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V. Leading Health Indicators Subcommittee

Dr. Fielding introduced Dr. Ronald Manderscheid, Chair of Subcommittee on LHIs for the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Dr. Manderscheid requested input from the whole Committee on key issues that the Subcommittee would need to address to produce a set of recommended LHIs. He said the Subcommittee wished to produce LHIs that were helpful, synoptic, and would reflect priorities. The LHIs should provide status updates and guidance for action. Using that as a framework, Dr. Manderscheid posed a series of questions to the Committee.

Dr. Manderscheid asked what role the LHIs should play. A Member responded that the LHI discussions can quickly transition to questions of priorities. He emphasized that it is important to be explicit that these are a set of measures to indicate health status and not to prioritize where investments should be made. The Subcommittee should seek to be explicit about where LHIs should be applied: the national-, state-, or local- levels. Dr. Fielding asked whether the Committee should recommend indicators that are available all the way down to the local level or those available only at the national- or state-level or even those with no availability at all. He asked if the Committee felt constrained by what is available.

Dr. Kumanyika said that at the national-level, the Committee should focus on indicators that reflect the state of the nation and are geographically neutral. Furthermore, thinking in terms that are not geographically nutral would not necessarily tell you how the nation as a whole is doing. She added that there are national surveys that cannot be disaggregated to the state- and local-level. There are other complementary activities that give a finer grain picture in states and localities, so the LHIs could be used for the broad evaluation but states and localities could use them as a reference point.

Another Committee Member noted that once the LHIs are released, it would helpful for ODPHP to develop a grid to indicate availability of data at the national-, state-, and local-level. There are a number of indicators available from national surveys, and it would be helpful to know where they are available at a state- and community-level. The Committee could primarily use LHIs for the nation, and possibly for driving data collection efforts at the state-level, but there may be a subset of LHIs available at the local-level.

A Committee Member said that when people hear the term “LHIs,” it is natural for them to think of it in analogy with other LHIs in widespread use, like the leading economic indicators, which are used to suggest the health and the direction of the national economy. He believes that perception will color the way people think about LHIs that are developed differently, but are given a similar name. Those expectations for past LHIs were not always met.

Dr. Manderscheid then asked who the appropriate audiences are for LHIs. If a goal of Healthy People 2020 is to touch the lives of every American, then the Committee must produce something that would reach out so people understand the importance of their own actions. Dr. Manderscheid asked how the Committee wished to focus on various audiences, including advocates, ODPHP staff, the Secretary, Dr. Koh, Congress, the Administration, and the media.

A Member said veteran Members of the public health community and those who are more data-focused are likely to use the LHIs. Thinking about the local community, the audience may include people who are developing and managing programs. This person asked whether the Committee thinks that these LHIs would be useful for that purpose. Another Member asked the Committee to think about what is valuable for target audiences. She believed that priority audiences include the public health community, academicians and Members of the workforce and private sector. Dr. Kumanyika said that she believes that all of the audiences listed are appropriate but she would add priority to the Secretary, Dr. Koh and the Administration.

Dr. Jonathan Fielding suggested that the Committee be parsimonious in selecting measures to be able to determine areas where the nation is moving forward and areas where it is not. He pointed out that there is no consideration of health as a label and function and asked if the Committee wanted to consider that.

Dr. Manderscheid asked what should be the underlying framework for the LHIs. Dr. Fielding said that it is important that indicators be used over the life course. A Member agreed and said the life course model offers a clear way of thinking about categories and how policies relate to outcomes. Dr. Kumanyika approved of the frameworks that the IOM Committee; they are similar to the ones that guided the Committee’s thinking. She added that an additional consideration could be the number of the indicators for which disparities are identified. Dr. Fielding added it is important to be explicit that some of the indicators are things that have been done in the past, and some are changes that reflect positively or negatively on health of the future.

Dr. Manderscheid a framework raises the question of how one should organize the indicators. He asked how the Subcommittee should go about putting the LHIs together. Dr. Manderscheid said that if the Subcommittee was going to use the social and physical determinants of health model over the life course, they may want to cluster LHIs into the model the advisory group put forth. Dr. Nerenz said that one observation that the IOM Committee noted was that there is a set of foundational health measures that were not mentioned at all in their charge, but it did occur to the Committee Members that in some ways those measures are already a set of LHIs. Dr. Nerenz indicated that these measures are included in the discussion because the IOM Committee was not sure what to do with those measures and their use as potential LHIs.

Dr. Manderscheid asked how the Subcommittee should handle differences over the life course if they are going to use the model of social and physical determinants of health over the life course. A Member said that some of the indicators are clearly life stage indicators and others would address the entire life course. He emphasized that the Committee should make explicit in the matrix and socio-ecological model that the health indicators can and should be applied across the life course when appropriate.

Dr. Fielding said that specific objectives that states and localities use will vary; the LHIs are not necessarily going to be the most helpful set for every jurisdiction, but they offer a snapshot of health status at the national-level. Dr. Kumanyika said that, in reviewing the IOM report, she considered whether there are certain priorities that reflect elements of health which when lost could not be re-established. Dr. Teutsch explained that part of the IOM Committee charge was to produce a set of indicators that would allow HHS to highlight one topic a month. The way to approach that may be to have some indices that can be used to effectively communicate topics and objectives. Dr. Fielding said many people are interested in direction, and this would be important for HHS and federal partners’ planning.

Dr. Manderscheid asked Members if the Subcommittee should focus on getting single synoptic measures that encompass a whole area, versus an indicator that is more discrete, like a consumer price index or the New York Stock Exchange industrial index. One Committee Member said that for LHIs in general, the primary concern is to develop a communication tool that doesn’t confuse the public. If too many objectives are included, it will be too much information for the public. LHIs serve several purposes, including communicating and reporting on health status, representing actionable objectives and mortality objectives, and providing an opportunity to talk to people about behaviors and systems change rather than an ultimate outcome of mortality.

A Member suggested that, for communication purposes, the group should examine other examples of indicators that may have something in common with these LHIs, such as the consumer confidence indicators, and how they are presented and used. Those indicators have helped shape the public discourse on the topic of relevance and why they are useful.

Dr. Manderscheid said that the comments and questions raised by the Committee will be reviewed and synthesized, and then used to help move the Subcommittee forward in developing recommendations. These recommendations will then be brought back to the full Committee for a thorough review and voting.

VI. Next Steps

Another meeting of the Committee will be scheduled for June 2011. That discussion will focus on discussing and finalizing a set of recommendations for LHIs to be put forward to the Secretary.