Section Three
POTENTIAL MODELS

Based on the many different ways leading health indicators may be conceptualized, a number of models can be postulated to reflect different, but overlapping, approaches to the development of such indicators. The working group identified 15 possible models to use in developing candidate sets of leading health indicators. The list is not exhaustive and could be expanded on several dimensions.

• Mortality Model: The mortality approach to the development of leading health indicators would focus on highlighting the Nation's progress in addressing the leading causes of death for Americans, as reported from vital statistics. In this case, the key indicators would be the death rates from the leading diseases and sources of injury: heart disease, cancer, stroke, injury, lung disease, pneumonia and influenza, HIV infection, suicides, diabetes, and homicide. Reports might be stratified by age, gender, and vulnerable population.
• Health Status Model: The health status approach to the development of leading health indicators would use 17 of the indicators identified by the Committee for Objective 22.1, plus 12 additional measures, to reflect the Nation's health status. This set of indicators includes death rates, disease rates, and risk factors, individually reported, for prominent issues: infant mortality, motor vehicle death rates, occupational deaths, suicides, lung cancer deaths, breast cancer deaths, cardiovascular deaths, homicides, and total death rates; incidence of AIDS, measles, tuberculosis, and syphilis; and occurrence of low weight births, teen births, first trimester prenatal care, childhood poverty, and persons living in places with low air quality.
• Disparities Model: The disparities approach to development of leading health indicators emphasizes drawing attention to those areas in which the health disparities are greatest among population groups. In this approach, any one of the models identified above, or some combination of the models, would be used to identify the key indicators, but the reporting would be undertaken not in terms of the absolute rate for the population as a whole, but in terms of the range of disparity that exists among population groups in the country with regards to any given issue. For example, the emphasis would not be on merely reporting a national death rate for strokes of 30 per 100,000, but of reporting that African-Americans are the group with the highest stroke death rate (50 percent higher than for the population as a whole).
• Leading Contributors Model: The leading contributors approach to the development of leading health indicators would focus on issues that are "actionable" as major contributors to unnecessary death and disability in the United States: tobacco use, dietary patterns, physical activity patterns, alcohol misuse, preventable infectious diseases, exposure to toxic environmental and occupational agents, firearms, risky and unprotected sexual behavior, motor vehicle factors, illicit use of drugs, lack of access to timely and appropriate medical care. Education levels and poverty rates might also be candidates for consideration in this model.
• Focus Area Model: The focus area approach to the development of leading health indicators would draw one key indicator from each of the focus areas of Healthy People 2010, identified as particularly representative of the major issues for the area, in consultation with the respective focus area working group. Although subject to change, the currently proposed focus areas are: mental and physical impairment and disability; chronic diseases; physical activity; nutrition; sexual health; unintentional injuries; tobacco; substance abuse; food and drug safety; environmental health; occupational health; infectious diseases; health services; mental health services; oral health; family planning; maternal, infant, and child health; public health infrastructure; educational and community based programs; and violent and abusive behavior.
• Summary Measures (Goals) Model: An approach given recent visibility by a World Bank/World Health Organization project, is the summary measures model: a calculus that is intended to express in a single measure (the disability-adjusted life year (DALY) measure, in the case of the World Bank) a variety of elements that affect quality and length of life. Because two broad goals of Healthy People 2000 (and likely Healthy People 2010)--increasing years of healthy life and reducing health disparities--may be useful in the summary measures approach to track progress, this could also be called the goals approach. In this approach, reliance could either be placed on aggregate indicators--e.g., DALYs, or its related measure, QALYs (quality-adjusted life years), and relevant health disparities by race, ethnicity, gender, age, or socioeconomic status--or on a small family of indicators (e.g., life expectancy, years of potential life lost, age-adjusted disability rates, infant mortality rates) reported by race, ethnicity, gender, age, or socioeconomic status.
• Social Indicators Model: The social indicators approach to the development of leading health indicators would emphasize indicators that target social determinants generally acknowledged as having powerful, if not dominant, influences on the Nation's health profile. The indicators in this model would include high school graduation rates, unemployment rates, poverty rates, crime and violence, children born out of marriage, homelessness, infant mortality, and other measures of health disparity.
• Environmental Model: The environmental approach to the development of leading health indicators would identify and track those policy-oriented issues that affect the physical and social environments in which people live and which have an important bearing on their health prospects. Measures would include issues such as the proportion of the population living in communities with clean air; the proportion of workers in smoke-free workplaces; the proportion of children in smoke-free homes; the proportion of the population with adequate seatbelt laws; the number of communities free of food- or waterborne disease outbreaks; the proportion of the population with access to parks, walking, or biking trails; the availability and accessibility of acute care services.
