3
Measuring Health for Improved Decisions and Performance

In this chapter, the committee presents six recommendations to address the challenges described in Chapter 2: (1) improving coordination at the national level, beginning with the primary federal health statistics agency (the National Center for Health Statistics [NCHS]) and with federal health data and statistics activities in general1; (2) adopting the determinants of health perspective at a fundamental level (to complement the health system’s predominantly biomedical orientation); and (3) enhancing responsiveness of the population health information system to the needs of end users.

IMPROVING COORDINATION AT THE NATIONAL LEVEL

Critical to progress on these challenges is leadership at the federal level, largely by Department of Health and Human Services (HHS). While HHS has 30 statistical offices and programs, NCHS, which is located within the Centers for Disease Control and Prevention, is the nation’s lead health-statistics agency (NRC, 2009). Although the array of information produced by those multiple efforts is rich, its great fragmentation—and overlap, suboptimal coordination, and remaining unaddressed gaps (for example, in data elements and in research needed to improve the quality, usefulness,

1

The HHS Data Council plays a key role in facilitating intradepartmental coordination on data and statistics issues. The Council has supported the development of the HHS Gateway to Data and Statistics (HHS, 2010), which represents one of several HHS efforts to make federal health data more available and accessible. The Council’s role in coordinating HHS data systems has also been discussed at a meeting of the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 (HHS, 2009b).



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3 Measuring Health for Improved Decisions and Performance In this chapter, the committee presents six recommendations to address the challenges described in Chapter 2: (1) improving coordination at the national level, beginning with the primary federal health statistics agency (the National Center for Health Statistics [NCHS]) and with federal health data and statistics activities in general1; (2) adopting the determinants of health perspective at a fundamental level (to complement the health system’s predominantly biomedical orientation); and (3) enhancing responsiveness of the population health information system to the needs of end users. IMPROVING COORDINATION AT THE NATIONAL LEVEL Critical to progress on these challenges is leadership at the federal level, largely by Department of Health and Human Services (HHS). While HHS has 30 statistical offices and programs, NCHS, which is located within the Centers for Disease Control and Prevention, is the nation’s lead health- statistics agency (NRC, 2009). Although the array of information produced by those multiple efforts is rich, its great fragmentation—and overlap, suboptimal coordination, and remaining unaddressed gaps (for example, in data elements and in research needed to improve the quality, usefulness, 1 The HHS Data Council plays a key role in facilitating intradepartmental coordination on data and statistics issues. The Council has supported the development of the HHS Gateway to Data and Statistics (HHS, 2010), which represents one of several HHS efforts to make federal health data more available and accessible. The Council’s role in coordinating HHS data systems has also been discussed at a meeting of the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 (HHS, 2009b). 67

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68 FOR THE PUBLIC’S HEALTH: MEASUREMENT and breadth of the information available)—makes the utility of the system’s combined efforts less than it should be. Many of the data sets described in Chapter 2 are built from core data el- ements that have been static for many years and reflect the sum of the health of individuals with few data on measures of the health of a community. The committee’s vision of measurement includes both a reconsideration of the use of older measures that may be less amenable to local action and account- ability and the building of new measures and potentially new measurement systems that report on more recently recognized loci for intervention. NCHS’s current mission is “to provide statistical information that will guide actions and policies to improve the health of the American people. As the Nation’s principal health statistics agency, NCHS leads the way with accurate, relevant, and timely data” (CDC, 2009). Although recognizing the statutory underpinnings of its mission, the committee believes that the cur- rent implementation of the NCHS mission is too limited (e.g., to conducting surveys). The 2002 HHS document Developing a 21st Century Vision for Health Statistics states that the NCHS vision should (HHS, 2002) · Reflect all manifestations of health and health care delivery. · ncompass population health, transactions between the population E and the health care delivery system, and the health care delivery system. · ddress the relationship and potential synergy between public and A private health data sets and national, state, and locally maintained data. Those three points are congruent with the committee’s findings about the statistics and information system’s needs, gaps, and opportunities. NCHS’s current mission statement and the committee’s understanding of the agency’s scope of work suggest that its current role consists primarily of conducting several major surveys on population health, as well as managing the nation’s vital statistics system and managing surveys of nursing homes, hospitals, outpatient facilities, and other clinical care providers (NRC, 2009). The committee believes that NCHS can and should play a broader leadership role in the population health information system, expanding its analytic capabilities, its research activities, its ability to collaborate with those who use its data, and its ability to help to modernize and integrate the system. Transforming the way the mission of NCHS is implemented could broaden the array of activities in which NCHS engages beyond surveys and basic statistical work and toward activities that facilitate and provide guidance for the “translation” of data into information and knowledge that decision-makers and communities can use. Facilitating a more highly integrated data system and a national popula-

