The impetus for the development of leading health indicators derives from various sources. To better communicate with the general public and with new partners in Healthy People such as managed care organizations and businesses, a tangible and accessible subset of the national health objectives is sought that can be portrayed as key hallmarks of the broader set. The leading health indicators are intended to meet this need. Also, the existence and use for some time of principal economic indicators, which are widely reported and which feed with varying facility into the policy arena, have enhanced the public's awareness of the economic status of the Nation. Leading health indicators may help prompt enhanced public awareness of the status and determinants of the health of the Nation.

Current Health Indicators

Driven in part by reporting requirements attendant to various authorized programs and in part by the greater availability of comparable data at the subnational level, substantial activity has been generated around the development of various sets of indicators using different approaches to characterize health status and progress. The purposes of these indicators are to chart progress, forecast trends, and direct programmatic attention and resources to areas that require attention. Some of the indicator sets draw predominantly from mortality statistics, others focus on the major risk factors that predispose to disease, injury, and death, or a mix of risk factors and their health outcomes; some incorporate relatively few items, others are much more inclusive; some attempt to reflect the status of the considered factors on a type of a numerical reference scale, others seek to aggregate them in some fashion; some include social factors, such as education or income, others depend primarily on issues that are directly within the purview of the health sector.

To better understand some of the current trends in development of health indicators, the working group reviewed several indicator sets. Examples of the sets reviewed include the work of:

• The Committee for Objective 22.1, which was convened by the Centers for Disease Control and Prevention to implement Healthy People 2000 objective 22.1, the objective that called for the development of a consensus set of health status indicators that would be collected in comparable fashion by public health agencies at all levels of Government. Non-Federal participants included those from the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), the U.S. Conference of Local Health Officials (USCLHO), and the American Public Health Association (APHA). A series of 18 health status indicators were identified, and have been the object of implementation activities since they were published in July 1991. The committee also identified 16 priority data needs which were not measurable at the State level in 1991. Eleven of these measures now are measurable at the State level. Both data sets include mortality measures, morbidity measures, and risk factor measures (Appendix E).
• The Institute of Medicine of the National Academy of Sciences, which reviewed a variety of candidate measures for assessing and reporting a profile of community health status and, drawing heavily from the work on 22.1 noted above, proposed a basic set of 25 indicators for common use, including sociodemographic characteristics (e.g., age, ethnicity, education, income, poverty, unemployment, uninsured, single parent families), health status (e.g., infant mortality, death rates for leading causes, incidence of leading infectious diseases, teen births, child abuse, immunization levels, tobacco use, obesity, air quality, water quality), health care resource consumption (Medicare spending), functional status (reported health status) and quality of life (reported as satisfaction with community and health services) (Appendix F ).
• A Lewin-VHI Study commissioned by the National Center for Health Statistics (NCHS), which identified approximately 80 candidate indicators for further consideration by the NCHS Key Indicator Working Group, including about 30 identified as primary indicators. The primary indicators were grouped into eight categories: 1) health status (years of healthy life, premature death from chronic disease, smokers, obesity, alcohol misuse, seat belt use, perinatal mortality, infant mortality, low birth weight, age-specific mortality, disability rates), 2) public perception (consumer confidence in care, views on health expenditures), 3) access (population with regular primary care, access to screening), 4) utilization (primary care utilization, preventive services utilization, avoidable hospitalizations), 5) quality outcomes (perinatal mortality, infant mortality, mortality rates by age), 6) consumer satisfaction (satisfaction with current health plan, satisfaction relative to past), 7) insurance (coverage, newly enrolled Medicaid), and 8) health spending (out-of-pocket spending relative to disposable income, national spending as share of gross domestic product).
• The Federal Interagency Forum on Child and Family Statistics, which in 1997 identified 25 key indicators of child well-being, including child poverty, food security, housing problems, parental employment, health insurance, prenatal care, infant mortality, low birth weight, immunization coverage, activity limitation, child mortality, teen mortality, teen births, tobacco use, alcohol use, substance abuse, crime victims, language difficulties, family reading, early childhood education, math and reading skills, high school completion, detached youth, higher education, and child neglect and abuse (Appendix G).
• The American Health Foundation, which developed a Child Health Report Card on progress according to 80 different parameters in 23 major areas, including health habits, risk factors, death rates, disease rates, hospitalization rates, health care utilization rates, immunization rates, child care patterns, physiologic measures of health status, dietary patterns, and school physical activity patterns. Letter grades (A, B, C, D, and E) were assigned to indicate the quality of progress in relation to the Healthy People 2000 goals and objectives (Appendix H).
• The State of North Carolina, which developed a Community Wellness Index as an accountability instrument for measuring county health status and health department progress. In this approach, the State identified eight areas--maternal and infant health, child health, heart disease and stroke, cancer, diabetes and other chronic disease, injury, communicable disease, adolescent health status--each with two to four indicators to develop a community's wellness profile. In addition, a set of 32 process indicators was developed to describe the nature, quality, and quantity of public health services that are provided in North Carolina. The State hopes to evaluate the impact of these services on health status outcomes (Appendix I).
• The State of Connecticut, which developed a report card instrument for the Healthy Connecticut 2000 process, as a means of indicating how Connecticut compared with other States on factors such as life expectancy, heart disease, cancers, AIDS, other sexually transmitted diseases (STDs), diet and nutrition, exercise, hypertension, screening, tobacco use, motor vehicle fatalities, seat belt use, violence, homicide, suicide, infant mortality, low birth weight, immunization, and substance abuse (Appendix J). Similar activities have been undertaken in many States and local jurisdictions.
• The UCLA Center for Healthier Children, which initiated a project to design community report cards on various dimensions of health status and health services in their communities. The project is based on the experience of the 76 percent of the communities which an initial survey indicated had already produced a report card of some type.
• The Northwestern National Life Insurance Company, which developed its ReliaStar State Health Status Index as a means to estimate by State the overall health of the population in each State. The index uses 17 health status measures from five categories (lifestyle, access to care, occupational safety and disability, disease, and mortality), assigns each measure a weight according to expert judgment on the measure's relative importance as a proportion of the total, and calculates an overall score by summing the weighted measures. A conversion factor corrects the scores, based on 1.0 as a national average for overall health status, scores above 1.0 representing poorer health status and below 1.0 representing better health. The scores ranged from 0.81 for New Hampshire to 1.24 for Mississippi (Appendix K).
• The General Accounting Office, on examining various assessments of population well-being, concluded that premature mortality offered the "best single proxy for reflecting differences" among States in the health of their populations. Although this report does not offer a complete review of the issues, the working group includes this as an interesting example of a single parameter approach to the development of leading health indicators (Appendix K).
• Rodale Press, which has for a number of years published a Prevention Index, based on a poll conducted by Louis Harris, as a measure of whether the profiles of lifestyles and utilization of preventive services among Americans were improving, retrenching, or staying about the same.
• The American Medical Association, which is developing a health index that will be a composite of subscores for three populations: youth, adults, and older adults. The index uses over 50 different measures, including opinion polling conducted by Gallup, of status with respect to tobacco, alcohol, drugs, mental health, fitness and nutrition, sexual health, chronic illness, participation in prevention, victimization, and acute illnesses. Weighting will be used to put the results on a common scale, and the composite numbers will be generated for the three life stage groups.