• Report Card Model: The report card approach to the development of leading health indicators would identify those factors which best lend themselves to comparison across communities, States, and countries--such as those in the Health Status Model--and establish a grading scale for reporting, pegged to the best performer, as if grading on the curve. For example, if the best State experience was an infant mortality rate of 6 deaths per 1,000 live births, grades of "A" could be reported for states in the 6-7 range, "B" for the 7-8 range, "C" for the 8-10 range, and "D" for the 11-12 range. Alternatively, an absolute scale could be developed, based on the performance with respect to either established goals or estimated best possible experience, given current knowledge and resources.
• Index Model: The index approach to the development of leading health indicators would develop aggregate measures on key dimensions by "summing" the numbers from several indicators to create a single composite indicator or a few such indicators. In this approach, indicators and their rates would be "clustered" so that a common, scaleable number could be developed to represent the overall status of the factors in the grouping. For example, factors related to pregnancy (prenatal care, low weight births, maternal mortality, infant mortality) could be grouped and the experience aggregated for a geographic area and reported on a 10-point scale that would allow geographic comparisons. Similar cluster analyses could yield indices for the prevalence of behavioral risk factors in a given area, the quality of the environment, or the availability and accessibility of a key health services.
• Single Parameter Model: The single parameter approach to development of leading health indicators would use a single indicator, chosen because of its power as a surrogate indicator of status with respect to multiple health factors. It would be determined using statistical analyses to identify the one currently available indicator which best predicts overall health prospects and differences in health status among population groups. An assessment by the General Accounting Office suggests that premature mortality might serve as a single parameter.
• Sentinel Model: The sentinel approach to development of leading health indicators would identify those events which, if they occur, indicate a serious problem in the system. The term is drawn from the use of canaries deep in coal mines to provide early warning, by virtue of their demise, of the presence of gases potentially toxic to the miners. Health sector-wide issues of this sort include the occurrence of cases maternal mortality, polio, measles, water- or food-borne disease, other unusual infectious diseases, medication-related deaths, and increases in infant mortality.
• Prevention Model: The prevention model approach to the development of leading health indicators would track and report national health progress related to the major opportunities for primary (e.g., vaccine-preventable diseases, diet, physical activity, tobacco, alcohol, drugs, sexual behavior, injury control measures, prenatal care), secondary (e.g., screening and intervention for inborn errors of metabolism, hypertension, elevated serum cholesterol, cervical cancer, breast cancer, colorectal cancer), and tertiary (e.g., management of diabetes, asthma, hypertension, osteoporosis, heart disease, depression) prevention.
• Human Development (or Life Stage) Model: The human development approach to the identification of leading health indicators emphasizes the use of targets of key transitions in life and the services that affect those transitions. Measures would be reported that reflect the experience by age grouping with respect to death rates, rates of disability, quality of life, services accessibility, and satisfaction with services.
• Change Theory Model: The change theory model approach to the development of leading health indicators focuses on the key things that have to happen to improve the health status of the population. Factors to be included, in addition to those identified in the leading contributors model noted above, might include institutional factors such as those related to education, choice in the workplace, and structure and incentives at work in health services delivery.

Because the working group approached its task by considering models that would reflect the strengths of the Healthy People initiative to the general population, models explicitly patterned on the Healthy People framework were viewed as strong candidates. For example, the summary measure (goal) model is based on the two proposed goals of Healthy People 2010; the focus area model is based on the topics covered in Healthy People 2010; the health status model is based on objective 22.1 in Healthy People 2000; the human development (life stage) model is based on the topics covered in the first Healthy People document (Surgeon General's report). All of these models, through their association with the Healthy People framework, would reflect the strengths of the initiative to the general public.

The leading contributors model, disparities model, social indicators model, change theory model, prevention model, sentinel model, and environmental model are examples of models that would help advance the initiative by focusing on areas that need more attention (lifestyle, disparities in health, social and environmental factors that influence health).

The mortality model (data available at the community level), the single parameter model, report card model, and the index model reflect current trends in developing indicator sets, but were not viewed as strong candidates by the working group. of Health and Human Services, 1979.

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