Appendixes



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 181
Improving Health in the Community: A Role for Performance Monitoring Appendixes

OCR for page 181
Improving Health in the Community: A Role for Performance Monitoring This page in the original is blank.

OCR for page 181
Improving Health in the Community: A Role for Performance Monitoring A Prototype Performance Indicator Sets This report proposes an organized activity—a community health improvement process—that uses performance monitoring to assess the impact of health improvement activities on health outcomes and to promote accountability among a diverse array of community stakeholders for participation in those activities (see Chapter 4). The process operates through two interacting cycles: (1) a broader problem identification and prioritization cycle, through which a community maintains an overview of its health and health-related activities and determines which health issues are of special concern; and (2) more narrowly focused analysis and implementation cycles, through which these specific health concerns are addressed. An essential component of the analysis and implementation cycle is the development of sets of indicators that a community can use to monitor the performance of its accountable entities (see Chapter 5). As proposed by the committee, these indicator sets should reflect the broad definition of health and its determinants that is embodied in the field model as presented by Evans and Stoddart (1994; also see Chapter 2 of this report) and should address the roles that multiple community stakeholders can play in shaping a community's health. The committee has developed prototypes for such indicator sets to illustrate how communities might apply these proposals.

OCR for page 181
Improving Health in the Community: A Role for Performance Monitoring Presented in this appendix are the committee's indicator sets for nine specific health issues: breast and cervical cancer, depression, elder health, environmental and occupational lead exposure, health care resource allocation, infant health, tobacco use, vaccine-preventable diseases, and violence. These issues were selected with several considerations in mind. The committee wanted to use as examples topics that are of concern at the community level and that can be addressed by community-level action. The committee also wanted to give examples that relate to the interests and roles of a diverse group of community stakeholders. A further consideration was illustrating different ways in which health issues might be framed (e.g., on the basis of population groups, risk factors, forms of morbidity, economic factors, societal concerns). The committee's examples also illustrate the interrelated nature of many health concerns. For example, reducing vaccine-preventable diseases carries benefits for both infant and elder health. Thus, interventions initiated in one context can have implications for other issues that may be of concern to a community. Once specific health issues had been selected, the committee developed its indicator sets using an approach like the community-based process described in Chapters 4 and 5. The domains of the field model provided a guide for examining each issue to formulate a broad list of potential performance indicators. From this list, about 10 indicators were selected as a proposed indicator set. The committee notes that for most of the health issues, the domain of genetic endowment includes few indicators because opportunities for intervention are currently limited. With growing knowledge in this field, however, additional interventions may emerge, making it possible to consider developing performance indicators. The selection criteria considered were those presented in Chapter 5: established validity and reliability of a measure to be used; an evidenced-based link between performance to be measured and health improvement; robustness and responsiveness of a mea-

OCR for page 181
Improving Health in the Community: A Role for Performance Monitoring sure to meaningful change in performance or health status; availability of data in a timely manner at a reasonable cost; opportunities to assign responsibility and accountability for performance; and inclusion in other monitoring systems (monitoring sets). Indicators must also be measurable; that is, it must be possible to formulate an operational definition that identifies units to be counted, a rate's numerator and denominator, or other appropriate components of a measurement. Ideally, an indicator should meet all of these criteria, with the exception of inclusion in another monitoring system; in practice, limitations in knowledge and available data may make it appropriate to begin with usable measures while efforts are under way to develop better ones. Resources that communities might draw on to identify potential indicators include documents that cover many health issues, such as Healthy People 2000 (USDHHS, 1991) and its "midcourse" review (USDHHS, 1995); Healthy Communities 2000: Model Standards (APHA et al., 1991); and the Health Plan Employer Data and Information Set and Users Manual (HEDIS; NCQA, 1993, 1996). More specialized resources are also available (e.g., Walker and Richmond, 1984; National Committee for Injury Prevention and Control, 1989; AMBHA, 1995; Fawcett et al., 1995). In using these sources, communities need to look beyond measures of health status to indicators that link performance and outcomes, and beyond measures for a small set of stakeholder groups to indicators that encompass the entire community. In a community setting, a variety of stakeholders should have the opportunity to participate in the selection of indicators through a mechanism such as a health coalition. For the examples presented here, a member of the committee or the study staff assumed primary responsibility for developing the materials on a given issue but was not necessarily an expert in that field. Comments were provided by other committee members, and for each health issue, advice was received from a small number of outside experts. As a result, the proposed indicators represent an informed but not definitive selection. The committee focused its attention on performance measures applicable at the community level or to a broad category of community stakeholders (e.g., health plans, Medicaid participants, schools, employers, the elderly), not on measures applicable to a specific accountable entity in any stakeholder group. Recognizing that communities will differ in how a health issue presents itself, what resources and policy options are available, and who the accountable entities are, the committee concluded that it could not,

