumanyika, Vice-Chair of the Committee, to comment on any additional issues before opening the floor for discussion.
Dr. Kumanyika suggested that the recommendation to develop an interactive Web-based Healthy People site be moved from long-term to short-term recommendations. The resources for developing this would be needed on an immediate and ongoing basis and should not be relegated to a list of items for future consideration. Dr. Fielding commented that the recommendations may be too state-centric; there should be direct collaboration with municipalities, as well as through local organizations, such as NACCHO.
He added that the recommendations should talk about how other agencies and departments should interface to adopt a Health in All Policies approach. He suggested that some sort of group is needed to reinforce what exists now and encourage agencies to work together. Finally, Dr. Fielding also commented that the recommendations regarding private companies should broadly address all companies and not simply those outside of the health sector. He felt that the Committee should, at its September meeting, consider a separate document that would be useful for the business community and worded in a way that is brief and consistent with the world views of the private sector. Dr. Fielding recommended that the proposed revisions to the document be incorporated and that the Committee consider a motion to approve. Dr. Kumanyika agreed, with the caveat that the recommendations of the National Business Coalition on Health should be incorporated. Ms. Moya concurred.
- Dr. Fielding requested a motion to approve the Subcommittee on Implementation recommendations. All members who were present voted to approve; none were opposed.
V. Healthy People 2020 Criteria for Evidence-based Strategies
Dr. Fielding explained that he and Dr. Steven Teutsch, an Ad Hoc group member, had incorporated the Committee's feedback from the July 10, 2009, meeting into a revised version of the Evidence-based Strategies report. The report was then circulated back to the Committee for feedback so that final recommendations could be made. Dr. Fielding thanked Steven Teutsch, Ned Calonge, Mike McGinnis, and Tracy Orleans for their contributions to the report. He emphasized that the criteria for evidence based strategies should not drive priorities, although it is probably one of the issues that should be taken into account. Before opening the floor for discussion, Dr. Fielding noted that the report addresses three basic questions:
- How should decisions be made about linking Healthy People objectives with evidence-based interventions?
- What should be done when there is insufficient evidence to identify effective interventions?
- And what guidance could be provided to users about what needs to be done?
A Committee member expressed concern that, given the size and complexity of the potential target audience, it would be a challenge to engage everyone at every level. When programs and policies are implemented in communities, the issues are very complex. One possible way to address this would be to consider possible uses of social networking to communicate about effective interventions.
Another member asked how Healthy People 2020 evidence-based practices should be coordinated with the health reform legislation. This legislation is defining criteria for evidence-based practices in clinical prevention and health promotion interventions. Dr. Fielding said there must be a clear mandate for the Community and Clinical Guides to continue their work. He invited Dr. Teutsch, who was present on the phone, to comment. Dr. Teutsch said much of comparative effectiveness research doesn't address population health interventions as fully as one would like. He stressed that it is important to bring this issue to people's attention.
Members should come to an agreement on the level of certainty that is needed, and what magnitude of effect, before it can be said that a particular strategy is worthwhile to pursue. Dr. Fielding noted that the Committee should review the report to ensure consistency and include any additional opportunities that may come from the legislation. As a final note, Dr. Kumanyika added that the report should include a disclaimer noting that standards of evidence will differ depending on health intervention.
- Dr. Fielding requested a motion to approve the report on selecting evidence-based actions. All members who were present voted to approve; none were opposed.
VI. Healthy People 2020 Priorities
Dr. David Meltzer, Chair of the Subcommittee on Priorities, gave an overview of the group's recent activities. During their July 10 meeting, Committee members had decided to explore two areas for priority-setting: 1) the gap between evidence and practice for each health area, and 2) the overarching Federal investment in areas that would have a pervasive effect. The latter would encompass the "3-four-50" approach (i.e., three risk factors affecting four chronic diseases that cause 50 percent of all mortality) and the idea of cross-cutting social determinants. Priorities could be chosen based on the "know-do" gap (i.e., thinking about what we know could be accomplished, based on the evidence, and comparing that to where we actually are now). Another approach would be to consider what effectively reduces the frequency and/or severity of the burden.
Since July, the Subcommittee had met twice and had developed a 3-pronged approach to priority-setting. This would involve setting priorities at three levels: 1) the FIW could use a quantitative algorithm to set priorities within topic areas; 2) certain pervasive health behaviors could be identified and targeted in order to address a spectrum of health issues (the 3-four-50 approach); and 3) a Health in All Policies approach could be used to address determinants in the social and physical environment by addressing some of the causes of health disparities.
The first prong, priority setting within topic areas, would involve the use of quantitative algorithms for setting priorities. He noted that priorities are not monolithic and would vary by stakeholder. Another challenge is that there may well be thousands of objectives, which would make it nearly impossible to apply a rigorous quantitative algorithm to all of them—especially within the context of the limited resources that the FIW will have for prioritization.
Dr. Meltzer then turned the session over to Dr. Teutsch, who presented a grid that could be used to set priorities among multiple sets of stakeholders. The grid includes various elements that pertain to how well an intervention works and how big of an impact it can be expected to have. Comparative effectiveness will be increasingly important for decision-making. Decisions should be about more than whether an intervention works at all, but whether it works better than something else. Another consideration that should be weighed is whether an intervention works better for some select populations than others. The grid provides transparency and demonstrates that there is no simple, formulaic way to arrive at the right answer. Deliberative processes are needed in order to adequately assess the various dimensions of these decisions.
After reviewing the proposed processes for prioritization, Dr. Meltzer asked for Committee feedback. Dr. Fielding clarified that there was no expectation that the Committee would come to the point of approving the recommendations on this day. It would be an important area of discussion for the September meeting. A member said the CDC and others are presently involved in trying to develop clear messages about social determinants for the public and stakeholders. There is emerging evidence in this area that may be useful.
Another member noted that his department had commissioned past research on framing health determinants and health disparities which he could share with the group. He also supported the idea of incorporating social determinants based on evidence that differences in health outcomes by population are 25 percent due to individual behavior and 75 percent due to social and environmental determinants. He added that the Subcommittee should incorporate recommendations from the World Health Organization's Commission on the Social Determinants of Health report. Dr. Fielding noted that the Subcommittee should work to produce a revised version of prioritization recommendations that would be discussed more extensively at the September 2009 in-person Advisory Committee meeting.
VII. Supplementary Report on Social Determinants
Dr. Kumanyika explained the rationale for developing a separate report to highlight how social determinants of health could be operationalized for users. The intent of this document was to offer additional guidance on concrete steps that could be taken to address these issues. Paula Braveman, Director of the University of California San Francisco's Center on Social Disparities in Health, had commented on an initial draft, and had also offered to point the Committee to additional resources that were used by the Robert Wood Johnson Foundation's Commission on Building a Healthier U.S. to write their report.
Dr. Kumanyika noted that the preliminary draft had been compiled from text from earlier Committee documents, such as the preamble in the Phase I report, that explicitly addressed social and physical environmental determinants. A more complete draft would be prepared for review in time for the September 2009 meeting. She said that Committee members should provide feedback on the report's content and structure to ensure that the social determinants perspective was clearly articulated. After a brief discussion about terminology (whether to use the term "social determinants," "societal determinants" or "social and physical environmental determinants") the Committee decided that these issues required additional discussion.
VIII. Wrap-Up and Next Steps
On behalf of the Advisory Committee, ODPHP, and the FIW, Dr Fielding thanked all Subcommittees for their hard work and members of the public for their attendance at the meeting.
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