III. IOM Committee on Leading Health Indicators for Healthy People 2020
Dr. Fielding introduced Dr. David Nerenz, Director of the Henry Ford Health System Center for Health Policy & Health Services Research and Director of Outcomes Research for the Neuroscience Institute at Henry Ford. Dr. Nerenz gave an overview of the IOM Committee’s background, charge, and recommendations. The Committee’s charge was to: (1) develop and recommend 12 indicators and 24 objectives for consideration by HHS and (2) build upon the 1999 IOM report “Leading Healthy Indicators for Healthy People 2010,” and on the work of the Committee on the State of the USA Health Indicators. Before reviewing the Committee’s recommended indicators, Dr. Nerenz provided the following definitions:
- Topic: a general category relevant to health, for example, chronic illness;
- Indicator: a measure (e.g., age-adjusted mortality rate);
- Leading Health Indicator: a quantitative expression of a health-related concept that reflects a major public health concern;
- Objective: a state of movement in an indicator toward a quantitative target.
Dr. Nerenz clarified that the IOM’s recommended indicators are quantitative expressions, not specific measures with defined numerators or denominators. He explained that indictors and objectives were selected through the use of a framework that integrates a Life-Course Model and a Health Determinants and Health Outcomes Model. Categories of the Life-Course Model include: Pregnancy and Infancy, Childhood, Adolescence, Young Adult, Adult, and Elderly. Categories within the Health Determinants and Health Outcomes Model include: Policy, Physical Environment, Social and Economic Environment, Health Behavior, Health and Health Care Services, and Outcomes. In addition to using the developed framework, the Committee developed 9 criteria for selecting objectives. Those criteria were:
- The objective is well-defined.
- The objective is worth measuring; it represents an important and salient aspect of the public’s health.
- The objective is valid and reliable and can be measured for the general population and diverse population groups.
- The objective can be understood by people who need to act; the people who need to act on their own behalf or that of others should be able to readily comprehend the objective and what can be done to improve the status of those objectives.
- The objective will galvanize action; the objective is of such a nature that action can be taken at the national-, state-, local-, and community- level by individuals as well as organized groups and public and private agencies.
- Action can improve the objective.
- Measurement of the objective over time will reflect the results of action; if action is taken, tangible results will be seen and indicated by improvements in various aspects of the nation’s health.
- Data for the objective are available for various geographic levels (e.g., local, national) and population groups (e.g., race/ethnic, socioeconomic states, rural/urban).
- The objective is sensitive to changes in other societal domains (e.g., socioeconomic or environmental conditions or public policies).
The 12 indicators and 24 objectives recommended by the IOM are presented in Appendix 1.
The IOM Committee was also tasked with making recommendations for Healthy People 2020 Topic Areas that currently lack objectives (i.e., Social Determinants of Health, Health-Related Quality of Life and Well-Being, and Lesbian, Gay, Bisexual, and Transgender Health). Their recommendations in these areas were as follows:
- Social Determinants of Health: Use the Hardship Index to monitor socioeconomic aspects of the social determinants of health.
- Health-Related Quality of Life and Well-Being: (1) use health-adjusted life expectancy as an indicator of health-related quality of life, (2) focus on measures that can be used to produce summary measures of health using a 0-1 health utility score, and (3) review measures and datasets related to the concepts of happiness and well-being as a basis for defining specific objectives.
- Lesbian, Gay, Bisexual, and Transgender Health: modify specific IOM Committee-identified objectives that focus specifically on lesbian, gay, bisexual, and transgender populations (e.g., modify AH 5L: Increase the educational achievement of lesbians, gay men, and bisexual and transgender adolescents and young adults).
IV. Discussion With Dr. David Nerenz and Dr. Steven Teutsch
Committee Members were invited to ask questions and provide comment. A Committee Member asked whether the IOM Committee included mortality rates as an indicator. In the1990 report, the Healthy People objectives included mortality outcomes by age group looking at quality of life. Dr. Steven Teutsch, who was present on the call and had also taken part in the IOM Committee, explained that, based on their charge, the IOM Committee could only consider and recommend objectives listed in the Healthy People 2020 document.
The Committee Member noted that some objectives, such as mental health, have measures available nationally but those measures are unlikely to be applicable to state and community sources. He asked whether availability of national-level versus state-level versus local-level measures played a part in the selection of objectives. Dr. Teutsch responded that it was one consideration, but was not overarching. When the IOM Committee was filtering down specific measures, they took into account what was known about the health impact of a particular measure and objective.
Another Committee Member noted the discussion around adjusting for quality of life and adjusting for quality of life related to disability. She raised a caution that as HHS thinks about the effects of disability on quality of life and recognize that these effects are compounded by environmental and social determinants of health. She emphasized that the quality of life of people living with disabilities should not be devalued, especially if the LHIs are meant to improve the quality of life. Dr. Nerenz agreed, and pointed out that some technical issues of using the metrics in a way that adjusts for as many relevant factors as possible was beyond the scope of the IOM Committee’s charge.
Dr. Shiriki Kumanyika, Committee Vice-chair, asked if the IOM Committee’s had considered that its approach would result in a sense of what the national priorities might be, or if they viewed indicators and objectives as being separate from national priorities. Dr. Nerenz said the IOM Committee did not make any attempt to prioritize within recommended objectives, indicators, or topics. The selection of 24 objectives seemed to be a very strong message, and the IOM Committee understood their task to be fundamentally about priorities. Dr. Teutsch said the IOM Committee recognized early on that setting national priorities was one of the uses of the LHIs; therefore, the Members were cognizant of selecting the objectives of most importance.
Dr. Kumanyika asked whether the IOM Committee strove to select indicators that represented the Nation’s top problems or whether it strove to balance its selection of indicators. Dr. Nerenz answered that the Committee did not seek to make any stronger statements about priorities within the recommendations because it would have gone beyond their charge.
Finally, a Committee Member asked whether the IOM Committee considered the evidence base for action in their selection processor expressed uncertainty in selecting indicators with less or no evidence. Dr. Nerenz said that given the limited timeline under which the Committee was working, a degree of uncertainty was implicit and if various experts thought the evidence base was weak between action and outcome or that a measurement had some uncertainty or data sources were not completely reliable, these had the effect of reducing enthusiasm for an objective or topic. To select the objectives, the IOM Committee had 3 distinct subgroups who took up the task of selecting the first cut of objectives. None of these subgroups used an explicit quantitative metric for uncertainty to serve as a filter.