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69 MEASURING HEALTH FOR IMPROVED DECISIONS AND PERFORMANCE tion health measurement strategy requires both governance and a high level of scientific guidance. In this chapter, the committee believes that NCHS, as the lead national health-statistics agency, must be strengthened to improve its ability to lead a system-wide effort toward better coordination and, as discussed below, enhanced information capacities for the health system. It is important to note here the roles of two federal advisory committees affiliated with NCHS: the Board of Scientific Counselors, which provides advice to NCHS, and the National Committee on Vital and Health Statistics (NCVHS), which is chartered to advise the secretary of HHS but is staffed in NCHS and closely identified with its work. NCVHS also has a population health subcommittee.2 The committee recognizes that two provisions of the Affordable Care Act (ACA)3 have potential pertinence to strengthening the nation’s popula- tion health information system. First, and most important, the new National Prevention, Health Promotion, and Public Health Council (NPHPPHC)— comprised of twelve cabinet secretaries and agency heads, under the leader- ship of the Surgeon General (Public Law 111-148)—offers an unprecedented opportunity for all sectors of government to come together around a de facto Health in All Policies effort. In recent years, there have been efforts around the country to examine the ramifications of all types of policy deci- sions on health outcomes, by using such tools as health impact assessments, as part of an approach called Health in All Policies, which calls for consider- ing the health effects of all government policies and is internationally used (for example, in the European Union) (CDC, 2010b; Koivusalo, 2010). The council is to make “recommendations to the President and the Congress concerning the most pressing health issues confronting the United States and changes in Federal policy to achieve national wellness, health promotion, and public health goals, including the reduction of tobacco use, sedentary behavior, and poor nutrition” (Congressional Research Service, 2010). The executive order establishing the council creates a forum for collabo- ration and coordination among twelve federal departments and agencies that have roles with implications for population health. For the purposes of enhancing the nation’s population health information system, the council’s composition (for example, the inclusion of other agencies) could provide an independent or fresh perspective from outside HHS that could be useful in supporting the department and NCHS (in addition to ensuring that the transformation of NCHS takes place as a primary requirement for meeting 2 The Subcommittee focuses on both “(1) population-based data such as vital statistics and health surveys concerning the U.S. population generally and (2) data about specific vulnerable groups within the population which are disadvantaged by virtue of their special health needs, economic status, race and ethnicity, disability, age, or area of residence” (NCVHS, 2008). 3 The Patient Protection and Affordable Care Act and the Health Care and Education Af- fordability Reconciliation Act, known jointly as the Affordable Care Act (ACA).