To a great extent, differences in approach stem from differences in purpose. The profile of data incorporated into an indicator set may look quite different, depending on whether the sponsoring institution is an agency with responsibility first and foremost for ensuring the integrity of the Nation's vital statistics; a consortium of Federal, State, and local agencies seeking to develop common instruments that will allow cross-boundary comparisons and conclusions; a State or regional perspective; an agency with a focused mission such as the environment or child health; a program concerned with highlighting and addressing the particular challenges to low income, high risk populations; or an organization seeking to draw attention to issues of individual behavior that impact on health status.

The discussion of health indicators and indices has suggested analogies to economic indicators. Indeed, some indication of the types and utility of health indicators may be provided by considering the types and uses of economic indicators. Drawn from a wide range of economic statistics collected and disseminated by the Federal Government, two sets of indicators--the principal economic indicators and the indexes of leading, lagging, and coincident economic indicators--are seen as key summaries of the condition of the economy (Appendix L). In some ways, these two sets are similar to the sentinel or leading health indicators discussed here.

The principal economic indicators are determined by the Office of Management and Budget from a variety of statistical databases that describe the current condition of the economy, including those from U.S. Department of Agriculture (USDA) related to issues such as crop production and agricultural prices; those from the Department of Commerce related to issues such as the GDP, housing starts, retail sales, and manufacturers' shipments and inventories; those from the Department of Labor related to issues such as the employment situation, the consumer price index, and real earnings; and those from the Federal Reserve Board related to issues such as the money stock, consumer credit, and selected interest rates. In all, they represent dozens of indicators, released periodically throughout the year, and are rarely presented together, but taken as a whole they provide ongoing updates of economic activity and a general sense of the health of the economy.

