 |
Healthy People Home > Healthy People 2020 > Secretary's Advisory Committee > Third Meeting > Minutes > Day 1 |
|
|
Secretary's Advisory Committee on
|
|
| Minutes of Meeting 1 (January 31-February 1, 2008) were approved (12
in favor, 1 absent). Minutes of Meeting 2 (May 1, 2008) were approved (12 in favor, 1 absent). |
Rear Admiral (RADM) Penelope Slade Royall, Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion), thanked Committee members for their efforts. She gave an overview of the six Healthy People regional meetings that had taken place between March and May, 2008 (Atlanta, GA; San Francisco, CA; Fort Worth, TX; Chicago, IL; New York, NY; and Bethesda, MD). Through the meetings, the U.S. Department of Health and Human Services (HHS) received feedback about aspects of Healthy People 2010 that have been working well, and areas where change is needed. A member of the Advisory Committee participated at each regional meeting.
A total of 1,264 people participated in the regional meetings; of these, 267 submitted oral public comments. Comments received at the meetings generally supported a two-pronged approach to developing Healthy People 2020 (i.e., including both risk factors/determinants and specific diseases). Regional meeting participants touched on a broad range of issues: county and city level data; media outreach, marketing, and dissemination of Healthy People; and implementation plans. HHS has also gathered over 125 comments to date through the Healthy People online database at http://www.healthypeople.gov/hp2020/Comments/.
RADM Royall provided an update on the work of the five FIW subgroups. Healthy People 2020 is taking an important new direction by exploring the use of Healthy People by other federal agencies. HHS is also looking into creating partnerships with non-HHS agencies (several examples of potential partners were given). HHS Secretary Michael Leavitt has requested that Healthy People include the issues of prevention, preparedness, and health IT in Healthy People 2020. In defining Healthy People objectives and targets, the FIW has raised some significant issues in its discussions, including the number of objectives, whether targets should be ambitious or achievable, and whether cost considerations should be taken into account. She explained that Richard Klein would offer more remarks about the FIW's work later in the day.
Dr. Fielding presented on the Los Angeles (LA) County experience with Healthy People 2010. Dr. Fielding highlighted LA County's emphasis on partnerships and accountability. There are 2,864 local health departments (LHDs) in the U.S.; their governance varies. In some cases, LHDs are units of state government; others are units of local government; and some have a mix of state and local governance. Most (62 percent) LHDs serve populations smaller than 50,000. There are noteworthy differences between large and small health departments in their resources, capacities, and in-house expertise.
Dr. Fielding described the characteristics of LA County and its 10.5 million residents; programs and services delivered by the health department; and the department's use of Healthy People 2010. Many States and Washington, DC have a comprehensive plan based on Healthy People 2010, but California and LA County do not. Many LA County programs have used selected Healthy People objectives for planning, evaluation, and benchmarking. There is a department-wide workgroup on reducing health inequities. Healthy People 2010 was also used as a data resource for planning a random digit dial telephone survey. The Healthy People objectives have helped to set program priorities and have been a source of baseline data for Continuous Quality Improvement (CQI). Healthy Workforce 2010 has also been useful for planning LA County's worksite wellness efforts.
A Committee member said his LHD uses Healthy People objectives to present the community's health status relative to that of the nation and to set budget priorities. Another member asked whether, in compiling recommendations on levels of evidence, the Committee should examine whether subpopulations have been included in generating evidence. She said disabled populations are often left out of clinical trials. Dr. Fielding agreed that much evidence comes from a small range of populations. It is important to try to determine external validity, and to talk to leaders in underrepresented communities to ensure relevance. Other issues raised in this discussion included:
Dr. Abby King, Subcommittee Chair, presented the recommendations and products of her group with the caveat that their work was still being finalized. As of its most recent conference call, the subcommittee had developed the following recommendations:
The subcommittee expanded upon the Healthy People 2010 definitions of "social environment" and "physical environment" to encompass broader issues such as socio-economics, the natural environment, the built environment, and neighborhoods. They also drafted some overarching principles and recommended activities. Dr. King remarked on the need to diminish the negatives, and enhance the positives concerning people's interactions with their environments. How can these issues best be addressed, given scarce resources? The subcommittee's emphasis was on higher-level interventions that diminish the burden of choice for making health decisions. Members also highlighted emerging social and physical environments, such as the Internet.