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70 FOR THE PUBLIC’S HEALTH: MEASUREMENT the nation’s population health information needs). The council’s work could have ramifications for cross-department information and data efforts. For example, as discussed in Chapter 2 and below, data on determinants of health reside in many government agencies outside HHS, and linkages to make such data available to the public health community are not optimally developed or are in very early stages of development (the US Department of Agriculture Food Environment Atlas is an exception; see USDA, 2010). The council, under the leadership of the surgeon general, has been charged with preparing a national prevention strategy and an annual report on its progress in implementing the strategy. Second, the act includes a provision to establish a Key National Indica- tors Initiative (Congressional Research Service, 2010). The initiative will develop and disseminate key indicators on health, education, the economy, agriculture, transportation, and other parts of American society in recogni- tion of the cross-cutting information needs involved in forming a full picture of the status of American society. With respect to health, it could create a forum for integrating data from different levels of government and sectors. A stronger and adequately resourced NCHS would be in a position to play a coordinating and leadership role in rationalizing, harmonizing, and integrating population health data collection, analysis, and reporting efforts and to provide scientific guidance on developing and selecting indicators and reflecting on the effects of various determinants of health. In continually reviewing the nation’s population health information system and its contri- butions to understanding health at the community and subpopulation level, NCHS could facilitate a move toward a more coherent system. In reviewing the major domains in which data are collected, the agency could call for new indicators to be added and for those of decreasing relevance to be culled. The process could be likened to those in other important societal arenas, such as changing the components of the consumer price index or the stocks included in the Dow Jones Industrial Average. In its 2009 report Principles and Practices for a Federal Statistical Agency (Fourth Edition), the National Research Council’s Committee on National Statistics outlined the key characteristics and roles for such agen- cies as NCHS, including Practice 8 (an active research program intended to improve data content and the design and operation of data collection and to make information more useful to decision-makers) and Practice 11 (co- ordination and cooperation with other statistical agencies) (NRC, 2009). As noted in Chapter 2, two recent external reviews of NCHS’s National Health Interview Survey (NHIS) and its National Health and Nutrition Examina- tion Survey have found that the agency needs greater financial and staff resources to undertake improvements in these major statistical activities, including methodologic and other research (NCHS, 2008, 2009). Three- fourths of NCHS’s estimated budget supports the purchase of data collec-

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71 MEASURING HEALTH FOR IMPROVED DECISIONS AND PERFORMANCE tion and reporting services from state and local governments, the Bureau of the Census, and private contractors (NRC, 2009), leaving few resources to support those other critical endeavors. The committee has learned that others have examined the nation’s health statistics and information system and have suggested ways to en- hance coordination and integration to serve the overarching objective of improving population health. Proposals have included a call, in the 2002 HHS document Shaping a Health Statistics Vision for the 21st Century, for an “integrating hub” to facilitate coordination of statistical activities within HHS (HHS et al., 2002) and a call for a population health record (Friedman and Parrish, 2010). In its information-gathering sessions, the committee learned from public health practitioners that they often lack local-level data needed for funda- mental planning and priority-setting and that federally produced statistics or measures meet only some of their information needs (IOM, 2010a,b). The committee heard repeatedly that the federal government’s own efforts to col- lect health-related data have historically occurred in silos (e.g., along vertical programmatic lines, with little or insufficient cross-cutting integration and collaboration) both within HHS and with other government departments and agencies. The population health information system as a whole is not ideally structured to facilitate interaction, collaboration, and data exchange and integration between the public and private sectors. Another concern is minimizing inefficiencies to avoid burdensome procedures and costs for agencies and organizations, such as requests to provide the same data in different formats to different national, state, or local entities. Coordination is necessary to facilitate user access to data that originate from different government sources. That suggests the need for coordination to establish systems that maximize efficiency, streamline bu- reaucratic procedures, and expand the new HHS data warehouse (through the Community Health Data Initiative [CHDI] effort) while facilitating the integration of data from different sources on population health into an ac- cessible, well-designed, and interactive interface to enable users to obtain relevant data at the geographic level of interest easily (see Chapter 2 and Appendix B discussion of CHDI, which represents a start). Given the challenging nature of coordination and integration and the centrality of the need, the committee believes that a patchwork approach will not be adequate to meet the information needs of the health system. Comprehensive change, beginning at the core of federal work in this field, is needed to lead the way in addressing the gaps discussed in Chapter 2 and to support the development of a population health information system capable of responding to and forecasting the opportunities and meeting the challenges of the next decade and beyond.

