Dr. Remington noted that Healthy People 2010 was not always transparent about target-setting methods used. Dr. Remington said there is a need to look back at the past decade of experience, project where things would be in 2020 if those trends continued, and then decide how that trend can be improved. “If/then” scenarios might be helpful. He said that the important thing would be to clearly describe whatever methods are used. The Subcommittee felt that targets should be set at levels that are realistic, but also a reach. If targets are set at unrealistic levels, it could be demoralizing. Ultimately, target-setting should tie to putting effective programs and policies in place; evidence should be used when available. He added that Healthy People should acknowledge when targets are not evidence based.
Dr. Remington asked the Committee if objectives should have a single target (for the entire population) or multiple targets (for select populations). A single target offers the advantage of being easy to communicate about, but there might be select populations that have already achieved the target. The subcommittee felt that a single target would be useful for eliminating disparities. It should be recognized that there may be some populations that have already achieved the target, but should be encouraged to continue improvement. Dr. Remington said it was important to reduce the overall distribution of disease among racial and ethnic populations. Healthy People could attempt to reduce the mean and improve health or reduce variation between groups. He briefly discussed the issue of whether “disparities targets” should be set, but felt the most important resource for addressing disparities would be tools for states and regions. NCHS should provide guidance on this issue.
A Committee member indicated that one of the major criticisms of Healthy People 2000 was that it set two separate targets for communities of color and other populations. The use of two sets of targets was viewed as tacitly endorsing health disparities between populations. In 2010, Surgeon General David Satcher developed a single target.
Another member noted that there should be separate disparities targets, stating that having such a target would bring disparities to people’s attention. Rather than calling it a disparities target, he suggested called it an equity target. Dr. Fielding added that one critical principle is transparency. The methodology for setting targets may not be consistent, so it needs to be made clear which method is being use. The Committee noted that trends are another issue that needs to be considered. The Committee considered recommending a single overall target to which all groups need to progress a certain amount. Dr. Fielding expressed satisfaction with the Committee’s discussion and suggested that the Subcommittee provide guidance and tools to get this done. He also indicated that relating sub-objectives to objectives is important.
A Committee member commented that the lead-in language to Healthy People 2020 should concentrate on determinants and health equity. He reiterated that having another set of objectives for disparities detracts from the overall cause and may reduce buy-in from the nation as a whole. Dr. Fielding added that he did not think it would be possible to create tools right now and suggested that the Committee consider a core indicator set based on SMART targets or a holistic set. The work of State of the USA around national indicators should be considered.
Dr. Fielding also noted that determinants are critical to the equity issue. For most of these categories, the social and economic aspects are important. As targets are set for 2020, there may be some objectives where data are not available. To move forward, it is important to include emerging areas. In these areas, it is reasonable to allow several years for improvement. This means that midcourse reviews are all the more important. Dr. Remington agreed and emphasized that it may make sense to set some of the objectives with a shorter timeframe. Dr. Fielding added that there are proximal and distal outcomes. Dr. Remington added that this could be an important recommendation that could change 2020. The path to achieve targets might start from other objectives. There should be steps toward the overall targets. Dr. Fielding said that the Committee would send this issue back to Dr. Remington and the Subcommittee for further work. He noted that this would be the major topic of discussion on the Committee’s next call, on May 15, 2009.
V. Next Steps
Dr. Fielding noted that the Subcommittee on Implementation has a lot of work to do.
Subcommittee co-chairs Eva Moya and Adewale Troutman indicated that the Subcommittee could be ready to present by June or July.
The Committee discussed possibilities for the next in-person meeting. ODPHP staff Carter Blakey and RADM Slade-Sawyer suggested the Committee target the week of Labor Day 2009. Dr. Fielding indicated that there were scheduling challenges at that time of year, but members could work with NORC to identify potential dates for the next in person meeting.