Phase II:

Implementation, Evidence-based Actions, and

Process for Choosing National Priorities

Secretary’s Advisory Committee on National Health

Promotion & 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

July 10, 2009

Welcome

Howard Koh, M.D., M.P.H.

Assistant Secretary for Health

Office of Public Health and Science

U.S. Department of Health and Human Services

Update on HHS Activities

Carter Blakey

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

Update on HHS Activities

Objective Development

Public Engagement

• Public meetings

—Kansas City, October 22

—Philadelphia, November 7

—Seattle, TBA

• Public Comment Web site, healthypeople.gov

• Healthy People Consortium

Desired Outcomes for the Meeting

Discuss potential recommendations for:

Implementation strategies

Use of evidence in selecting interventions

A process for selecting national priority objectives

Data and information technology

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Implementation Strategies:

Short- and Long-Term Recommendations

Committee Vice-Chair: Shiriki Kumanyika, PhD, MPHUniv. Pennsylvania School of Medicine

Subcommittee Co-Chair: Eva Moya, LMSW, PhD (c)U.S.-Mexico Border Health Association

Members of the

Subcommittee on Implementation

External Members Internal Members

ASTHO*: Julia Pekarsky Adewale Troutman, Co-Chair

NACCHO Lou Brewer Abby King

America’s Health Plans (AHIP),

James Glauber

Shiriki Kumanyika

Business Coalition on Health,

Andrew Webber

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* Association of State and Territorial Health Agencies

National Association of County and City Health Officials

Efforts of the

Subcommittee on Implementation

Met by teleconference five times since March

Charged with addressing the questions:

• How do we move from the framework to action?

• How can we ensure accountability?

• What are users’ needs for tools, aids, and guidance?

• What examples can be put in place?

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Implementation Issues Discussed

Action-orientation

• Address past criticisms that Healthy People did not

tell users how to accomplish objectives

• What’s needed is not only information (though that is

important), but also an infrastructure for accountability

Accountability

• Public Health Accreditation Board

—What if they adopted the Healthy People priority objectives?

• State Healthy People Coordinators

—Traditionally, role has been undefined & is up to states

—An enthusiastic, engaged group that has done a good job,

with few resources. Visibility varies.9

Implementation Issues Discussed

Incentives

• Public recognition for action (e.g., awards, media)

• Memoranda of understanding

• Monetary incentives for effective implementation

Tools, resources, guidance

• Compiled sample resources and reports

• What is most useful?

—Case studies

—Success stories

—Templates to guide planning

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Immediate Recommendations for

Implementing Healthy People 2020

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Note: Numbering in this list does not imply prioritized actions.

Subcommittee Charge Immediate Recommendations

Action-orientation 1. Foster continuity, build on current activities/strengths,

especially relating to social determinants of health

2. Jump start and support innovation for social

determinants approach

Accountability 3. Build accountability and incentives into Federal health

programs

4. Facilitate evaluation

Tools & Guidance 5. Provide more detail about how to implement at the

state and local levels through a toolkit

6. Help users to prioritize and focus their efforts

7. Assess and meet technical assistance needs

Longer-Term Recommendations

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Subcommittee

Charge

Longer-Term Recommendations

Action-orientation 1. Interactive website that will make Healthy People a “living

document”

2. Make participation in the HP Consortium meaningful

Accountability 3. Make HP2020 a cornerstone of national prevention efforts

4. Create a clear, empowered role for state HP Coordinators

5. Adopt a “health in all policies” approach & ensure that HP

is included in the strategic plans of other federal agencies

Tools & Guidance 6. Offer an assessment tool on the Website to crosswalk HP

objectives with existing state & local programs

7. Leverage resources through partnerships and networks

Examples 8. Models of Excellence, with core components:• A State Coordinator is in place

• Effective strategies are used to make advancements

Note: Numbering in this list does not imply prioritized actions.