The subcommittee had explored several ecological models. Dr. King presented one from James Sallis' "Active Living Research" group in San Diego, CA. Its strength is its weakness: while it shows the complexity of interactions, it can also be overwhelming. No one is expected to take on all of the interventions in the model, but as a teaching tool, it can help people to find their level and expand on the interventions they are doing by exploring "one level up and down." Members sought to take the unwieldy ecological approach and operationalize it by creating a "proposed dimensions of intervention" table. Dr. Lew Lampiris, a subcommittee member representing the Oral Health Association, completed the table using ideas from the topic of oral health as an example.
A Committee member asked if the Committee should strive for a single model, or a set of models. Dr. Fielding said that a simple model is sometimes easier to understand than a complicated one. When you offer too much detail, there are issues of omission. Dr. King agreed. The subcommittee found this approach to be a useful heuristic that led to fruitful discussion and consensus. Another member noted that models should have a learning objective associated with them, and should be thought of from the perspective of what Healthy People would like its users to do.
Dr. Fielding encouraged members to submit their suggestions to Dr. King so that the subcommittee's work can be approved and adopted by the full Committee. He asked Advisory Committee members to comment on which pieces of this subcommittee's work they should adopt, vote on, and approve. Issues raised by the Committee members included:
Dr. Ron Manderscheid, Subcommittee Chair, presented recommendations and products of the Health Equity and Disparities subgroup to date, noting that members were continuing to finalize concepts, key measures, and definitions (see Appendix: Health Equity and Health Disparities—Draft Definitions and Key Concepts). The subcommittee felt they needed a simple, underlying model to explain what they were talking about and to show how Healthy People 2020 would advance the Nation's health promotion and disease prevention agenda. The concepts of health disparities and health equity were viewed as being foundational. The subcommittee plans to continue working on definitions in collaboration with federal agency staff. Dr. Manderscheid explained that the current draft definition of "health equity" shows progression from action to effect. The draft definition of "Health Disparities" incorporates definitions from both Healthy People 2010 and the Office of Minority Health (OMH).
The subcommittee developed a list of five key concepts that are reflected in the definitions of these two terms. The subcommittee would like feedback from the full Committee on the principles reflected in the terms health equity and health disparities. The intent is to drive action on health disparities that would lead to health equity. Health equity involves pursuing improvement for everyone. While it is a cornerstone concept of public health, it is not its only concern. Dr. Manderscheid noted that there is a close relationship between this definition of health equity and the issue of setting priorities, as well as looking at social and physical environments.
Dr. Fielding expressed concern about the phrase "highest level of health" in the first key concept. It implies that health is more important than anything else, and regardless of cost. He also asked if the second key concept is saying that differing levels of income are discrimination, commenting that this notion does not reflect the full range of social and physical determinants. A Committee member who had participated in the subcommittee said this was not the intent, but the social gradient is viewed as a primary driver of disparities. He stressed that disparities are not simply a result of personal choices.
Dr. Manderscheid and the other subcommittee participant responded that the key concepts are meant to articulate a vision—not to guide operations. The vision should indicate to LHDs that "nothing less is acceptable," so that they will make achieving health equity a priority. In terms of the definitions' functional and operational application (e.g., implications for Medicare and Medicaid) the subcommittee can work with the wording. Dr. Kumanyika added that the Committee's definition of health will be critical because, "You can picture a person who spends their time trying to achieve the best possible health who's miserable." She advocated including the concept of "creating conditions." Dr. Fielding asked Committee members to provide feedback on the definitions to Dr. Manderscheid.
Additional comments offered were as follows:
Dr. Douglas Evans, Subcommittee Chair, explained that the products and recommendations he would talk about represent work in progress. The subcommittee has been discussing which audiences Healthy People 2020 should reach. He shared a draft audience matrix that specifies Healthy People audiences and their informational needs. One major distinction among audiences is that some "need to have awareness raised," while others are information-seekers (e.g., LHD program managers). Dr. Evans said the matrix lists the general public among target audiences, reflecting the subcommittee's view that Healthy People should be promoted to the general public. There should also be health behavior "prescriptions" for promoting individuals' health. The inclusion of the public as an audience represents a departure from the approach taken in previous Healthy People iterations.