OCR for page 181
Improving Health in the Community: A Role for Performance Monitoring and should not try to, propose indicators that link specific stakeholders to specific types of performance. Some likely points of accountability are noted, however. Each community will have to tailor indicators to its particular circumstances. To improve the resources available to communities seeking to implement a performance monitoring program, the committee has recommended a national effort to develop model indicator sets with standard measures. The work of scientific panels convened to review evidence linking performance and health outcomes and to address technical issues in measurement and data analysis of particular relevance at the community level will have to be integrated with guidance from community representatives on matters of acceptance and implementation. The extensive consultation on and analysis of performance measures undertaken by the U.S. Department of Health and Human Services for the proposed Public Health Performance Partnership Grants (see NRC, 1996; USDHHS, no date) and by the National Committee for Quality Assurance (NCQA, 1996) for HEDIS 3.0 illustrate the level of effort that could be needed. In this appendix, each of the committee's prototype indicator sets is presented with a brief review of the health issue that touches on points such as the population health burden, social costs, and opportunities for change. That section is followed by a discussion of potential indicators suggested by the domains of the field model and of the likely roles of various stakeholders. The next part of each presentation focuses on the 10 or so community-level measures that were selected from among the potential indicators. Comments are provided on why individual indicators were selected and their relationship as an indicator "set." Also noted are special considerations in obtaining data or interpreting the measures used. A summary table maps each of the proposed indicators to a domain of the field model and, in some cases, suggests stakeholders that are likely to have an interest. Each indicator has been assigned to a specific domain but may be relevant to other domains as well. Additional or alternative stakeholders may also be appropriate. The field model domains and an illustrative set of stakeholder groups that the committee used as reference points are listed in Table A-1. All of the health issues were addressed in the same general manner, but each topic poses unique problems and committee authors each brought a particular perspective to the task of formulating a prototype indicator set. As a result, the character of

OCR for page 181
Improving Health in the Community: A Role for Performance Monitoring TABLE A-1 Field Model Domains and Examples of Stakeholder Groups Used in Developing Prototype Performance Indicator Sets Field Model Domains Stakeholder Groups Disease Health care providers Individual behavior and response Health care plans Genetic endowment Local government Social environment State public health agencies Physical environment Local public health agencies Health care Environmental health agencies and organizations Health and function Education agencies and institutions Well-being Business and industry Prosperity Community-based organizations   Populations with special health risks   Disease or patient organizations   General public the presentations and indicators varies across issues, offering illustrations of different approaches that might prove useful in a community. REFERENCES AMBHA (American Managed Behavioral Healthcare Association). 1995. Performance Measures for Managed Behavioral Healthcare Programs. Washington, D.C.: AMBHA. APHA (American Public Health Association), Association of Schools of Public Health, Association of State and Territorial Health Officials, National Association of County Health Officials, United States Conference of Local Health Officers, Department of Health and Human Services, Public Health Service, Centers for Disease Control. 1991. Healthy Communities 2000: Model Standards. 3rd ed. Washington, D.C.: APHA. Evans, R.G., and Stoddart, G.L. 1994. Producing Health, Consuming Health Care. In Why Are Some People Healthy and Others Not? The Determinants of Health of Populations. R.G. Evans, M.L. Barer, and T.R. Marmor, eds. New York: Aldine De Gruyter. Fawcett, S.B., Sterling, T.D., Paine-Andrews, A., et al. 1995. Evaluating Community Efforts to Prevent Cardiovascular Diseases. Atlanta, Ga.: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. National Committee for injury Prevention and Control. 1989. Injury Prevention: Meeting the Challenge. New York: Oxford University Press.

OCR for page 181
Improving Health in the Community: A Role for Performance Monitoring NCQA (National Committee for Quality Assurance). 1993. Health Plan Employer Data and Information Set and Users Manual, Version 2.0 (HEDIS 2.0). Washington, D.C.: NCQA. NCQA. 1996. HEDIS 3.0 Draft for Public Comment. Washington, D.C.: NCQA. NRC (National Research Council). 1996. Assessment of Performance Measures in Public Health. Phase 1 Report. Draft for Comment. Washington, D.C.: National Academy Press. USDHHS (U.S. Department of Health and Human Services). 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . DHHS Pub. No. (PHS) 91-50212. Washington, D.C.: Office of the Assistant Secretary for Health. USDHHS. 1995. Healthy People 2000: Midcourse Review and 1995 Revisions . Washington, D.C.: USDHHS, Public Health Service. USDHHS. No date. performance Measurement in Selected Public Health Programs: 1995–1996 Regional Meetings. Washington, D.C.: Office of the Assistant Secretary for Health. Walker, D.K., and Richmond, J.B., eds. 1984. Monitoring Child Health in the United States: Selected Issues and Policies. Cambridge, Mass.: Harvard University Press.