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72 FOR THE PUBLIC’S HEALTH: MEASUREMENT Recommendation 1 The committee recommends that: 1. The Secretary of Health and Human Services transform the mission of the National Center for Health Statistics to provide leadership to a renewed population health information system through enhanced coordination, new capacities, and better inte- gration of the determinants of health. 2. The National Prevention, Health Promotion, and Public Health Council include in its annual report to Congress on its national prevention and health-promotion strategy an update on the prog- ress of the National Center for Health Statistics transformation. The committee believes that NCHS is the right body to provide leader- ship in changing the nation’s population health information system because it is the nation’s main health-statistics entity, has a long history of work and accomplishment, and has many of the requisite connections with other fed- eral agencies. Although federal agencies depend to a large extent on political realities and therefore have some limitations of independence, the committee was not able to envision a sustainable source of funding that would support a new public–private entity charged with playing the major coordinating role that it has described. The committee believes that the reporting struc- ture laid out below, which includes an accountability mechanism, could help to buffer the agency against political vicissitudes that may affect its evolution to greater strength and capability. The transformation of NCHS will require changes in the agency’s mis- sion (or, more specifically, its implementation), capabilities, authority, and resources. Its current output is largely statistically analyzed data, but as described in this chapter, its role needs to be broadened to include capaci- ties and activities to translate data into information and to conduct related research, such as research on the development and construction of indica- tors. Although “analysis by a statistical agency does not advocate policies or take partisan positions” (NRC, 2009), the committee believes that there is a substantial difference between advocacy and playing an active and central role in improving the quality and usefulness of indicators and other tools for disseminating population health information and enhancing the research infrastructure and agenda to support these activities. An independent and influential external body will be necessary to over- see the progress of the transformation. Given the cross-cutting nature of the new NPHPPHC and the fundamental value and necessity of population health information for the prevention and health-promotion strategy that it is charged to develop, the committee believes that the council (with input from their Advisory Group on Prevention, Health Promotion, and Integra- tive and Public Health, which can provide input from other sectors) can play

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73 MEASURING HEALTH FOR IMPROVED DECISIONS AND PERFORMANCE an important role in monitoring changes in NCHS that can support or fa- cilitate improvements in the nation’s population health information system as a whole. A considerable challenge is that NCHS will require continuing funding outside the political process. Although statistical agencies, such as NCHS, do not advocate, some of the information they produce could sug- gest or lead to action that is not consonant with particular political agendas. A possible solution would be to devote a portion of HHS funds to NCHS without requiring yearly appropriations. The national prevention and health-promotion strategy is intended to include specific goals, and the NPHPPHC is asked to describe “corrective actions recommended by the Council and actions taken by relevant agen- cies and organizations to meet” the goals.4 The committee believes that NCVHS, working at the behest of the secretary of HHS, may serve as a technical resource to the NPHPPHC in evaluating the success of NCHS’s transformation (and the NCVHS Subcommittee on Population Health has additional expertise that would lend itself to this task, although it would need to include public health practice and community development). Al- though the executive order establishing the council does not explicitly refer to the centrality of statistics and measurement (and this is not one of the kinds of expertise listed in the charter of the advisory group of the council, which is still under development), the committee notes that the council’s first annual report lists eight principles that guide its work, including reviewing “data on the leading and underlying causes of death” as part of its focus on prevention (National Prevention Health Promotion and Public Health Council, 2010). An adequately resourced and transformed NCHS would possess the mission, capabilities, resources, and authority to improve aspects of current activities and to undertake new activities. NCHS could · oordinate research on and support the development of—within C HHS and in collaboration with relevant stakeholders—several population health information tools and processes described in recommendations elsewhere in this chapter: o standardized set of measures of community health (see Recom- A mendation 2). o standardized set of health-outcome indicators that can be used A at the national, state, and local levels (see Recommendation 2). o summary measure of population health (see Recommendation 2). A o odeling to elucidate the complex relationships between health M and its determinants (see Recommendation 6). 4 Executive Order No. 13544, 75 Fed. Reg. 33983 (June 10, 2010). http://edocket.access. gpo.gov/2010/pdf/2010-14613.pdf (accessed June 14, 2010).