The audience matrix can be expanded to indicate messages and content for dissemination to specific audiences (i.e., a kind of marketing plan). It will also be important to determine how to aggregate and disaggregate the information produced and clarify the nature of the information to be disseminated. Questions to be addressed include:
Dr. Evans said the subcommittee will also discuss how best to integrate other subcommittees' work.
A Committee member asked whether the audience matrix suggests that the optimal, primary user is the American citizen, not health departments. Dr. Evans stated that this was not the view of the subcommittee; there was no intent to rank one audience above the others. Another Committee member said that he recently gave a talk to a group of second-year medical residents, asked how many of them had heard of Healthy People, and found only a few were familiar with it. Dr. King said the Environment and Determinants subcommittee's "Dimensions of Intervention" table includes a row for "information, education, and awareness." She asked if the User Questions and Needs subcommittee could find a way to integrate its issues into the "Dimensions" table, so that people are not only aware of information, but know what they should do with that awareness.
Dr. Fielding suggested changing the audience list to include state and local health departments and state and local elected officials. He also recommended separating out the federal government, because there are many federal users, not all within the health sector; combining community-based organizations (CBOs) and advocates; and adding the private sector and business. Other Committee members raised the following issues for consideration:
Dr. Fielding commented that, if the Committee views the users as critical, they should expand activities in this area and perhaps have subcommittees to reflect each of the key user groups. These groups could identify the "business requirements" (an IT term referring to the elements or processes necessary to do business, which can be expressed in textual documents or graphical models) for each audience. While they may not be the only input into defining audience needs, they would be an overriding one. In moving forward, he suggested that the Committee decide on what these audience subcommittees should be; then the User Questions subcommittee could develop charges for each. The groups could help to transition from Phase I of the Healthy People development process to Phase II. This might be a good way to think about organizing the objectives: providing a flexible tool that meets the needs of various user groups. The Committee took a one-hour break for lunch. Upon the members' return at 1:30 PM, the subcommittee reports continued.
Dr. Patrick Remington, Subcommittee Chair, recommended that healthy development be made a priority in Healthy People 2020. He discussed the impact of life stages on a specific health issue—obesity. Thinking about obesity exclusively as a health outcome is inadequate, because risk factors accumulate over the life course. Dr. Remington presented a simple logic model showing "the things that we do" (programs, policies, and systems) in relation to healthy development, behaviors, and environments, and short and long-term health outcomes. The elements on the right of the model (i.e., outcomes) are modifiable; those in the middle of the model (i.e., determinants) are static and measurable; and the items on the left of the model (i.e., interventions) are inputs, but it is not a causal model.
A Committee member asked about wellness benchmarks by age. How do ageism and norming fit in? How does one measure latent concepts of wellness by age? Dr. Remington said these issues are traditionally not measured in a population health framework. Instead, one looks at developmental assets. Research has defined forty external and internal factors that support healthy development; few are in the health domain. When developmental assets (e.g., family support, positive family communication, caring neighborhood) are correlated with health indicators (e.g., physical fitness, substance abuse, immunization rates), people with more assets have better health outcomes. None of the risk factors in the Foege model1 are without corresponding determinants. This model says risk factors are important, but if one doesn't examine root causes, the problems won't be impacted.
A Committee member asked why the model does not address the family, and why the emphasis is on institutional programs. The family is an important determinant of subsequent risk factors. Dr. Remington said that one could assume that family is an element of the model, or an attribute or metric within it, but he agreed family should be made an explicit factor in the model. Another member added that the model illustrates that family issues occur within a context.
Dr. Fielding suggested that the elements of the model be moved around. He viewed healthy development as an outcome that should belong in the same column as reduced disease and injury rates. He also thought that determinants should be placed on the left, and life course should be shown at the bottom. He noted that this paradigm was used in the community guide. It avoids the issue of behaviors, primary effects, and secondary effects.
