Dr. Remington moved on to discuss disease areas. The new disease area topics that the Subcommittee has proposed for Healthy People 2020 are blood diseases, global health, digestive diseases, and quality of life. It has been suggested by HHS that hearing and vision be separate topic areas in Healthy People 2020. A Committee member suggested revising the topic area “overweight” to “energy balance and overweight,” noting that this is a timely and important issue. Dr. Remington added that this is an upstream issue, and thus groups working on issues from nutrition and physical activity to the built environment would need to collaborate. Dr. Fielding stated that the phrase “energy balance” should be added to the topic area on overweight.
Dr. Fielding added that quality of life and global health are additions. A member commented on the proposed topic area on “quality of life.” He pointed out that there are many aspects of quality of life and asked if the Committee intended the concept to be so broad. Dr. Fielding asked if this would be better placed in the preamble as it is a cross-cutting issue. Another member said that quality of life deserves to be included as an outcome. She suggested the Committee adopt the term “quality of life and wellbeing;” quality of life is generally considered to be a legitimate and important outcome in itself. Another member noted that she would approve the phrase, “quality of life” as long as the definition of it is left to individuals. She explained that using a wheelchair could be unacceptable for some people but fine for others; therefore, the individual must be left to determine what is meant by quality of life.
A Committee member pointed out that the proposed list of topics areas continues to emphasize diseases, rather than positive health outcomes for people. He suggested that the Committee’s discussion of diseases should try to frame outcomes in a more positive way. He said that Healthy People 2020 should move the health agenda in a positive direction. Dr. Kumanyika said that it was her understanding that the model reflects that.
Dr. Fielding asked if Committee members had thoughts on the inclusion of “global health.” Dr. Remington said global health is a cross-cutting issue. He also noted that while Healthy People is a plan for the United States, global health needs to be considered. Dr. Fielding asked for clarification of what is meant by this phrase, and whether it refers specifically to the intersection of health in the U.S. and health elsewhere. Dr. Remington said that global health was raised as an issue in Subcommittee discussions in terms of social, economic, and infectious disease issues, particularly within the context of an economic crisis that affects the health of the nation.
Dr. Fielding said that the Committee should make clear that the focus is on the point of intersection between health from outside our borders and health inside our borders. He said that if the connection was not clear, Healthy People could spend all of its time on the health of developing nations. Dr. Remington said that the increasing view is that as infectious disease and community health evolve globally and have an impact on health in the United States. Dr. Fielding was comfortable with this rationale.
Dr. Manderschied recommended that the Committee change the phrasing of the topic area “substance abuse” to “substance abuse and dependence.” The Committee expressed unanimous approval for the change.
IV. Healthy People 2020 Target-Setting Recommendations
Dr. Remington moved on to address the issue of target setting. He said that the Subcommittee on Target-setting met twice and circulated a draft proposal via email. Summarizing their work, Dr. Remington said that the subcommittee’s members emphasized that the targets should be SMART (Specific, Measurable, Achievable, Realistic and Time-bound). He indicated that the definition of a target is a level of performance for an objective. Target-setting is the method to set the target. Dr. Remington said that in the past, a number of methods were used. He said that Richard Klein (National Center for Health Statistics) had been a resource for the group.
Dr. Remington indicated that the “better than the best” target-setting method was the most aggressive approach. Using the “better than the best” target setting method, the population group with the lowest rate for a given disease is considered “the best” and the target is set better than that. A challenge of the better than the best target setting method is that there are often inaccuracies or cultural reasons why a particular population group has a low rate. Thus, some targets that were set using a “better than best” approach were unrealistic for some groups. On a positive note, “better than the best” targets set ambitious levels for improvement, but those targets were not relevant in all cases. Other target setting methodologies used include percent improvement, universal coverage, and retention of the Healthy People 2000 target.