A “Health in All Policies” Approach

“Health in All Policies (HiAP) addresses the effects on health across

all policies such as agriculture, education, the environment, fiscal

policies, housing, and transport. It seeks to improve health and at

the same time contribute to the well-being and the wealth of the

nations through structures, mechanisms and actions planned

and managed mainly by sectors other than health. Thus HiAP is

not confined to the health sector and to the public health community,

but is a complementary strategy with a high potential towards

improving a population’s health, with health determinants as the

bridge between policies and health outcomes.”

Source: Staht T, Wismar M, et al., Health in All Policies: Prospects and Potentials, Finnish

Ministry of Social Affairs and Health, Health Department, Finland; 2006. Available online at:

http://www.euro.who.int/document/E89260.pdf

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Discussion of Committee Recommendations for

Healthy People 2020 Implementation Strategies

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Have the issues raised in the Committee’s charge been

addressed adequately?

• Action-orientation

• Accountability

• Tools, aids, and guidance

• Examples

Are changes/ revisions needed?

• Process for making any needed changes.

Is the Committee ready to vote on recommendations?

• Timeline for voting

Evidence-based Strategies

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

Los Angeles County Department of Public Health &

Health Officer, Los Angeles County

Ad Hoc Group:

Criteria for Evidence-based Strategies

Internal and external participants (Dr. Teutsch,

Dr. Calonge, Dr. Orleans, Dr. McGinnis)

Charged with addressing the questions:

• How should decisions be made about linking HP

objectives with evidence-based interventions?

• What should be done when there is insufficient

evidence to identify effective interventions?

• What guidance can be provided to users about what

really needs to be done?

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How can Healthy People offer Guidance

on “What Needs to be Done”?

Use the resources that have amassed best available

evidence and have developed valid methodologies

Interventions can be graded within levels of evidence,

but…

Compared to clinical settings, patterns of service delivery

in community settings are more variable due to

adaptations to fit community circumstances.

• Effectiveness of the same intervention may vary across communities.

• Therefore, it is more difficult to develop standardized grades for

community- based services.

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What Are Evidence-based Strategies?

What is meant by the term “evidence-based”?

• How can current practices that are widely accepted

but not yet supported by evidence of effectiveness be

formally evaluated?

How should findings of Health Impact

Assessments be included in evidence reviews?

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When Evidence Is Not Available

How should actions be chosen when there is no evidence?

• Two alternate viewpoints:

1. We should recognize interventions that are accepted, but may

be supported by weaker forms of evidence

versus…

2. We should prioritize the things that we know will work over

those that are unproven.

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Hierarchies of Evidence

Use a “hierarchy of evidence” to organize

different levels of evidence

• Community Guide, Clinical Guide at the top;

• Systematic analysis of all available studies by parties

free of conflicts of interest in peer-reviewed journals

would be listed next;

• Other types of evidence and related methods should

be included (e.g., HIAs)

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How Should Evidence be Considered?

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Various approaches exist for weighing evidence

Examples include:

• US Preventive Services Task Force— Recommendation Grid: Letter Grade of Recommendation or Statement of

Insufficient Evidence Assessing Certainty and Magnitude of Net Benefit

— Guide to Community Preventive Services

• “Review cycle of evidence-based intervention

strategies” and “Evidence typology for classification

of policy and environmental intervention strategies”— Transtria LLC, Washington University Institute for Public Health, The Robert

Wood Johnson Foundation

Key Messages on Selecting Strategies

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Proposed “critical information to be communicated”

to the FIW to help them select appropriate strategies

• Interventions from Clinical and Community Guides, Cochrane Reviews,

and other analyses

• Other available, validate/ proven techniques, including intersectoral

evaluations (HIAs)

• Priorities to consider while using Healthy People

• Policies that affect the physical and social environment may be better than

programs targeting individuals, given political support

• Explore ways to produce rapid syntheses of what is being learned from

evaluations of all types to help stakeholders feel that they are part of a

“learning organization,” and to “capture the wisdom of crowds.”