Another issue that was debated was the role of "individual behaviors." Dr. Fielding suggested this element be removed, because when individual behavior is singled out, it appears to be the only mediating factor. Factors such as the social and physical environment are also important. Dr. Remington argued that, although health behaviors have been over-emphasized, they are a critical measure. If it's not in the model, the first question would be, why not? A Committee member agreed, saying that health behaviors are critical measures in behavioral health. Another suggested adding the phrase "multi-level" to show that individual behaviors are not the only factor at play.
Highlights of other comments on the model included:
Dr. David Meltzer, subcommittee chair, began by explaining how the subcommittee had defined the terms "prioritization" and "framework." The approach was to avoid specifying what issues were priorities, and instead to say something about how priorities should be set. To facilitate decision-making, the subcommittee created a set of principles that could be used to develop priorities. Dr. Meltzer gave an overview of main principles for prioritization, including: population health impact; health disparities impact; improvability and feasibility of change; accountability; and cost effectiveness.
Dr. Meltzer noted that one issue raised during subcommittee meetings was about prevention. Is prevention of intrinsic value—something that one should always do—or is it a means to an end? If treatment strategies are less expensive than prevention, should Healthy People consider those? He then read a list of questions for discussion, and opened the floor for comment. He asked whether the principles would be useful in guiding the process forward, and noted that this was simply phase I of a multi-phased process. Later phases would address implementation.
Dr. Fielding found the review of past and proposed guiding principles prepared by this subcommittee helpful, but he didn't see accountability listed. Dr. Meltzer said the subcommittee review was meant to provide historical information. Dr. Fielding noted that the Task Force on Community Preventive Services found some interventions would not affect a large population, but would have a big impact on a small population; this should not be undervalued. Another member noted that there is a relative priority of a large versus small population, but there is also an absolute standard. Regarding accountability, he said most work that's been done in this area has been at the individual level; broad thinking is needed about accountability at the population level.
Dr. Fielding said that a provocative issue that had been raised by the subcommittee was about prevention and its value. He invited Dr. Kumanyika, Committee Vice-Chair, to lead discussion on this issue.
The Value of Prevention
Dr. Kumanyika expressed surprise that the Subcommittee had called into
question the importance of prevention in Healthy People 2020. Rather than
assume that prevention is a value within Healthy People 2020, she believed
it was important to guard against making the case that prevention is more
costly than treatment because people live longer and use more health
resources. She posed a series of questions to the Committee about what
prevention means, and how an understanding of prevention influences
priority setting.
Dr. Meltzer said several presidential candidates have argued that prevention can save money. He felt the issue has been misframed. It's not always true that prevention saves money, and that argument has distorted the way that public health thinks about prevention. If one thinks about it in terms of just "making people healthier," it's re-framed. A Committee member responded that public health has gotten into the habit of talking about cost analysis out of the need to convince people who are not in this sector, such as businesses and policymakers, that prevention is really important.
Dr. Meltzer said he believes in using terms of cost effectiveness to make decisions about prevention. Dr. Fielding agreed that part of the issue goes away when one of the main principles is cost effectiveness. However, he felt it is important to be biased towards prevention because the intent is to give people more years of healthy life. In most cases, that intervention must take place on the front end. If one is talking about the social and physical environment and determinants of health, those are inherently about prevention. Dr. Fielding also pointed out that the Committee is charged with helping the Secretary make decisions about Healthy People 2020. Treatment has to be part of that. There is no inherent desire to advocate prevention rather than treatment.
A Committee member noted the example of obesity. Today, bariatric surgery is one of the most cost-effective interventions. Conceptually, one would say that's where we should place our emphasis. But public health is inherently prevention-oriented, not surgery-oriented. Another member remarked that, if children were to become more active outdoors, bariatric surgery could be eliminated completely. Dr. Meltzer said he knows bariatric surgeons who are reimbursed at about 30 percent of costs for treating Medicaid patients on the South Side of Chicago. There's a year long waiting list of patients for bariatric surgery who cannot get it because the money's not there. The school program may help thirty years from now, but a set of people will die this year. We may believe that prevention is good, but we must prove it's good. Decisions must be based on measures of impact.