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74 FOR THE PUBLIC’S HEALTH: MEASUREMENT · odernize national data sets to concentrate on indicators known M to be pertinent to many conditions (for example, by combining NHIS, the Behavioral Risk Factor Surveillance System, and other questions about important social and environmental determinants not currently tracked in the data sets) and focus less on specific disease data sets. · ake recommendations about modern survey methods to collect M more valid data efficiently. Modernizing could include better ways of performing household surveys, collecting responses electronical- ly, and maximizing opportunities afforded by the shift from landline telephones to mobile phones. · rovide leadership in the uniform application of novel analytic P tools. · ollaborate with other health-related government agencies, includ- C ing on the collection of (and acting on) information on their user experience, their needs, and their use of available statistics. NCHS already has strong or growing collaborative relationships with an array of federal departments and agencies, such as the Bureau of the Cen- sus and various HHS agencies and statistical units. NCHS could strengthen or cultivate additional linkages with other federal departments that produce statistics and information relevant to population health—such as the De- partments of Agriculture, Transportation, Labor, and Education—and with external (private-sector) data organizations. The committee acknowledges that calling for strengthening of a govern- ment agency does not address the fundamental need for coordination among public- and private-sector data sources. However, it is pleased to note (and endorses) the NPHPPHC’s guiding principle pertaining to public–private collaboration (National Prevention Health Promotion and Public Health Council, 2010), and believes that a federal advisory committee like NCVHS (which includes private-sector representatives, whose numbers could be expanded) can play a role in facilitating interactions between, for example, government and business. Bringing Coherence to Indicators Building an understanding of the forces that shape and create health requires development and testing of new and evolving indicators and continuing tests of their relationships to one another—for example, as facilitated by modeling. On the pages that follow, the committee describes indicators that are inadequately developed (community-health indicators), require rationalization and standardization (health-outcome indicators for national, state, and local data sets), or are in evolution (summary measures of population health).

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75 MEASURING HEALTH FOR IMPROVED DECISIONS AND PERFORMANCE A Standard Set of Community-Health Indicators Chapter 2 summarized recent efforts to measure the health of commu- nities and present the results as a ranking or in comparative fashion (Com- munities Count, 2008; Community Health Status Indicators, 2009; County Health Rankings, 2010; Saskatoon Regional Health Authority, 2007). Most of the indicators produced by such efforts are aggregations of various health and risk measures of individuals at specific times rather than measures of the overall health of communities in and of themselves (i.e., the health of the social and physical environments in a community). The current usage of the term community health indicators differs somewhat from the committee’s thinking about true measures of community health that convey information about characteristics of the community as opposed to aggregated data on its individual members. Community-health indicators pertain largely to the local level. Consen- sus on the appropriate domains and indicators at this time is either impos- sible or extremely challenging. For example, there are different measures of “walkability” in a community—some that have been used in studies, such as pedestrian facilities (for example, sidewalk completeness and traffic-signal density) and street connectivity (street and intersection density), and some that have been included in municipal or community reports (for example, the ratio of sidewalks to roads in a community and the distance to such ame- nities as grocery stores, libraries, and parks; see, for example, Jakubowski and Frumkin, 2010; Zhu and Lee, 2008). Similarly, for healthy-food access or availability, there is no consensus about what indicators are best for dif- ferent purposes—whether to select the ratio of convenience stores to grocery stores, the prevalence of fast-food outlets, or some other metric—and indi- cator validation has only recently begun (Glanz, 2009; Lytle, 2009). Social cohesion, trust, and support; health literacy; social vibrancy; and different types of environments all require consensus with respect to specific indica- tors (Lantz and Pritchard, 2010) that could be used and tested to further develop a balanced portfolio of community-health indicators. There also is no high-quality, widely accepted overarching measure of environmental health from an exposure perspective, although there are several focused measures, such as ozone and PM2.5 (Jakubowski and Frumkin, 2010). Both a more robust set of indicators and a set of criteria for selecting among them are needed (as an example, see Healthy People 2020 [HP 2020] criteria for selecting objectives [HHS, 2009a]). Beyond their direct effects on the health of individuals, social, envi- ronmental, and economic factors rooted in communities also influence the overall health of communities, which in turn influences the health of indi- viduals. (Chapter 1 summarizes some of the evidence on the determinants of health.) Community-health indicators are needed to capture, understand, and describe those factors to community members and to decision-makers.

