The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (SAC) has proposed a two-phase process for selecting Leading Health Indicators (LHIs) from the Healthy People 2030 (HP2030) objectives (again, the objectives are currently available in draft form, with the final set expected in 2020). In phase 1 of the LHI selection process, all core objectives should be assessed across the following four criteria:
- Public health burden—relative significance to the health and well-being of the nation;
- Magnitude of the health disparity and the degree to which health equity would be achieved if the target were met;
- The degree to which the objective is a sentinel or bellwether; and
- Actionability of the objective.
In phase 2, the following four criteria are applied to the set of potential LHIs emerging from phase 1:
- “The LHIs represent a balanced portfolio or cohesive set of indicators of health and well-being across the life span.
- The LHIs are balanced between common, upstream root causes of poor health and well-being and measures of high-priority health states.
- The LHIs are amenable to policy, environmental, and systems interventions at the local, state, tribal, and national levels.
- The LHIs are understandable and will resonate with diverse stakeholders to drive action” (SAC, 2018a, pp. 3, 4).
The committee has reviewed the criteria in the two-phase process for selection of the LHIs. The SAC’s description of the phases and criteria, and the rationale for each, are provided in the SAC’s report on the LHIs (see Appendix D). As noted above, the LHIs are defined by the SAC as a “selected set of measures of determinants and sentinel indicators of current and potential changes in population health and well-being” and “drawn from Healthy People objectives to communicate the highest-priority health issues.” Highest-priority health issues, the National Academies of Sciences, Engineering, and Medicine committee adds, would include not only those that characterize the health of the country, but also, the health of communities.
The committee agrees with the phase 1 and phase 2 criteria for the LHI selection—they cover all essential characteristics of individual LHIs and a well-constructed set of LHIs, and they are also consistent with previously described criteria (e.g., previous reports from the National Academies that addressed the criteria for selecting a small set of indicators). The committee notes that the main goal of phase 1 is to ensure that the LHIs meet certain specific criteria, such as public health burden, that demonstrate their importance to the nation’s health and well-being. The main goal of phase 2 appears to be a diagnostic check on phase 1 to ensure that the selected LHIs comport with the ideas identified in phase 0 (the proposed additional phase discussed below).
The committee has a few observations to share about the LHI criteria. Regarding the phase 1 criteria, “The magnitude of the health disparity and the degree to which health equity would be achieved if the target were met” seems to be a fairly aspirational criterion, because the data needed for this kind of analysis are often not available. The second criterion in phase 2—balancing upstream root causes with high-priority health states—may need to be applied earlier, perhaps as part of phase 1, given the importance of having a set of LHIs that addresses both upstream root causes and high-priority health states. The third criterion in phase 2, that “LHIs are amenable to policy, environmental, and systems interventions at the local, state, tribal, and national levels,” a criterion to be applied to the full complement of the LHIs, may need to be revised to replace the and in “local, state, tribal, and national levels” with an or, as it does not seem realistic to expect that each LHI would be amenable to interventions of all types at every level.
As noted, the draft core objectives from which the LHIs are to be derived are currently characterized by the limitations described above—the collection of draft objectives offers both too much and too little for
identifying the LHIs that are aligned with the HP2030 Framework. It is easy to get lost in the minutiae of myriad objectives, but the HP2030 Framework offers a coherent vision and pathway, one that also seems well aligned with the frameworks for national or local indicators showcased at the National Academies committee’s May 28, 2019, information-gathering meeting (NASEM, 2019). The HP2030 Framework developed by the SAC appears designed to balance the need for continuity with the past with the need to evolve to meet emerging and future opportunities and challenges. However, given that the LHI selection criteria begin by calling for assessing “all core objectives,” having objectives that are minimally aligned with the HP2030 Framework may lead to an inadequate, subjective, and ineffective process of identifying indicators to serve the field in the future. Providing a more well-rounded collection of objectives that show the “big picture” articulated by the Framework will be essential to ensuring that meaningful and useful LHIs can be selected.
Finding 4: The committee finds that if the existing criteria for Leading Health Indicator (LHI) selection were applied to the existing Healthy People 2030 draft objectives, the resulting LHI set would not be aligned with the Healthy People 2030 Framework—it would not tell a coherent story about the nation’s (or communities’) health, well-being, and the state of health equity.
Recommendation 1: The committee recommends that the Department of Health and Human Services and the Federal Interagency Workgroup add to the Healthy People 2030 objectives topics or implement a structural reorganization (with additional topics) that will yield more core objectives that reflect the Healthy People 2030 Framework and could lead to better Leading Health Indicators. Cross-cutting topics (i.e., topics that refer to or link with multiple health states, life stages, systems, and all dimensions of health) should include health equity; the social, physical, and economic determinants of health; shared responsibility and multiple sectors; and all levels of government.
Inspired by the SAC’s efforts in framing the Healthy People 2030 initiative, the committee also recommends the following:
Recommendation 2: The committee recommends a three-phase process should be used for Leading Health Indicator (LHI) selection from the Healthy People 2030 objectives. A new phase would
precede the existing two, and it would apply the Healthy People 2030 Framework (especially the vision, mission, foundational principles, and overarching goals) in consideration of additional objectives and in selecting LHIs.
The term phases implies a chronological sequence; however, the committee notes that the term filter may more accurately describe the manner in which criteria would likely be applied, and also includes a recognition that some of the criteria from phase 1 and phase 2 may in fact be applied concurrently. The main goal of adding a new phase (or filter) to the LHI selection process, let us call it phase 0, would be to ensure that the major concepts of the HP2030 Framework are represented in the LHIs as a collective set.
The existing objectives could remain under consideration as LHIs in accordance with the guidance already provided by the SAC in Report 7, but additional selection criteria are needed to determine which objectives can be the LHIs. The committee believes that the three-phase process recommended is needed to help “see the forest for the trees” among all the currently proposed objectives/indicators, and to operationalize the vision, mission, foundational principles, and goals of HP2030 in “filtering” the vast range of indicators represented in the collection of HP2030 draft core objectives.