Other issues raised during discussion of the value of prevention were as follows:
Next Step: Dr. Fielding concluded by saying that the value of prevention should be addressed in the front matter for Healthy People 2020. He asked NORC support staff to assist in putting together background material to help the Committee to further examine and respond to this issue.
Richard Klein, Chief, Health Promotion Statistics Branch, Office of Analysis and Epidemiology, National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, provided an overview of how the Federal Interagency Workgroup's (FIW) thinking about the framework has evolved. Healthy People 2010 did not include a graphic element to illustrate how the framework fits together. Mr. Klein showed how the FIW's draft models had been evolving in recent months.
The first graphic, which was based on the NORC report, was viewed as being overly two-dimensional. In January, the Secretary's Advisory Committee developed a revised framework that was a significant improvement. NORC used that version to develop a more three-dimensional graphic that has overlapping elements. Kindig et al. recently published an article in JAMA providing a similar framework. Mr. Klein asked the Committee for their input on how the major domains of the framework should interrelate.
A Committee member said she still was unclear about what the word "framework" means. What is the purpose or goal? Dr. Fielding explained that the Committee is trying to provide advice on how the document should be framed. What subjects should be covered? What principles should be used for setting objectives? Should there by many objectives, or few? What's the orientation? Is Healthy People for public health professionals, or other groups of users? Is it for all of those audiences? What changes should we suggest from the 2010 approach? The framework is all of the things that the Committee has been doing, without calling it a framework. If one were telling somebody how to put Healthy People together, what should they be told without going into subject area expertise?
Carter Blakey said HHS has begun to think there may not be one stagnant framework. The framework might have elements that would change, depending on who the user is, especially in the Internet age. Dr. Fielding agreed that the approach should be flexible and dynamic to ensure its usability and effectiveness. Another Committee member asked whether the Committee should think of the framework in terms of a logic model, or in terms of elements (i.e., not necessarily laid out in causal, punitive terms). The Committee discussed how the framework should be depicted graphically. No formal decisions were made, but themes of the conversation are highlighted below.
Dr. Fielding acknowledged the difficulty of defining the framework, but did not view this as problematic. When asked for clarification on whether the goal is to create a model of what affects public health, he said the goal is to create a model for modifying the determinants of health. The framework elements provide direction for how to construct Healthy People for maximum utility. Another Committee member said that the pictures are inadequate to communicate this. He suggested creating written principles for those who are more linear—"ten commandments of health." Dr. Fielding supported this idea, and said work would continue on Day 2 of the meeting.
Mary Kruger, Senior Advisor, Office of the Assistant Secretary for Preparedness and Response (ASPR) HHS, provided a federal perspective on preparedness in public health. ASPR's mission is to lead the nation in preventing and preparing for disasters. It is the lead agency at HHS for medical public health preparedness and response. ASPR offers integration at all levels, including situational awareness (i.e., the Secretary's Operations Center); a National Disaster Medical System (NDMS); an Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP); a Medical Reserve Corps; patient tracking; and other mechanisms. ASPR also coordinates with states and localities for evacuation plans and medical countermeasures delivery platforms. Driven by Presidential Directive ASPR is facing aggressive deadlines to develop an implementation plan.
Dr. Richard Hatchett, National Institutes of Health, reflected on the concept of preparedness as it relates to developing objectives for Healthy People 2020. Stating that he was not representing the views of a particular office or agency, he recommended that the Advisory Committee “think long and hard” about including preparedness as a focus area. He explained that public health preparedness depends on capabilities that are beyond the scope of public health. It is based on metrics such as: How long does it take for a community to plan for and report on a problem? What agreements are in place to practice across state lines? The Department of Homeland Security (DHS) has developed these metrics, but the process has been complicated; existing systems often do not provide the needed data. He argued that if Healthy People takes on this issue, it could risk being duplicative; deriving and assessing such measures could detract from the Healthy People mission. Thus, the best contribution Healthy People could make to preparedness would be to keep its focus on prevention.
