Implementation of Healthy People 2020 should be linked to the national health reform effort. The issue of health reform is extremely visible, and has a strong public health and population health focus. Implementation efforts for Healthy People 2020 would be strengthened if they were linked to something visible and well-received. At the conclusion of the discussion, Dr. Kumanyika said it seemed that additional refinements to the document were needed in the coming weeks. The Subcommittee would present its final recommendations to the full Committee for vote at the next meeting on August 14, 2009.
IV. Healthy People 2020 Criteria for Selecting Evidence-based Strategies
Dr. Fielding started the discussion of evidence by thanking several individuals who provided input through one of the Advisory Committee's subcommittees on this issue, including Steven Teutsch (Los Angeles County Public Health Department), Ned Calonge (Colorado Department of Public Health and Environment), Tracy Orleans (Robert Wood Johnson Foundation), and Michael McGinnis (Institute of Medicine). He offered an overview of issues discussed by the group, which were summarized in a draft report by Dr. Fielding and Dr. Teutsch. (This document was included in the meeting briefing books.) Questions included how decisions should be made with regard to linking Healthy People objectives to evidence-based interventions, what to do when there is insufficient evidence to identify effective interventions, and what guidance should be provided to users about what really needs to be done.
Dr. Fielding provided an overview of challenges in this area. It is important to make available the best evidence as has been accumulated through systematic reviews and graded of levels of evidence. The clinical paradigm cannot always be used when addressing population health issues, because randomized clinical trials aren't always available. In community settings, interventions are context-sensitive. Thus, an intervention may be effective in one place but not another; it may need to be adapted.
Examining the term, "evidence-based" Dr. Fielding asked how one can evaluate accepted current practices that aren't supported by evidence and how should the findings of Health Impact Assessments be included to promote an inter-sectoral approach to evidence reviews? He noted that when evidence is not available, there are two alternative view points about how to proceed: 1) Recognize interventions that are accepted, but may be supported by weaker forms of evidence (e.g., expert opinion), or 2) Prioritize the interventions that one knows will work over those that are unproven.
The draft report, Evaluating Sources of Knowledge for Evidence-based Actions adopts the second approach. There are often gaps between what we know can work and what is currently being done to achieve the same objectives. A "hierarchy of evidence" can be used to organize different levels of evidence. At the top level of the hierarchy, the Community Guide and Clinical Guide can be used as references, but other sources are of interest as well. Systematic analyses are needed of all available studies using standardized methodologies and conducted by persons free of conflicts of interest (e.g., Cochrane reviews). Other types of evidence are designated at the next level of the hierarchy, and include best available methods (e.g., Health Impact Assessments). Translation tables can be used to weigh the evidence. Examples from the U.S. Preventive Services Task Force and the Guide to Community Preventive Services are included in the report.
Priorities should be informed by the best available evidence. Policies affecting a large number of individuals (i.e., through the physical and social environment) may have greater impact overall than programs that target individuals. The FIW should explore ways to produce rapid syntheses of what is being learned from evaluations of all types, including support for more practice-based evidence. Web 2.0 applications can be used to learn what stakeholders want to know.
Dr. Fielding said criteria for selecting evidence-based practices should be developed with the view that this information will be used for priority-setting, because that is where Healthy People users will be making systematic decisions. The issues should be framed in a positive way. He noted that there are more than 200 high priority topics that the Preventive Services Task Force has not been able to review due to its limited staff and resources. He hoped that this need would be redressed through the Federal budget process.
A Committee member recommended integrating efforts that are being proposed for Healthy People 2020 with the Agency for Healthcare Research and Quality (AHRQ)'s comparative effectiveness research. He suggested looking at the report of the Federal Task Force on Comparative Effectiveness, which was due to Congress at the end of June. Comparative effectiveness research is needed for population- and clinical-level interventions. Dr. Fielding said decisions on priorities are likely to be made on a short timeline. He suggested that the Committee recommend to the Secretary that population-oriented interventions be made a priority for the comparative effectiveness research efforts underway at HHS. The other Committee Members concurred.
Another Committee member pointed out that people with disabilities are systematically excluded from clinical trials. People with multiple chronic conditions or sometimes any chronic conditions are also excluded from the trials that produce the grade A level of evidence; thus, these two populations have no clinical evidence to guide therapeutic decision-making. She asked whether there are also certain select populations that are excluded in public health initiatives research.
Dr. Fielding agreed that some communities may be excluded or have less data available to demonstrate the effectiveness of community-based interventions. He said the Committee should make the point that in the development of the evidence through linkage to objectives, it is critical that such gaps be filled. The evidence should address priority public health and clinical preventive that could expand the evidence base and increase equity in terms of who is being looked at and who is being served. Another Committee member commented that community-based participatory research could be used to close gaps in the evidence base.