A set of leading economic indicators is no longer produced by the Government. Since 1995, the Conference Board, a nonprofit organization located in New York City and made up of senior executives from 2,300 corporations in some 60 nations, became the official source for composite indexes of leading, lagging, and coincident economic indicators. The leading economic indicators are those that tend to shift direction in advance of the business cycle: average factory work week, initial unemployment claims, new orders for consumer goods, plant and equipment orders, building permits, change in unfilled durable orders, sensitive material prices, stock prices, consumer expectations, and money supply. The coincident economic indicators, such as employment and production, are broad series that measure aggregate economic activity; thus they define the business cycle. Finally, the lagging economic indicators tend to change direction after the coincident series. Percentage changes in the composite numbers for each of the three categories are computed and reported monthly. Complexities in the business cycle hamper the use of the indicators as predictors--often the indicators reveal where things are going about the time of arrival--but they nonetheless are considered useful in providing an earlier indication of trends than would otherwise be available, and they have considerable experience behind them.

Implications of the Economic Indicator
Experience for Healthy People 2010

There are obvious differences between the health and the economic sectors which limit the applicability of the economic indicators approach to health trends. Perhaps most basic is the fact that the economic indicators describe a system which is cyclical, one in which ebbs and flows and peaks and valleys are expected. There is no comparable cycle in health. With some notable exceptions--such as the emergence of HIV, the clustered outbreaks of certain previously contained infectious diseases, and fluctuations in the rates of homicide, suicide, and other injuries--for the most part health indices have generally reflected a steady improvement over time. The primary fluctuations have not been so much in reversals of fortune as in rates of change.

Still, there are several ways in which the economic indicators might inform consideration of the proper role and structure for leading health indicators. First, the economic indicators measure a complex system from multiple angles. The grouping and labeling of "principal" indicators was built slowly over time--rather than created out of a "model" from whole cloth--these measures give observers of the economy a picture of how one thing relates to another, as well as the status of the whole. The health of the population could be viewed in the same way. It is complex and must be viewed through multiple lenses. It is also affected by multiple external factors, and internal factors relate to one another in multiple ways. Like a system to predict weather, the economic indicators take readings in many places, feed that information into a model of how one thing relates to another, and generates a "short-term forecast." The key is to have many measures in many different places and a model that fits them together. The working group believes this will prove important in the development of leading health indicators.

Second, the economic indicators can be grouped into elements that may serve as a basic model for the Healthy People 2010 effort. They cover assets (e.g., manufacturing inventories). They cover inputs (e.g., plantings). They cover outputs (e.g., durable goods shipments). And they cover the volume and pace of transactions (e.g., U.S. international transactions). The health of the American population has similar key elements. There are assets of the population (e.g., the age structure of the population, good attitudes toward health, and a functioning public health system). There are inputs to good health (e.g., exercise and diet). There are outputs (e.g., years of healthy life). And there is a volume and pace of transactions (e.g., doctor visits, hospitalizations).

Finally, the concept of "leading, coincident, and lagging" indicators may have some parallel in the health field. There are indicators of activities that occur today (e.g., unhealthy behaviors) whose results shape the health status of the population in the future. There are also indicators that reflect impact or results today (e.g., mortality and morbidity data) which are known to be coincident with other current health problems (e.g., sexual behavior), and there are lagging indicators that help drive home the sustained impact of certain results (e.g., economic burden of disease). These concepts may offer utility in the design of leading health indicators.

The Relationship of Healthy People 2010 to
Strategic Planning and Performance Measurement

The Government Performance and Results Act of 1993 (GPRA) aims to improve the efficiency and effectiveness of federally funded programs by holding Federal agencies accountable for spending public dollars. Under GPRA, Federal agencies must submit a five-year strategic plan and an annual performance plan, beginning with the President's fiscal year 1999 budget, which was submitted in January 1998. Within HHS, Healthy People 2000 has provided a framework for initial development of the strategic plan as well as the GPRA plan. The efforts are mutually supportive and exert an influence on each other. Beginning with fiscal year 1999, it is expected that Healthy People 2010 will serve as a rich source of measures for future strategic plans and GPRA plans.

However, Healthy People, the HHS Strategic Plan, and GPRA differ in important ways. Healthy People sets 10-year targets, whereas the Strategic Plan sets five year targets and GPRA sets annual targets. Healthy People is focused on national achievements, whereas the strategic plan and GPRA are focused on the performance of a specific agency.

The Federal Government plays an essential role in achievement of Healthy People targets, and this will continue to be reflected in the HHS Strategic Plan and GPRA plan. Indeed, 22 percent of the HHS strategic objectives were adopted from Healthy People 2000. Healthy People therefore offers a reliable database for tracking progress for not only the national health goals, but also the Department's strategic and performance measures.

HHS hopes to continue learning about the links between Healthy People objectives and the strategies to achieve the objectives (i.e., the effectiveness of strategies for reducing risk, providing protective services, etc.) and to describe these links in future strategic and GPRA plans. In this way, the role and accountability of HHS and its agencies for achieving national health objectives can be better described.

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