A Committee member commented that there are two ways to think about the question of how to address disaster preparedness within Healthy People 2020: 1) how can Healthy People be brought to preparedness? And, 2) how can preparedness be brought to Healthy People? He noted that 9/11 brought changes not only to the physical environment, but to the psychosocial environment. Both are vast contributors to health. Thus, he saw a role for public health and Healthy People in preparing for disasters. Dr. Hatchett answered that he thought Healthy People should be brought to preparedness, and not vice-versa. Another member said Dr. Hatchett seemed to warn against measuring, for example, gallons of potable water per household, or similar indicators.
Dr. Fielding noted that it would be easy for Healthy People to say, “The more effective we are, the more we help.” But before dismissing the role of Healthy People, he raised the fact that the Committee had not yet discussed the issue of safety. Many objectives will be safety-oriented; Healthy People will also address the social and physical environment. Incorporating preparedness would not be a leap from these issues. Dr. Fielding was not ready to dismiss the relevance of Healthy People to preparedness, and said the HHS Secretary will ultimately decide whether to include this topic. Ms. Kruger urged mindfulness of the HHS role—pertaining to public health and medical health—versus that of DHS. Dr. Fielding said Healthy People is not just an HHS charge; the Secretary is developing health promotion and disease prevention objectives for the nation.
After breaking for a presentation on Health IT (see below) the Committee continued discussing whether Healthy People should address preparedness. Although Dr. Hatchett had left the meeting, a member asked Ms. Kruger why Healthy People 2020 shouldn't seek to reinforce the information and messages that DHS is putting forth. The member felt that the public health community would view Healthy People as being remiss if it does not mention preparedness. Ms. Kruger answered that preparedness is difficult to measure—more so than disaster response. A committee member answered that, for certain natural disasters, it's fairly simple to measure preparedness by looking at behavioral indicators. Ms. Kruger said measures of disaster awareness, or “community resilience” would be helpful. What backup systems are in place? How can that be measured?
Dr. Fielding noted that LA County tracks these kinds of indicators; they know which segments of the population are most likely to have emergency preparedness kits. This isn't any more difficult than many other measures in public health where there are some gaps. A Committee member said the emphasis should be on the most vulnerable communities. Dr. Kumanyika agreed that this is an opportunity for public health to define how it interfaces with preparedness. Another member expressed interest in hearing a non-governmental perspective on preparedness.2
Dr. Charles Friedman, Deputy National Coordinator, Office of the
National Coordinator for
Health Information Technology (ONC), HHS, joined the meeting via
conference call. He explained that the ONC was established in 2004 as a
result of an executive order. ONC is coordinating a nationwide effort to
lay the foundation for a connected system of person-focused health care
and population health. On June 3, 2008, the office released its
strategic plan, which is available online. Health IT is not an end in
itself, but a means to an end. Dr. Friedman described the strategic
plan, and explained how it would enable patient-focused health care and
improve population health. He also described the work of the FIW's
Communication and Health IT subgroup.
A Committee member said it would be important for the Advisory Committee to work with the Health Communication and Health IT subgroup to bring Health IT to Healthy People 2020. Public health data must be viewed as more than clinical data writ large; there are “value-adds” to population-level data. Dr. Friedman agreed, and said that objective 2.3 of the strategic plan implies that there is interplay between communities, public health agencies, community providers, and individuals. He would like to see the FIW subgroup and Secretary's Advisory Committee work in the most coordinated manner possible. Dr. Fielding noted that the Advisory Committee would be open to that.
Next Step: Dr. Fielding recommended that the Advisory Committee interface closely with the FIW's Communication and Health IT subgroup (within any limits of FACA regulations) to address data needs and gaps, and to identify existing strategies. Later (on Day 2 of the meeting) it was decided that Dr. Manderscheid would be the point-person for this follow-up work.
Dr. Fielding asked the members to turn their attention to Mission
element #4, on which they had not voted in January. He asked whether
Advisory Committee members were ready to vote on it now, or if additional
discussion was needed. The Committee wished to discuss the item further.
Dr. Fielding stated that the Day 2 discussion would focus on revised
versions of the framework models, as well as revised definitions of key
terms. It would also be important to prepare elements of a set of
requirements for the draft Healthy People framework.
Content for this site is maintained by the Office of Disease Prevention & Health Promotion, U.S. Department of Health and Human Services.
Last revised: September 16, 2008