• Use Web 2.0 applications to learn about what stakeholders want to know.

Preliminary Recommendations:

Criteria for Evidence-based Strategies

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Criteria for selecting evidence-based practices should

be put within the context of priority-setting, because this

is where people will be making systematic decisions.

The issue should be framed in a positive way.

• Evidence has been helpful in the clinical setting;

• We need more evidence of what works at the community level too.

Next steps and timeline for finalizing evidence guidance

Identifying National Priorities

Subcommittee Chair: David Meltzer, MD, PhD

University of Chicago

Subcommittee Co-Chair: Abby King, PhD

Stanford University

The Need for National Priorities

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Why create a set of national priorities?

• They provide valuable information for broad numbers

of people and government agencies

• They enable cross-agency collaboration

Key characteristics of national priority objectives

• They should be supported by a compelling rationale

• They should be relevant to agencies with a broad

range of mandates

National Priorities vs. LHIs

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Differentiating between national priorities and

leading health indicators (LHIs)

• HP 2010 LHIs were originally created to provide a

broad picture of our nation’s health

• Over the decade, there was confusion that LHIs,

because they were a small and manageable set,

could be viewed as priorities.

• LHIs are not priorities.

• LHIs and priorities must be separately and clearly

defined to ensure that they are not used

synonymously or interchangeably.

National Priorities, Defined

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Priority issues are of national urgency.

• They are important enough that every level of

government should monitor and undertake

efforts to improve them.

Identifying National Priorities:What is the Committee’s Role?

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This Committee will not set national priorities

• Because it is not a broad-based, representative

group, the Advisory Committee is not the correct body

to develop a set of national priorities.

• However, we can recommend a process whereby

national priorities can be identified.

• The “audience” for these recommendations is DHHS

and other participating federal agencies.

(Priorities will likely be identified by the FIW).

Developing Recommendations for a

Process to Identify National Priorities

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Proposed during Subcommittee meetings:

• A single, suggested set of criteria for making these

choices (rather than a menu of possible processes)

• Should combine quantitative and qualitative

approaches (a hybrid, based on the work of Lomas)

• Must be practical, not overly academic

• Should convene public health experts and top experts

from other fields (e.g., housing, transportation,

agriculture) to find priorities that each of them can use.

Priorities Subcommittee Next Steps

Are additional meetings needed?

What decisions need to be made?

What should be the process for finalizing

this group’s recommendations?

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Subcommittee on Data and IT: Recommendations

Subcommittee Chair: Ronald Manderscheid, PhD

SRA International

Data and IT Subcommittee:

Guiding Questions

HHS Data for HP2020 Measures:

• What actions should be recommended to improve the coverage and quality of HHS

epidemiology, services, and services cost data, as relevant to HP2020, so that

they are better able to meet the data needs of HP2020?

Federal Data on Social and Physical Determinants of Health:

• What actions should be recommended so that key federal data sources on the

social and physical determinants of health are available to meet the data needs of

HP2020?

Phased Development of HP2020 IT:

• What high level actions should be recommended so that HP2020 is on a course to

make effective use of new developments on EHRs/PHRs, esp. with respect to:

— an online national public health epidemiological data system

— an online HP2020 community of users

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Data and IT Subcommittee:

Process and Recommendations

Have met by teleconference eight times since March

Began by organizing data systems into three types:

epidemiological data, services data, and encounter data

Reviewed HHS data sources systematically, and

explored non-HHS data sources

Drafting recommendations regarding immediate and

long-term needs for HHS and non-HHS data sources.

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Data and IT Subcommittee:

Next Steps

Draft high-level recommendations around the IT

needs of Healthy People 2020.

Specifically, these will address:

• Building public health IT infrastructure;

• Enhancing the capacity to share data.

Next steps and timeline

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Next Steps for the

Secretary’s Advisory Committee

Future Meetings• August 14th, 1:00 – 3:00 P.M. (ET)

• September 17-18, Washington DC

(pending an extension of the Committee’s charter)

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