Metrics That Matter for Population Health Action Workshop Summary (2016) / Chapter Skim
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2 The Metrics Landscape
2 The Metrics Landscape
Pages 5-34
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From page 5... ...
Schaeffer Center for Health Policy and conomics, senior E f ellow at the Public Health Institute, and adjunct professor at the Fielding School of Public Health, University of California, Los Angeles (UCLA) , reviewed a few of the available metrics sets, described some of their characteristics, and discussed some of the opportunities that they provide to move from measurement to action.
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Such surveillance, he said, is ongoing and not a "one-shot affair." It is systematic in that it is done in a coherent manner, and it involves the collection, analysis, and interpretation of health-related data essential to planning, implementing, and evaluating public health practices. For the most part, public health surveillance has been a part of governmental public health practice, but at this workshop the discussion includes public health in a broader sense.
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Turning to the definition of a population, Teutsch noted that there are many different conceptions of populations and subpopulations (see Figure 2-1)
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A metrics set, he said, is an organized set of measures to assess and improve population health and health equity, while a core metrics set is a parsimonious set of measures that provides a quantitative indication of current status on the most important elements in a given field and can be used as a standardized and accurate tool for informing, comparing, focusing, monitoring, and reporting change (IOM, 2015)
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The County Health Rankings (University of Wisconsin Population Health Institute, 2015) , which have been available since 2004, separate health outcomes, such as length of life and quality of life, from the determinants of health that contribute to outcomes (see Figure 2-3)
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in many ways to the County Health Rankings model, but it places more emphasis on policies and combines community engagement and environmental factors. The IOM's Vital Signs report uses a different framework (IOM, 2015)
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Another challenge is to address the paucity of good equity measures for an entire community. Current approaches, Teutsch explained, gather
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FIGURE 2-5 The Vital Signs framework. SOURCES: Teutsch presentation, July 30, 2015; IOM, 2015.
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Similarly, different metrics sets use data representing various levels of aggregation. The Vital Signs report, for example, uses national data, while America's Health Ranking uses primarily state data and the County Health Rankings use county data.
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14 RESOURCES and CAPACITY HEALTHY CONDITIONS Including research Health behaviors HEALTHY OUTCOMES Public health and health care access/quality Long, healthy lives INTERVENTIONS Social/economic/educational for all factors Policies, programs, services Environments FIGURE 2-6 Logic model for developing quality measures for the Leading Health Indicators. SOURCES: Teutsch presentation, July 30, 2015; IOM, 2012b.
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15 SOURCES: Teutsch presentation, July 30, 2015; IOM, 2012b.
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Measures must be tied to interventions, he added, and they need to be part of collective action and quality improvement processes if they are to drive change. RWJF CULTURE OF HEALTH2 Building from the constructs, challenges, and opportunities that Teutsch introduced, Alonzo Plough described the process and framework that RWJF used to develop the set of national measures for its Culture of Health initiative.
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In total, RWJF selected 41 Culture of Health national measures based on the availability of national data, their application to the entire lifespan and "health span," the connection to broad determinants and upstream drivers, the appeal to multiple audiences, and equitability. He noted that achieving health equity in the United States is one of RWJF's overarching concerns.
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"It is a measure of a problem, but it is also a measure that speaks to the kind of engagement that we want to get to resolve that problem," said Plough. For the fourth action area of the Culture of Health action framework -- strengthening integration of health services and systems -- the drivers are access, consumer experience and quality, and balance and integration.
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For example, the Culture of Health measures include the number of states with expanded practice laws for nurse practitioners as a window on actions to improve access to health care, which the County Health Rankings track. With regard to the Vital Signs (IOM, 2015)
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One function is to communicate the magnitude of needs and problems. 3 This section is based on the presentation by Rajiv Bhatia, Executive Director of The Civic Engine, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.
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The San Francisco Health Department responded by bringing together nonprofit organizations, businesses, and public agencies to examine growth plans through a health and equity lens and consider what healthy growth would look like. The 40 community organizations involved in this examination wanted a yardstick to measure progress and to hold the city accountable to a vision of healthy development.
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22 METRICS THAT MATTER FOR POPULATION HEALTH ACTION FIGURE 2-8 Heat maps showing measures of public transit, recreation, and quality elementary education.
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The indicators were also used to justify impact fees, change the way infrastructure funding was targeted in the city, and promote community advocacy. One lesson learned from this example, said Bhatia, is that indicators could be effective in catalyzing population health action in multiple sectors when they reflected collective needs and priorities determined by community stakeholders and were measured at a human scale.
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He noted that this seems to be the approach that RWJF is taking with its measures. On a regional level, Bhatia recounted an effort of the Bay Area Metro politan Transportation Commission that integrated health and neighborhood well-being indicators to prioritize transportation funding based FIGURE 2-9 Injury density per mile in San Francisco.
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A group of domain experts examined 220 indicators reviewed against these criteria, producing a set of 90 that went through a final review process. A national advisory committee commented on the proposed set, and HUD selected 37 core indicators and 5 city-level contextual indicators that were organized in 10 domains.4 This project is currently in a pilot phase in Albuquerque, Minneapolis, Providence, and San Diego -- jurisdictions which have collected the measures, ranked every neighborhood on all 37 indicators, and posted 4 The domains of the Healthy Communities Index indicators: environmental hazards, natural areas, transportation services, housing, social cohesion, educational opportunities, employment opportunities, neighborhood characteristics, economic health, health systems, and public safety.
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26 FIGURE 2-10 Bay Area regional indicators for transportation planning. NOTE: VMT = vehicle miles traveled.
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FIGURE 2-11 Regional indicators used to score a proposed transportation project. NOTE: ABAG = Association of Bay Area Governments.
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So far, multiple cities have been able to implement uniform methods to "measure health resources at a neighborhood scale in multiple cities," said Bhatia. He considers the ability to reconcile multiple data sources with community– defined neighborhood definitions a particular innovation of the work.
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Bhatia concluded his talk by describing two simple prototypes of highly effective indicators: a speedometer and a blood pressure cuff. Both provide measures that can lead to action -- stepping on the gas or brake pedal to change velocity in the case of the speedometer, or changing health behaviors or taking high blood pressure medication in response to readings from the blood pressure cuff.
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Israel Nieves-Rivera from the San Francisco Department of Public Health asked the panelists if gentrification was factored in their work with county health rankings. Teutsch said he could not speak directly to the matter of gentrification, but he did recount Bhatia's remarks about GDP not painting a complete picture of the nation's well-being.
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Kindig agreed with the last statement with regard to the mortality data that he uses in policy research, though he noted that a measure such as low birth weight can be more proximal and more directly related to policy. Kelly Hunt from the Hunt Strategy Group commented on the importance of teaching community members who are working on population health projects to collect their own data, something that she is doing in conjunction with the New York State Health Foundation.
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Teutsch agreed that this was a challenge, noting that the Healthy People objectives, for example, are simply national percentage reductions. "It is helpful to have local data that are from relevant comparison areas that can be used as a standard," said Teutsch.
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" Plough pointed out that RWJF uses the term "national measures" when referring to its metrics set because it can get national averages for them, but that the goal is for them to serve as catalysts for thinking about what is most meaningful at other levels, be it at the community, neighborhood, or block level. He used jazz as an analogy, where the proposed measures are just the initial tune and the end result includes what the band members do with key changes and variations.
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