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76 FOR THE PUBLIC’S HEALTH: MEASUREMENT Domains that require representation include aspects of the physical environ- ment (such as sidewalks, pollution, green space, and housing), of social sup- port (such as cohesion, social capital, and social efficacy and engagement), and of community vibrancy (such as participation in the arts and sports). The literature exploring the use of those indicators is developing. Some of the domains that may serve as examples include · ncome and income distribution, education, unemployment and job I security, employment and working conditions, early-childhood de- velopment, food insecurity, housing, social exclusion, social-safety network, sex, and race (Mikkonen and Raphael, 2010). · cope of early-childhood development programs, education and S skills, employment and good jobs, minimum income for healthy living, and healthy communities (community capital) (The Marmot Review, 2010). · ood and water, housing, a nonhazardous work environment, a F nonhazardous physical environment, security in childhood, impor- tant primary relationships, economic security, physical security, and education (Doyle and Gough, 1991). To track and understand those domains, public health agencies and their health-system partners at state and local levels require data from other sectors. For example, a local public health agency may have access to some indicators of the social determinants of health, such as educational attainment and income, but not to others, including more complex (or less well-understood or well-defined) community features or resources, such as social capital (Drukker et al., 2005; Prentice, 2006), the availability of healthy and fresh foods in the community, or the health literacy of its inhab- itants. An employer or school planning department may need data on the community’s use of public recreational venues, such as parks, in developing physical-activity interventions. The presence of smoking restrictions, requirements of menu labeling (before the ACA provision that pre-empted such local and state laws), pedistrian-friendly planning, and effective regulation of the clinical care sys- tem are all examples of regulatory and enforcement environments as good markers of aspects of community health (e.g., National Complete Streets Coalition, 2010).5 Communities that have higher levels of civic engagement 5 One example of a potential area for legislative attention pertaining to the built environment is found in the work of the National Complete Streets Coalition. The coalition is a diverse partnership advocating for national, state, and local legislative action to institute “complete street” policies (e.g., policies that influence transportation planning and seek to ensure that transportation in all communities is optimally safe, results in lower emissions, and facilitates increased physical activity) (National Complete Streets Coalition, 2010).

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77 MEASURING HEALTH FOR IMPROVED DECISIONS AND PERFORMANCE and similar characteristics are typically better equipped than others to enact policies that change environmental conditions to foster healthier behaviors (such as access to healthy foods and places for physical activity). Access to supermarkets and healthy food sources (and, conversely, the density of fast-food outlets, convenience stores, and liquor stores) is of established relevance to overweight and obesity and thus points to potentially important indicators of community health that could be routinely collected and shared. In summary, although a number of national indicator sets include a few indicators of broad social determinants of health, the committee believes that unified guidance is needed to describe and build an evidence base for an actionable set of additional indicators that would support community decision-making with respect to local health-promoting initiatives. Data availability and research elucidating causal pathways may pose limitations, and the committee believes that galvanizing local partners to work in con- cert toward health gains will require a shared understanding of the factors that influence the health of communities. Developing that understanding rests on capturing new indicators and exploring their utility through ex- perimental and observational studies and modeling. The committee finds that many of the so-called community indicators that are in use focus largely on aggregates of individuals’ social risk fac- tors, such as income and education, such health outcomes as mortality and disease-specific morbidity rates, and such individual risk factors as smok- ing. The committee recognizes that the evidence base available in many of the categories discussed here, including geographic relevance, is under- developed. It believes that knowing and communicating about the health of communities is essential for informing health-improvement efforts. Small area (community level) analysis is critical to identifying disparities, such as vulnerable subpopulations with considerably poorer health outcomes than those of the larger population (e.g., a metropolitan statistical area) within which they are embedded. The committee acknowledges the need for re- sources in capturing new information and understanding it. A Standard Set of Health-Outcome Indicators As discussed in Chapter 2, indicators of population health in the United States currently form a rich amalgam rather than a coherent whole that can be used in public health practice in a way that is considered and consistent over time. Although several existing measurement efforts described in Chapter 2 include a variety of health outcomes (i.e., distal outcomes such as disease rates and disease-specific mortality rates), and although such indica- tors are sometimes similar from one set to another and based on similar or identical sources of data, no standardized set of indicators has been vetted and found to be useful in serving population health planning at all levels.

