Originally posted 8/31/2011
In my last post I suggested that those who allocate resources must provide ample guidance to ensure that local level health improvement strategies actually align with the best available evidence. I mentioned the University of Wisconsin What Works data base as well as the approach that the previous administration allocated its State Health Improvement Plan (SHIP) resources in the state of Minnesota. But I indicated that What Works is not tailored to individual communities and that the Minnesota example is limited to health behavior interventions, not all population health determinants.
We know from the County Health Rankings and our own experiences that communities vary widely in both their health outcomes and the factors or determinants of those outcomes. There are many examples of both high and low ranking counties which vary on their determinant profile…some have high health care quality and access but poor behaviors, others have high social factors like education and income but poor air and water quality. Given limited resources, it is critical that investments be made carefully to have the most impact.
Would it be helpful to identify a set of Population Health Policy Packages that suggest the best options for local communities to make, given their outcomes and health determinants profile? While there is enormous variation across the country in such profiles, it is likely that a reasonable number of representative situations exist for most communities/counties. For each profile, using the best evidence available from sources like What Works and the CDC Community Guide, a set of investment priorities would be developed, covering all the determinants of health. It would be as broad as the global evidence allows, but would be tailored to a community’s strengths and weaknesses. Options for improving behaviors like smoking would not be as highly suggested for places already doing well in this factor. The packages would not be prescriptive, but merely a menu of the investments likely to produce the best health outcome improvement. Where possible, options would include the strength of public and private sector policies beyond dollar investment in specific programs.
The initial set of Policy Packages would not be ideal, for a variety of reasons. We still have incomplete evidence of effectiveness of different programs and policies, particularly regarding cost-effectiveness beyond effectiveness itself. It is not clear which level of investment in a particular determinant or factor is optimal, or where diminishing return sets in and when resources should be moved to other factors. We are limited in evidence for different types of outcomes, particularly disparity reduction.
However, we shouldn’t let the perfect be the enemy of the good. A beginning set such as in the Minnesota SHIP example (i.e., improving nutrition, increasing physical activity, and reducing tobacco use and exposure) might be helpful in many places where discussions are taking place regarding improving the health of their communities. It would help ensure that local passion and commitment would be channeled in an evidence based direction, while preserving autonomy and sensitivity to community preferences.
What do you think about this? How long will we say we don’t have adequate evidence to guide population health investment decisions?