Dr. Fielding thanked the members of the audience for their participation and acknowledged his distinguished colleagues on the Committee, including Vice-Chair Shiriki Kumanyika. He reviewed the expectations for the meeting, which included: identifying opportunities to support the Federal Interagency Workgroup (FIW) in the coming year; recommending a process for creating a set of national priorities; discussing ways to operationalize the concept of social determinants of health; and discussing opportunities to build on recommendations for evidence-based actions and implementation strategies. He thanked ODPHP for their dedication to the Healthy People process and their support of the Committee.
IV. Federal Interagency Workgroup Update
9:45 AM – 10:45 AM
RADM Slade-Sawyer presented an update on HHS progress in developing Healthy People 2020, including plans for engaging the public through regional meetings and a public comment database. She noted that the Secretary had approved the same versions of the vision, mission, and overarching goals framework and guiding principles for Healthy People 2020 that the Committee had reviewed at an earlier meeting. The materials were included in the Committee’s briefing books and are posted online at Healthypeople.gov.
RADM Slade-Sawyer said the FIW was in the midst of developing specific objectives for Healthy People 2020. For each topic area, the workgroups and subject matter experts reviewed all of the Healthy People 2010 objectives. Using objective selection criteria that were created with input from this Committee, they discussed which objectives should be retained, modified, or added as new objectives. They then prepared and submitted detailed memoranda for each proposed objective, providing explanations of their decisions, and indicating which social determinants of health would pertain to which objectives.
Workgroup coordinators present their proposals to the FIW, which vets each objective based on current science, reliability, periodicity of the data, availability of data to track progress over time, and several other factors. Existing Healthy People 2010 topic areas have been retained for the review process. The FIW used subject matter expert guidance to identify new topic areas, and workgroups for these areas are submitting objectives. Since July of 2009, the FIW has reviewed hundreds of proposed objectives in numerous all-day meetings; the process will continue through the end of September. HHS faces several challenges, including the sheer number of objectives to be proposed, reviewed, and vetted. Issues being considered include: whether to include objectives that address prevalence versus those that address outcomes and preventable actions; whether to include objectives that have low rates or no data; and how to select appropriate measures for tracking objectives in more abstract areas, such as quality of life and social determinants of health. HHS will begin collecting public comments on objectives in October 2009, through both an online database and public meetings to be held across the U.S.
RADM Slade-Sawyer described the recent efforts of the FIW’s Implementation Strategy Subgroup, which has been meeting since June to develop guidance for how to select action strategies for inclusion in Healthy People 2020. The subgroup includes representatives from across HHS and other agencies. It has produced draft materials that, once they are approved by the FIW and have gone through HHS clearance, will be distributed to the topic area workgroups. The draft documents (written guidance for selecting implementation strategies and descriptors for organizing the objectives within the Web-accessible database to facilitate user searches) were included in the briefing materials for the meeting. RADM Slade-Sawyer devoted the remainder of her presentation to explaining these materials; she discussed challenges faced by HHS in developing the Web -accessible database and in putting forth evidence-based guidance for action.
Dr. Fielding thanked RADM Slade-Sawyer for her presentation. While the Committee is excited about health reform, the members are equally convinced that the U.S. cannot become the healthiest nation by just improving access to quality health care. Despite the fact that the U.S. spends more than any other developed nation on health care, our key indicators don’t reflect better health outcomes. Healthy People 2020 is an opportunity to increase our productivity and improve our competitiveness, particularly by focusing on the physical and social environmental factor that influence health. To accomplish this, other sectors must be involved. If they are not at the table to address the social and physical environment, then efforts to improve the health outcomes of the nation will be hampered.
He argued that the value proposition for Healthy People 2020 is lacking. What’s the return on investment? He called for looking at comparative effectiveness evidence. A hierarchy of evidence is critical, because not all evidence is of equal caliber. Without such guidance, there is a risk that users will see many options, and will choose those they like best instead of those that work. In some situations, the best thing to do is to wait; if we do something that is not supported by evidence, the opportunity to do other things that could have an impact is lost. Expert opinion has not always proven to be accurate; systematic reviews have different findings. If a systematic review is available, one should not use expert opinion. He suggested that the criterion for selecting a strategy because it “Went through departmental clearance” was inadequate. Healthy People 2020 must be extremely careful about the actions it puts forth, as users will view that inclusion as an endorsement. Members of the Committee added their input to Dr. Fielding’s remarks; key comments were as follows:
- Consider the potential for private (i.e., for-profit) entities to contribute in areas important to public health.
- When considering implementation strategies on the basis of evidence, take contextual factors into account in every situation, because certain populations have been systematically excluded from research.
- Healthy People has been under-utilized. How do we create a demand for this product?
- Give more thought to the criteria for selection. Consider the tradeoffs of cost-effectiveness and effect size. What should the characteristics of a recommendation be in order for it to rise to the top? Does it work? Even if it works 50% of the time, but it reaches the whole population, it might be worth it.
- The issue of requiring that an intervention is “enjoyable” or “palatable” is problematic because it places the onus on program developers. Many things are important to do that people will not enjoy (e.g., colonoscopy).
- Provide concrete examples that go from social determinants through to implementation strategies.
V. Committee Discussion: Operationalizing “Societal Determinants” of Health
10:45 AM- 12:00 PM