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Dr. Kumanyika said the Committee should push back against the idea that "uniformity of evidence" is the goal for data collection. The push for diversity in clinical trials was due to the fact that people realized that studying homogenous populations did not provide answers for all population groups. It is important to emphasize that approaches are needed that fit the different circumstances of populations. Generally, the need for tailored approaches depends on the type of intervention. For instance, inventions to encourage seat-belt usage would be fairly uniform, while interventions related to increasing the amount of park space would not. Dr. Fielding recommended adding this point to the evidence paper.

The Committee agreed that the final version of the evidence report should be integrated with the final priorities document. Evidence could inadvertently drive priorities if it is not integrated in the priority-setting schema. For instance, the Carter Center report entitled, Closing the Gap, examined the issue of preventable burden in trying to identify opportunities. Yet the fact that one asks the question doesn't mean there is a sufficient evidence-base available to clearly define criteria like preventable burden. Dr. Fielding said the issues raised during this discussion should be incorporated into the final version of the Committee's evidence recommendations.

V.  Healthy People 2020 Priorities

Dr. Abby King, Co-chair of the Subcommittee on Priorities, provided a summary of the Subcommittee's recent work. In its first phase, the Subcommittee had presented general recommendations for priority setting at different levels (e.g., Federal, state, and local). Now, members had been charged with thinking about national priorities. They decided to explore some fundamental questions. First they asked, "Why create national priorities?" Their discussions led them to conclude that national priorities are needed because they can be used across broad numbers of people and government agencies and can also enable cross-agency collaboration. They discussed key characteristics of national priority objectives (e.g., supported by a compelling rationale and relevant to agencies with a broad range of mandates).

Dr. King differentiated between national priorities and leading health indicators (LHIs). Healthy People 2010's LHIs were originally created to provide a broad picture of our nation's health. Yet over the decade, there was confusion about the function of LHIs. It was thought that, because they were a small and manageable set, LHIs were priorities; yet they were simply intended to serve as a means of gauging the nation's health. National priorities are issues of national urgency; they are important enough that every level of government should monitor and undertake efforts to improve them. Dr. King noted that Healthy People 2020 should separately and clearly define LHIs and national priorities to ensure the terms are not used interchangeably.

Dr. King said the Committee had previously concluded that they would not be the correct body to develop national priorities, as they are not broad-based. However, they could recommend a process that the FIW—comprising HHS and other participating Federal agencies—could use to identify those priorities. This would ensure a priority-setting process that is not exclusionary, but includes diverse constituencies and areas of health. The Subcommittee was working on a suggested set of criteria for the FIW to use to make these choices. It would combine quantitative and qualitative approaches, and would include input from public health experts and experts from other fields (e.g., housing, transportation, agriculture). They are preparing recommendations for priority-setting methods that are practical and not overly academic. Dr. King opened the floor for discussion.

A Committee member commented that priority-setting processes can be fairly straightforward, or can quickly become complex. He mentioned the 3-four-50 initiative of the Oxford Health Alliance (http://www.3four50.com/ External Web Site Policy), which is based on the idea that three risk factors lead to four chronic diseases, causing fifty percent of preventable mortality. In earlier conversations, the Committee had discussed an approach as simple as identifying the three risk factors that could be connected to the LHIs. He said this Committee should recommend that somebody does need to set national priorities, and that the process for doing so must be well-defined, but not overly complex.

An inherent complication in setting priorities is that, if you make it too simple, you will exclude somebody. For example, Dr. Fielding was concerned that someone who has devoted their life to the issue of hearing would feel disenfranchised if the national priorities are, for example, set as obesity, physical activity, and nutrition. Within topics, it is important to look for the gap between what the evidence says is possible, and where we are today; that will help to define what the priorities are in getting from here to there. This guidance can be used to help to set priorities within every topic.