Healthy People 2000 Consortium Meeting November 7, 1997

Summary of Breakout Group Discussion Concerning Priority Areas 15 and 16: Heart Disease and Stroke and Cancer

Comments Received At the Meeting

The Cancer and Heart Disease and Stroke focus areas met together and discussed the following issues.

Issue: Special Populations—reducing vs. eliminating disparities—the switch to "eliminating health disparities" for HP 2010.

Comments

• This is a great idea. Would provide more attention to groups with greatest disparity.
• This is symbolic and provocative. It may force collaboration and may make leadership refocus attention—provides new direction and new way of thinking.
• It may drive the development of new data tracking systems to assess progress.
• May have to take a number of issues into consideration—one major one being the allocation of resources to "eliminate disparities." We do not have control over how agencies decide to allocate resources for Healthy People activities.
• ODPHP may need to conduct focus groups to ascertain how "special populations" feel about the two concepts—and, whether special populations want separate objectives.
• This issue will require/warrant political action and redistribution of resources.
• There may be "fallout" or negative publicity if the Healthy People report indicates that progress is not being made in equity with the general population—because the target is much too ambitious.
• Are there interventions/science/data to justify that these ambitious objectives can be achieved? We need to focus on what is reachable, not ideal.
• What does it mean if "elimination" is chosen as the focus for the special population objectives?
• Some groups may have to double or redouble their efforts if "elimination" is selected. This may create frustration for some groups if they interpret this as a government mandate.
• We need to develop linkages and partnerships with the business community to help with areas of high need if the focus is "eliminating disparities."
• To eliminate disparities, we need to make Healthy People outcome measures link better with performance measures such as GRPA and Possibly NCQA/HEDIS.

Issue: The Framework-the FAN

Comments

• The structure is not clear. Special populations are isolated—and the relationship presented between chronic diseases and health behaviors does not work.
• What is the purpose of the fan? If it is to be a visual to communicate what Healthy People 2010 is—then it does not communicate this very well. It should be a simple graphic with a few straightforward messages.
• The focus of the framework should be on health behaviors—If interventions target health-risk behaviors and lower them, then the result should be less morbidity and mortality from chronic diseases.
• The fan needs "breakdowns" to identify the kinds of things that we want to accomplish. There is just too much information to digest. Also, too many artificial divisions among focus areas.
• There need to be attention given to where research is going—it seems prudent that research advances should have an effect on the way the framework is structured.
• We need to consider the "ethics" of the Healthy People 2010 framework (relative to delivery (system) of health care and to increasing the years of healthy life.
• A pyramid structure was suggested as an alternate framework.
• The enabling goals were found to be acceptable, except that special populations need to transcend the FAN.
• Some of the focus areas were confusing and seemed misplaced.
• Suggested to use building blocks to try to relate risk factors and health behaviors to chronic diseases in a more scientific manner.

Issue: No Duplicate Objectives and Types of Objectives

Comments

• Having no duplicate objectives is nice because there will be fewer objectives overall; however, this does raise questions about how objectives that fit in multiple focus areas will be distributed among relevant focus areas..
• One can cross-reference objectives in other chapters.
• Who decides where the duplicate objective will reside (its homeroom??)
• There may be agency rivalry regarding placement of duplicate objectives.
• Suggest using a table to show duplicate objectives ("homeroom") and all the focus areas that would have it as a duplicate objective.
• We may want to keep the duplicate objectives and allow them to appear in relevant chapters.
• It is a good idea to have both measurable and developmental objectives. Developmental objectives could drive the development of new data systems.
• In some cases, we may need to keep an objective even though it may not have data for evaluation purposes. Suggest changing certain objectives from "developmental" since they will be deleted if data are not available by 2005. It is important to recognize that we sometimes need to keep an idea or an issue on the "agenda" even though we do not have data. This can make government agencies more sensitive to an issue or it may even bring about a degree of embarrassment if the issue is not addressed. We are not suggesting that we eliminate the term "developmental"objectives—we simply need to think about whether we should use another term if we want to keep the objective beyond 2005 even if no data exist to measure progress.

Healthy People 2000 Objectives

The Healthy People 2000 Objectives for Cancer and Heart Disease and Stroke were reviewed in preparation for Healthy People 2010. The group was asked the following question:

Are there objectives you wish to ADD, DELETE or are you SATISFIED with the current objectives?

Cancer Objectives

Comments

• No objectives to be deleted.
• Add a developmental objective on genetic testing?
• counseling by primary care providers
• training of health care providers
• support systems
• patient education
• support groups
• For objective 16.17 use "larynx" instead of oral cavity.

