Phase I Report
Recommendations for the Framework and Format of Healthy People 2020

Appendix 14.
Explanation of Prioritization Criteria for Sorting Objectives

Overall burden. The burden of a disease is a numerical description of the health impact of disease and injury at the population level. Burden can be measured in terms of the number of deaths in a population, or the number of existing cases in a population. A summary measure, or index, of population health can also be used. The quality-adjusted life year (QALY) is a summary measure that is commonly used to describe burden. It is a measure of years of life lived (or years of life gained due to an intervention), that has been statistically adjusted to take quality of life into account.

Preventable or reducible burden. This is an estimate, based on best available evidence, of the degree to which a particular disease and its overall burden can be prevented. Decision makers at multiple levels can use this information to decide which clinical preventive services matter the most, so that they can prioritize their actions. For example, preventable clinical burden can be calculated to include the cumulative effect of delivering a service multiple times at recommended intervals over a recommended age range, instead of delivering the service at a single point in time to one large sample of individuals.⁴⁰

A variety of approaches can be considered to determine the preventability of disease burden. For example, one could look at the burden of death and disability that can be avoided through means such as: vaccination, early diagnosis, timely and adequate medical treatment, application of hygienic measures, environmental sanitation, implementation of policy change (e.g., increased tax on alcohol products), or health educationusually coupled with other actions.

Cost-effectiveness. Cost-effectiveness analysis is used to evaluate the outcomes and costs of interventions that are designed to improve health. It has been used to compare costs and years of life gained for interventions such as screening for breast cancer and vaccinating against pneumococcal pneumonia.⁴¹ The outcomes are usually not assigned monetary values, as is the case in cost-benefit analysis.⁴² Instead, results are typically summarized in terms of ratios that show the cost of achieving a unit of health outcome (such as the cost per year of life, QALY gained) for different types of patients or populations and different types of interventions.⁴³ The purpose of analyzing the cost-effectiveness of interventions is to examine the trade-offs, or "opportunity costs," of making various choices.

Several concerns have been raised about use of cost-effectiveness analysis for setting priorities. These include the difficulties of: measuring quality of life; developing valid summary measures of population health over the life course; generalizing results to different settings; accounting for the fact that programs work synergistically (thereby making it difficult to isolate the effects of one intervention); and addressing "uncertainty" and lack of information about the cost-effectiveness of many potential interventions.⁴⁴

Despite the validity of these concerns, they need not prevent the use of cost-effectiveness analysis to inform decision making. For example, uncertainty about the cost-effectiveness of an intervention does not necessarily mean that the intervention should not be implemented. Information about the probable costs of an intervention, as well as the likelihood that it will be effective can be taken into consideration in calculating an estimate of its expected cost-effectiveness.

To help users make decisions based on the best information available, Healthy People 2020 should provide data on the degree of confidence concerning these key factors. For example, in the case of burden, Healthy People 2020 should provide quantitative estimates of uncertainty (i.e., information about the reliability of the estimate based on current evidence), as well as qualitative information that could influence uncertainty, (e.g., factors such as the estimate of current burden).

In the face of substantial uncertainty, users will need to make decisions based on incomplete information. Presenting the best available information can permit informed decision-making. In some cases, effects can be quantified by drawing on statistical, epidemiological, economic or other quantitative methods. Sensitivity analysis (a technique for assessing the extent to which changed assumptions or inputs will affect the ranking of alternatives) may be used⁴⁵ (e.g., how the life expectancy gains of cancer surgery change as the rate of surgical mortality changes).

Value of information (VOI) analysis could also be used to determine when collecting more information on uncertain factors could be worth the cost of generating that information. In other cases, more qualitative approaches to decision-making under uncertainty will need to be used.

Net health benefit. A program's net health benefit is the difference between the health benefit achieved by a program, and the amount of health gain that would be needed to justify the program's costs. If resources are spent on one program instead of another one that would create a higher net health benefit, an opportunity for greater net gains in health is lost. The difference between the net health benefit of two different interventions is the cost of choosing to spend resources on the "wrong" program. Thus, net health benefit is different from cost-effectiveness in that it looks more explicitly at the "opportunity costs" of investing in programs of lesser net value.⁴⁶

Synergy. A "systems" approach to public health program planning acknowledges that results are usually greater when multiple interventions of proven effectiveness are put in place simultaneously. It is important to understand that single interventions, implemented one at a time, are usually insufficient to reduce all preventable burden.

Healthy People 2020 should present a "menu" of interventions. Where data are available, they should be characterized by their cost-effectiveness, the size of the benefit, and the population affected. In some cases, the cost-benefit is unknown, but it is important to identify the potential benefits of effective interventions. The Healthy People menu of interventions should highlight a key intervention or group of interventions (presumably with the strongest evidence base), along with a set of alternatives.

Timeframe. To improve the health of populations and reduce health disparities, it is important to prioritize a mix of issues that require short, medium, and long-term investment. Many elected officials are concerned with the timeline for expected outcomes because they want to demonstrate timely results to their constituents. It can be easier to argue for program funding if elected officials can reasonably expect improved outcomes on a shorter timeline. Yet it is also important to invest in programs that will yield results over the long term. Healthy People 2020 should communicate clearly about the value of interventions that have long-term payoffs that may not be evident in the short run. For example, programs and activities to address chronic disease will require a longer timeline for investment than those dealing with infectious disease.

Reduced health inequities. Some have noted that health inequities can be reduced by diminishing the health status of those who are better-off. Healthy People 2020 should be explicit about the need to focus on improving the health status of those who are worse off. Because minority populations in the United States often have worse health status than the general population, this principle specifies the need to improve the health of these groups.

It must also be acknowledged that data-based criteria for priorities could disadvantage population groups with limited data or limited tests of interventions. Lack of complete data about these population sub-groups should not justify a lack of action aimed at reducing disparities. Improving the data on the needs of these groups and intervention effectiveness for these groups should be a priority.

Accepting accountability and working together. This principle addresses the fact that, if no one is responsible for achieving demonstrable improvements, results are less likely to occur. Although public health departments have been a primary audience for prior versions of Healthy People, when working alone they are not able to effectively reduce the burden for all diseases and injuries. These organizations must set realistic priorities in order to accomplish feasible goals and find ways to work together.

Governmental public health agencies can make progress towards achieving a much wider set of health objectives by partnering with other key stakeholders. Although they cannot accept sole responsibility for accomplishments when they are only one member of a broad partnership, they should take a key role in convening and coordinating such partnerships. Lack of full capacity, or political challenges, do not justify a lack of action on issues where there is a high burden and proven interventions to address outcomes and/or determinants.

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