Phase II Voting on Topic Areas and Finalizing 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 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 Meeting  Vote on Recommendations for Topic Areas Selection  Finalize Recommendations for Target-Setting  Provide feedback to Subcommittees on next steps. 4

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,

Ad Hoc Group on Topic Areas Subcommittee Chair: Patrick Remington, MD, MPH University of Wisconsin Population Health Institute Dr. Jonathan Fielding Discussion and Vote for Approval of Recommendations

Review: 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 7

Differences between HP 2020 Topic Areas and 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. 8

How 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. 9

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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.” 12

How can objectives be assigned to 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. 13

Organizing Information within HP

Example: Web of Risk Factors, Determinants, CHD 15

Proposed 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 16

Proposed 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 17

Proposed 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 18

Criteria 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 19

Standards 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. 20

Introductory 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. 21

Topic 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 22

Target-Setting Recommendations Finalizing Draft Recommendations Subcommittee Chair: Patrick Remington, MD, MPH University of Wisconsin Population Health Institute Dr. Jonathan Fielding Discussion and Next Steps for Finalizing Recommendations

Definitions 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. 24

Methods 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). 25

Why 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. 26

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 27

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

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. 29

Should targets incorporate knowledge of 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. 30

Target-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. 31

Other Subcommittee Efforts  Implementation  Data & IT  Priorities 32

Summary and Next Steps  Remaining work on target-setting  Next steps for subcommittees  Next Committee meeting dates Friday, May 15 th : 1:00 PM- 3:00 PM (ET) Should a meeting be scheduled for July/ August?  Other issues 33