Phase IIPhase IIVoting on Topic Areas and Voting on Topic Areas and

Finalizing Target-Setting MethodsFinalizing Target-Setting Methods

Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020

Committee Chair: Jonathan Fielding, MD, MPH, MA, MBA

Director, Los Angeles County Department of Public Health &Health Officer, Los Angeles County

April 20, 2009

Update on HHS ActivitiesUpdate on HHS Activities

Rear Admiral Penelope Slade-Sawyer, PT, MSW

Director, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services

Update on HHS Activities

Phase I Status Work of Federal Workgroup Coordinators,

Federal Interagency Workgroup HHS timeline for development of the

objectives and public engagement

Desired Outcomes for the MeetingDesired Outcomes for the Meeting

Vote on Recommendations for Topic Areas Selection

Finalize Recommendations for Target-Setting Provide feedback to Subcommittees on next

steps.

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Key Dates for Deliverables Key Dates for Deliverables

Topic Area categories: March, 2009(To be finalized during this meeting)

Target-setting Methodology: April, 2009(To be finalized during the May 15 meeting)

Final inclusion criteria for evidence-based resources: May, 2009

Implementation strategies: June-July, 20095

Ad Hoc Group on Topic AreasAd Hoc Group on Topic Areas

Subcommittee Chair: Patrick Remington, MD, MPH

University of Wisconsin Population Health Institute

Dr. Jonathan FieldingDiscussion and Vote for Approval of

Recommendations

Review: Functions of Topic AreasReview: Functions of Topic Areas

Organizational functions:• Identify and group objectives of related content • Highlight like or closely related subjects

Managerial functions:• Are assigned to a federal “lead agency” that is responsible for

tracking, monitoring, and reporting on objectives within the topic

Communication functions: • Can be organized in a user-friendly way to help locate content

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Differences between HP 2020 Topic Areas Differences between HP 2020 Topic Areas and HP 2010 Focus Areasand HP 2010 Focus Areas Organizational functions:

• HP 2020 Topic areas are not mutually exclusive.

Managerial functions:• Multiple topic areas, with objectives of like content, may be

assigned to a single working group of federal staff.

Communication functions: • Objectives may fall under multiple topic areas.

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How Topic Areas Relate to the HP2020 FrameworkHow Topic Areas Relate to the HP2020 Framework

Topic area categories should not be developed in an ad hoc manner, but should be consistent with the framework.

• Three broad framework categories: Interventions, determinants, outcomes.

• Users would enter through these categories to begin locating content

Once users enter a category, topic areas would appear.

• Topic areas would be the same, regardless of which category the user chooses.

Each topic area would have a logic model that shows how objectives within that topic relate to each other.

• The user’s choice of entry category would determine the point in the logic model that would come up when the user selects the topic.

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Example of a Search: “Cancer”Example of a Search: “Cancer”

1. The user enters “interventions” and selects “cancer”• A collection of objectives would be provided, e.g., (HP2010) objective 3-10:

“Increase the proportion of physicians and dentists who counsel their at-risk patients about tobacco use cessation, physical activity, and cancer screening.”

2. The user enters “Outcomes” and selects “cancer”• A collection of objectives would be provided, e.g., (HP2010) objective 3-3:

“Reduce the breast cancer death rate.”

3. The user enters “Determinants” and selects “cancer”• A collection of objectives would be provided, e.g., (HP2010) objective 19-6:

“Increase the proportion of persons aged 2 years and older who consume at least three servings of vegetables, with at least one-third being dark green or orange vegetables.”

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How can objectives be assigned to How can objectives be assigned to positions within Topic Area models?positions within Topic Area models?

Federal staff members who are preparing objectives for their assigned Healthy People 2020 topic area could “tag” each objective to show how it should be positioned within the topic area logic model.

Labels would indicate where each objective falls in the topic area logic model.

The “tags” would reflect relevant elements for that area.

• Interventions: Programs, policies, information

• Determinants: Social factors, economic factors, environmental factors, innate individual traits

• Outcomes: Behavioral outcomes, specific risk factors, diseases, mental disorders, disability, injury, and quality of life.