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100 FOR THE PUBLIC’S HEALTH: MEASUREMENT BOX 3-2 Health Impact Assessments (HIAs) A current IOM committee, the Committee on Health Impact Assessment, is developing a report that will explain the rationale of HIAs, enumerate their core ele- ments and activities in the HIA process, describe the current practice, and provide guidance and provoke further exploration on effective HIA practice (expected to be released in 2011a). An overview of HIAs and a few examples are provided below. An HIA is commonly defined as “a combination of procedures, methods, and tools by which a policy, program, or project may be judged as to its potential ef- fects on the health of a population, and the distribution of those effects within the population” (WHO and ECHP, 1999). An HIA is implemented before a project or policy is put into action to deter- mine its potential health effects objectively. It brings together information from sectors beyond public health (such as transportation) to help in the decision- making process. It focuses on health outcomes, such as obesity, physical inactivity, asthma, injuries, and social equity (CDC, 2010b). The major steps in conducting an HIA include (CDC, 2010b): · Screening (identify projects or policies for which an HIA would be useful). · Scoping (identify which health effects to consider). · ssessing risks and benefits (identify which people may be affected and A how they may be affected). · eveloping recommendations (suggest changes to proposals to promote D favorable or mitigate adverse health effects). · Reporting (present the results to decision-makers). · Evaluating (determine the effect of the HIA on the decision). ent interventions on pandemic outbreaks (Epstein, 2009; Ford et al., 2006), to study consumer eating behavior (Hammond, 2008), for cancer-screening optimization (Subramanian et al., 2010), and even for public health plan- ning (Homer et al., 2007). Health impact assessments (HIAs) use a variety of modeling techniques to assess the benefits and harms of policy options—for example, the effects of living-wage laws, land use, and menu labeling (UCLA HIA-CLIC, 2010) (see Box 3-2 for more information on HIAs). Examining and leveraging existing simulation models would be useful. For example, the National Collaborative on Childhood Obesity Research has partnered with CDC, the National Institutes of Health (NIH), the Robert Wood Johnson Foundation, and the US Department of Agriculture to “forecast the impact of public health policies and interventions on childhood obesity on a pop- ulation-wide level and among specific subpopulations” to simulate health

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101 MEASURING HEALTH FOR IMPROVED DECISIONS AND PERFORMANCE There are many ways in which an HIA can be implemented; depending on the method and tools used, they can be completed in a few days or take several months (Cole et al., 2005). HIA is used in Canada, Europe, Australia, and New Zealand; for some it is part of the regulatory process, for others it is voluntary (CDC, 2010b; Cole and Fielding, 2007; Cole et al., 2005). Several state legisla- tures—including those of California, Maryland, and Massachusetts—are consider- ing bills that would implement HIA. The following are examples of HIA use in the United States: · he San Francisco Department of Public Health regularly uses HIA to T analyze community issues and provides education and training on HIA (City and County of San Francisco Department of Public Health, 2010). · he White House Task Force on Childhood Obesity recommended that T communities consider using HIA as part of their decision-making process (White House Task Force on Childhood Obesity, 2010). · n Hawaii, the Department of Agriculture is partnering with Kaiser Per- I manente, the Center for Health Research, Human Impact Partners, and the Kohala Center to develop an HIA that will inform the development of a County of Hawaii Agriculture Development Plan, which is in response to the loss of sugar plantations that once dominated the economy (The Kohala Center, 2008). For more information, see CDC Healthy Places (CDC, 2010a), Dannenberg et al. (2006), Health Impact Assessment Gateway (APHO, 2007), and the WHO Health Impact Assessment (WHO, 2010). a See http:www8.nationalacademies.org/cp/CommitteeView.aspx?key=49158 (accessed September 8, 2010). outcomes and potential cost savings from alternative health-promotion interventions (NCCOR, 2010). In Canada, government health statisticians have been using simulation modeling to project the health-status trajectories of a longitudinal sample of people to inform health priorities and policy decisions (Wolfson, 1999) (see Box 3-3 for an example of some single outcome-specific uses of mod- eling). Various risk-behavior states in the population are interrelated to multiple outcomes—for example, smoking and multiple types of cancers and cardiovascular diseases. In the United States, the NIH Office of Behav- ioral and Social Sciences Research is leading efforts to accelerate the use of systems-based modeling in health (Mabry et al., 2010). CDC has also em- braced systems-based modeling to advance community-based intervention strategies. This form of analysis can identify common causes of coexisting and synergistic conditions, such as substance abuse, violence, and sexually