Heart Disease and Stroke Objectives

Comments

• Do not delete any objectives even if met already.
• Develop an objective on Heart disease for American Indians
• Need an objective on awareness about stroke—Early treatment
• Need to consider disability data on stroke.

Comments Received After the Consortium Meeting

These comments were provided by the Centers for Disease Control (Amy Holmes-Chavez—CDC/NCCDPHP) after the consortium meeting.

• Comments on the "Fan"
  
  All of the enabling goals are important to public health approaches to health improvement. However, the graphic model should be modified to reflect the fact that health promotion and reducing mortality in most focus areas draws on a variety of the approaches expressed in the enabling goals. Currently, the "fan" model attempts to divide focus areas into singular approaches to health improvement. The model should suggest the interrelatedness of focus areas rather than create rigid lines separating the Healthy People focus areas.
  
  All morbidity and mortality focus areas of HP 2010 should appear under "Increase Years of Healthy Life." Currently, only "Impairment and Disability" and "Chronic Diseases" appear under this goal. This does not make sense, as prevention of the other morbidity and mortality focus areas proposed (HIV, STDs, Infectious Diseases, Violence and Injury, Mental Health) also contributes directly to increasing years of healthy life. The inclusion of only disabilities and chronic diseases under this goal may imply that chronic diseases are a concern only of the
  
  elderly. To the contrary, prevention of chronic diseases should begin early in life.
  
  The graphic model should demonstrate that eliminating health disparities, and focusing on special populations, are concerns that should be addressed throughout the Healthy People effort. Currently, the goal "eliminating health disparities" and the focus areas for "special populations" seem tacked on to the end of the model. They should be integrated into the model.
  
  Goals and focus areas in this model should be stated in prevention terms. In order to increase years of healthy life, we want to prevent and control impairment and disability, heart disease, use of tobacco, cancer, HIV, violence, etc. Likewise, we want, "Tobacco Use Prevention and Reduction," not "Tobacco." The focus areas are currently stated as if we want to give people diseases.
• "Heart Disease" and "Stroke" should be combined into one area entitled "Heart Disease and Stroke."
  
  "Heart Disease," "Stroke," "Cancer," and "Diabetes" should continue to be listed as separate focus areas rather than be rolled into one "Chronic Diseases" focus area. "Chronic Diseases" has little meaning to the general public, while "Cancer," "Heart Disease and Stroke," and "Diabetes" are major public concerns. In addition, given the number of organizations involved in efforts to prevent each of these diseases, a single focus area/work group attempting to address all three, as well as other important chronic diseases, would be unmanageable. The group would either be extremely large, or it would have to set participation caps and exclude important partner organizations. The network of organizations across the country involved in preventing and controlling these diseases is broad and includes Federal and State agencies, professional associations, and highly visible not-for-profit disease-focused organizations such as The American Cancer Society, the American Heart Association, etc. A "mega-work group" would also find it very difficult to focus on accomplishing progress in any particular disease area because of the diversity of risk factors that would have to be addressed.
  
  Clarity is needed as to how responsibility for objectives will be handled, given that objectives will not be duplicated. One suggestion might be to identify a primary "home" for each objective, but have the objective referenced in other relevant focus areas.
• "Eliminate Health Disparities"
  
  This goal is important. Understanding factors contributing to health disparities will help us improve the health of populations that have historically experienced a heavy burden of disease and disability.
  
  Agree on the establishment of a common target for all populations. Many people have been unhappy with the decision to have different targets in the year 2000 objectives.
  
  The role of special populations "focus areas" under "Eliminate Health Disparities" is unclear. Subobjectives could be created for objectives for which particular populations bear a disproportionate burden of death, disability, unhealthy behavior, etc. Progress reviews
  
  on eliminating health disparities would then focus on progress in eliminating disparities for these objectives. Special populations focus areas could also present general approaches to improving health for special populations.

Participants

Bruce Black, American Cancer Society
Janet Brown, American Speech, Language, and Hearing Association
Georgia S. Buggs, Office of Minority Health, Department of Health and Human Services
E. Frank Ellis, Department of Health and Human Services, Region VII
Rob Fulwood, National Heart, Lung, and Blood Institute
Betty Lee Hawks, Office of Minority Health, Department of Health and Human Services Amy Holmes-Chavez, National Center for Chronic Disease Prevention and Health Promotion
Carole Johnson, American Heart Association
Kathleen King, National Stroke Association
Barry Portnoy, National Cancer Institute

Breakout Session List