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Organizing Information within HP2020Organizing Information within HP2020

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Example: Web of Risk Factors, Determinants, CHDExample: Web of Risk Factors, Determinants, CHD

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InterventionsEvidence-based Policies, Programs

Determinants Outcomes

Proposed List of Specific Topic Area CategoriesProposed List of Specific Topic Area Categories

1. Interventions (Programs; Policies; Information)1. Emergency Preparedness

2. Food Safety and foodborne illness

3. Health Communication

4. Health IT

5. Health Promotion

6. High Quality Health Care

7. Immunizations

8. Medical Product Safety

9. Nutrition

10. Occupational Safety and Health

11. Oral Health

12. Physical Activity and Fitness

13. Public Health Infrastructure

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Proposed List of Specific Topic Area CategoriesProposed List of Specific Topic Area Categories

2. Determinants (Social, economic, & environmental factors; innate individual traits.

1. Access to Health Care

2. Built Environment

3. Natural Environment

4. Lifestages — Prenatal— Preschool— Primary School— Adolescent Health— Adult— Healthy Aging

5. Health Equity/Disparities

6. Social and Economic Environments

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Proposed List of Specific Topic Area CategoriesProposed List of Specific Topic Area Categories

3. Outcomes (Behavioral outcomes; risk factors; diseases, mental disorders, disability, injury; QoL)

1. Arthritis, Osteoporosis and Chronic Back Conditions

2. Blood Diseases

3. Cancer

4. Chronic Kidney Disease

5. Communicable Diseases

6. Depression & Suicide

7. Diabetes

8. Digestive Diseases

9. Disability and Secondary Conditions

10. Global Health

11. Hearing

12. Heart Disease and Stroke

13. HIV

14. Mental Health and Mental Disorders

15. Overweight

16. Quality of Life

17. Reproductive Health

18. Respiratory Diseases

19. Sexually Transmitted Diseases

20. Substance Abuse

21. Tobacco Use

22. Unintentional Injury

23. Violence

24. Vision

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Criteria to Refine the List of Topic AreasCriteria to Refine the List of Topic Areas

The topic area is an “organizing principle”• Groups of objectives can be organized within that category

Federal leadership has been identified for the topic area • Has expertise to adequately monitor and address the issue over

the course of the decade

The topic area allows sufficient focus and action• Minimum number of objectives to ensure focus • Manageable number of objectives to facilitate action

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Standards for the Content of Topic AreasStandards for the Content of Topic Areas

A logic model to clarify how objectives are related Coherence of content; clarity of emphasis within/

differences among topic areas Each topic area should:

• Reflect a body of available literature that can be accessed to promote health, prevent disease or injury

• Reflect our understanding of the pathophysiology and multiple underlying determinants of health;

• Relate to a schema or conceptual model that links to the framework;

• Have accountable groups with complementary expertise to adequately address the issue;

• Permit sufficient focus to ensure feasibility and accountability.

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Introductory Material for Each Topic AreaIntroductory Material for Each Topic Area

Introductory material for each Topic Area must highlight issues related to the concepts of:• An ecological approach to health promotion

• Health equity;

• Life stages.

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Topic Area RecommendationsTopic Area Recommendations

Discussion• Clarification of terms;

• Clarification of concepts;— Many outcomes are also determinants. Should this be addressed to enhance

usability?— How does the Committee conceive of “Topic Area logic models”?— How does the Committee conceive of conceptual models that show the relationships of

objectives across Topic areas? — How detailed should these models be, assuming that there may be more than 500

objectives in Healthy People 2020?

• Changes to proposed approaches/ strategies.

Committee vote to approve

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Target-Setting RecommendationsTarget-Setting Recommendations

Finalizing Draft Recommendations

Subcommittee Chair: Patrick Remington, MD, MPHUniversity of Wisconsin Population Health Institute

Dr. Jonathan FieldingDiscussion and Next Steps for Finalizing

Recommendations

Definitions of Key TermsDefinitions of Key Terms

SMART Objectives:• National, specific, measurable, and realistic statements of

intended outcomes over a stated period of time (by 2020)

Target:• The level of progress or performance expected for an objective.