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102 FOR THE PUBLIC’S HEALTH: MEASUREMENT BOX 3-3 Examples of the Use of Modeling by Statistics Canada The Population Health Model (POHEM) is a microsimulation model of dis- eases and risk factors in which the basic unit of analysis is the individual person. The simulation creates and ages a large sample population representative of Canada, one individual at a time, until death. The life trajectory of each simulated person unfolds by exposure to different life-like events, such as smoking initiation and cessation, changes in weight, and incidence and progression of such diseases as osteoarthritis, cancer, diabetes, and heart disease. POHEM combines data from a wide array of sources, including nationally representative cross-sectional and longitudinal surveys, cancer registries, hospi- talization databases, vital statistics, census, and treatment-cost data. The model inputs may be altered at the user’s request to investigate what-if scenarios. The scenarios can be useful for policy-makers by providing information beyond what is available from retrospective population studies. Earlier versions of POHEM were used to estimate lifetime costs of breast and colorectal cancer and for assessments of health technology in cancer control, such as chemotherapy options for advanced lung cancer, the use of preventive tamoxifen in Canadian women, and the impact of population-based colorectal- cancer screening. More recent generations of POHEM models have been developed for other common diseases—such as osteoarthritis, acute myocardial infarction, and dia- betes—and for disease risk factors, such as obesity and physical inactivity. The risk-factor modules enable users to simulate the effects of changes in obesity or physical activity on key health outcomes.a a The examples above illustrate the more traditional applications of population health model- ing, but more recent Canadian work has moved in the direction of exploring multiple variables (from behavioral risk factors to the broad determinants of health) and their effects on health outcomes, including health-adjusted life expectancy (Wolfson and Rowe, 2009). Michael Wolfson has highlighted the potential uses of a summary measure of population health but notes that the health-adjusted life expectancy of a population is a reflection of myriad factors, some of which can be influenced by public policy. Modeling can use data to explore the rela- tionship of health-related policy to broad health outcomes. However, arriving at a more robust and evolving understanding of how to maximize the health of populations and subpopulations requires exploration of the effects of social, environmental, and other determinants. SOURCE: Statistics Canada, 2010. transmitted diseases (Milstein, 2008), that contribute to disease burdens in communities. The complex, changing nature of the conditions (e.g., social, economic, environmental) that influence health, productivity, and the volume of pa- tients flowing into the clinical care system requires increased use of analytic approaches that elucidate interactions and interdependences among differ-

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103 MEASURING HEALTH FOR IMPROVED DECISIONS AND PERFORMANCE ent systems and sectors, such as those between the traditional health sector (clinical care and government public health) and transportation, employ- ment, and education (Collins et al., 2009). The success of the United States in dramatically reducing mortality from motor-vehicle collisions is a good illustration of the effects on health of actions taken in other sectors. Despite the meteoric rises in the numbers of motor vehicles and of miles driven per person, motor-vehicle fatality rates declined precipitously throughout the second half of the 20th century. That was a result of system-wide and mutually reinforcing interventions ranging from vehicle-safety design to traffic management, road construction design, alcohol regulation and enforcement, seat-belt laws and enforcement, workplace substance-abuse policies, and numerous community-based programs, including designated- driver and family-oriented engagement initiatives (Bolen et al., 1997). The transformation of the Department of Veterans Affairs health care system in the 1990s provides an example of dramatic system-wide improvement oc- curring in a short time through use of overlapping and reinforcing change strategies, including integrating and coordinating services and creation of an accountable management structure (Kizer and Dudley, 2009). “Bending the curve” of effects of chronic diseases and injury on functioning, produc- tivity, clinical care use, and cost will require better information to support systemic improvements. Insights from modeling are essential for improved decision-making regarding priorities for intervention, collaboration among health-system sectors, and resource allocations. However, modeling itself will require further development and research. Recommendation 6 The committee recommends that the Department of Health and Human Services (HHS) coordinate the development and evalua- tion and advance the use of predictive and system-based simula- tion models to understand the health consequences of underlying determinants of health. HHS should also use modeling to assess intended and unintended outcomes associated with policy, funding, investment, and resource options. CONCLUDING OBSERVATIONS The need for better and consistent measures at all levels to inform those who work to improve the health of the nation is great. This chapter makes recommendations that, if implemented, will lead to a more coherent popula- tion health information and statistics system. Advancing the timeliness and usefulness of data by creating standards, addressing inefficiencies, aligning health objectives, and improving coordination is key to meeting that goal. Communication of data to policy-makers and the public can help to create

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