Target-setting:• Methods used to set the value for a target.

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Methods used for Healthy People 2010Methods used for Healthy People 2010

Better than the best. Percent improvement. “Total coverage” or “Total elimination” (for targets like

100 percent, 0 percent, all States, etc.). Consistent with __________________(another national

program, for example, national education goals). Retain year 2000 target (the Healthy People 2000 target

has been retained).

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Why these Methods were InadequateWhy these Methods were Inadequate

Not adequately specific Left too much room for inconsistency “Better than the best” approaches:

• Provided little guidance was provided for how much better the rate should be; • Are unrealistic, especially when applied to the most affected subpopulations;• Often designated a “best,” reference population based on problematic data; • Have not been notably effective in contributing to the elimination or even the

narrowing of health disparities.

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What processes and data should be used?What processes and data should be used?

Targets should:• Be rooted in and build on past experience (i.e., HP 2000 and HP 2010)• Be set with a focus on objectives that have existing data to track progress to

2010, so that a trend can be projected to 2020• Be set using a variety of target-setting methods, with clear explanation of the

rationale for selecting a particular method

Guidelines for target-setting should be provided, but exceptions should be permitted when necessary.

• Guidelines (--not the targets themselves) should be put out for public comment

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A Single Target or Multiple Targets?A Single Target or Multiple Targets?

Recommendation: set a single population target for each objective that would represent an improvement for most of the population, but might not be better than the “best” subpopulation.

A single target would be easy to communicate about, but: • If based on the status of a reference population, it could be virtually unachievable for

some subgroups. • If based on a population average, some groups may already have met the target.

Consider setting a “disparities” target to reduce variation in the population, in addition to the general target for the population.

• The disparities target would lessen as disparity between the subpopulation with the highest health status and those with the lowest health status diminishes

• A challenge in setting a disparities target would be identifying a means of clearly communicating about it to the users of Healthy People 2020.

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Aspirational or Realistic Targets?Aspirational or Realistic Targets?

Healthy People 2020 should set realistic targets based on:• A projection of where the objective would be by the target date (e.g., 2020) “if

nothing changed” (i.e., a projection based on trend data.)• Knowledge of what is potentially achievable given the health issue• Current or emerging knowledge of interventions, programs, and policies that

might result in improvement.

Targets should represent "a reach,” and should be more than a continuation of the status quo.

• Targets should be based on the projected positive trend, plus implementation of “aspirational interventions” (i.e., implement the things that we know will work.)

• The setting of Healthy People 2020 objectives and targets should ultimately result in the implementation of effective interventions, programs and policies.

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Should targets incorporate knowledge of Should targets incorporate knowledge of effective interventions?effective interventions? Targets should incorporate knowledge of past, current, and future,

in terms of the effects of interventions. • In many areas, adequate interventions have not been identified. • The possibilities of what "could become available" should be highlighted.

When describing methods used to make projections and setting targets, an explanation should be provided of how information about effective interventions was incorporated.

The best available knowledge about effective interventions should be linked to targets as one avenue for assisting users to work towards improved health for the nation.

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Target-setting: Discussion and Next StepsTarget-setting: Discussion and Next Steps

Unresolved issues:• Should there be a disparities target?• What guidance/ tools should be provided for states, regions, and localities?• Should there be a smaller number of objectives that have a data-driven, science-

based, SMART targets (such as a “core indicator” set)?

Guidance and processes for completing this work.

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Other Subcommittee EffortsOther Subcommittee Efforts

Implementation Data & IT Priorities

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Summary and Next StepsSummary and Next Steps

Remaining work on target-setting Next steps for subcommittees Next Committee meeting dates

• Friday, May 15th: 1:00 PM- 3:00 PM (ET)• Should a meeting be scheduled for July/ August?

Other issues

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