J. Michael McGinnis

Making the Case for Active Living Communities

At first glance, a dearth of sidewalks may not seem like a significant public health concern. However, the disappearance of sidewalks is one of many environmental barriers to active living that transform the health of American communities in powerful ways. Evidence shows that physical activity brings substantial health benefits to people of all ages. However, much more needs to be done to create opportunities and enhance existing community structures to support physical activity. Environments that promote active living help us all--from children who need safe routes for walking and biking to school, to busy adults who might leave cars at home if they had pathways linking them to local destinations, to older adults who can maintain functional independence longer through routine walking. In each scenario, the critical role of something as basic as sidewalks becomes clear. Through research and demonstration programs, The Robert Wood Johnson Foundation is focusing on active living as a top-priority health concern. This emphasis has evolved primarily in response to Americas overweight and obesity crisis, and the serious associated health risks. KW: SR2S Read More: http://ajph.aphapublications.org/doi/full/10.2105/AJPH.93.9.1386

Measuring Vital Signs: An IOM Report on Core Metrics for Health and Health Care Progress

Two truisms apply to the current state of performance measurement in health care. The first is that if something (eg, a process, an outcome) cannot be measured, it cannot be improved. The second is that it is possible to have too much of a good thing. The recent enactment of HR 2: Medicare Access and CHIP Reauthorization Act of 2015, the so-called Doc Fix legislation, confirms the broadening societal embrace of the first truism.1 The new law makes plain that public policy makers are intent on measuring the value of health care services and rewarding clinicians and health care entities that improve that value. Private payers are also shifting rapidly to pay-for-performance models, as illustrated by the work of Catalyst for Payment Reform to develop scorecards, databases, and other value-driven tools on behalf of employers and other health care purchasers. The budding enthusiasm for performance measurement, however, has begun to create serious problems for public health and for health care. Not only are many measures imperfect, but they are proliferating at an astonishing rate, increasing the burden and blurring the ability to focus on issues most important to better health and health care. Measures of the same phenomenon also vary in specification and application, leading to confusion and inefficiency that make health care more expensive and undermine the very purpose of measurement, namely, to facilitate improvement. Not uncommonly, a health care organization delivering primary care to a typical population is asked to report and collect hundreds of measures aimed at dozens of conditions. In response to these issues, a new report from the Institute of Medicine (IOM), Vital Signs: Core Metrics for Health and Health Care Progress,2 addresses the major opportunities and current problems in the health care measurement enterprise. The document identifies a set of standardized measures required at national, state, local, and institutional levels and recommends the steps necessary to implement and refine those measures. Vital Signs was written by the IOM Committee on Core Metrics for Better Health at Lower Cost. The committee’s charge was to conduct a study of the current status of measurement of health and health care; identify the measures most reliably reflective of overall health status, care quality, engagement and experience of people, and costs of care for individuals and populations; propose a basic, minimum set of core metrics; and make recommendations on how the core set could be implemented, maintained, and improved and related to more detailed measures tailored to different conditions and purposes. The committee defined core metrics as a parsimonious set that provides “a quantitative indication of current status on the most important elements in a given field, and that can be used as a standardized and accurate tool for informing, comparing, focusing, monitoring, and reporting change.” The committee sought a limited set of measures that are outcomes oriented, reflective of system performance, and meaningful and have utility at multiple levels of the health care system (while recognizing that any particular measure will vary in its utility at different levels). Applying these criteria, the committee identified 15 measures as the core metrics for better health at lower cost—the US societal vital signs. • Life expectancy—measure for a validated basic health concept that reflects overall system performance with respect to a wide range of factors influencing health. • Well-being—measure of self-reported health status, as a general indicator of elements shaping quality of life. • Overweight and obesity—measured by BMI and largely the product of diet and physical activity patterns, together representing leading sources of preventable early deaths. • Addictive behavior—measure of dependence on tobacco, alcohol, or other drugs, which, together, impose high social and economic burdens on individuals and their families. • Unintended pregnancy—measure with generational implications that reflects a combination of behavioral, social, and cultural dynamics. • Healthy communities—index of a community’s profile on health-related social and environmental dimensions, eg, education, housing, income, parks, and air and water quality. • Preventive services—index of receipt of immunization, screening, counseling, and chemoprophylaxis services recommended by the US Preventive Services Task Force. • Care access—measure of ability of individuals to receive the care they need in a timely fashion. • Patient safety—index of system priority and performance in avoidance of harm to patients in the course of care. • Evidence-based care—index of system priority and performance in the delivery of care best supported by scientific evidence as to appropriateness and effectiveness. • Care match with patient goals—measure of the extent to which patient and family goals have been ascertained, discussed, and embedded in the care process. • Personal spending burden—measure of personal expenditures for health care relative to income. VIEWPOINT

Does Proof Matter? Why Strong Evidence Sometimes Yields Weak Action:

Health and well being are fundamental to satisfaction in every aspect of life. Why, then, does so much evidence apparently generate so little action when it comes to opportunities for public health and prevention to improve the health of Americans? Despite compelling evidence of the potential for many preventive interventions to reduce the occurrence of disease, thwart needless suffering, and improve the health and vitality of populations, the uptake of these interventions often lags far behind the potential. The case for the effectiveness of prevention is strong on many dimensions. Public health has long led the way for the use of observation and evidence for health inaprovement. In preventive medicine, our classic reference point is the intervention of physician John Snow, who during the London cholera epidemic of the mid-1850s (30 years before Robert Koch’s identification of the Vibrio cholera organism), found that those most affected by the disease were converging on the Broad Street Pump. By removing the pump’s handle, he halted the epidemic. Before that, the power of scrutiny and documentation was revealed by James Lind’s 18th-century observations that sailors who consumed citrus fruit were spared the scurvy which so often afflicted the others. And in 1796, Edward Jenner discovered through observation that mild infection by cowpox anaong milkmaids bestowed them with immunity to the deadly smallpox plague. More recently, much of our success in understanding the factors that shape the health of populations have come from gathering evidence of where and how we live and discovering how these factors alter our health futures. In the United States, lessons regarding the impact of behavioral choices on health outcomes from researchers such as Kannel et al. ~ in the Framingham study and Breslow et al. 2 in the Alameda County study have been vital to our understanding. Similarly, from the United Kingdom

Best Care at Lower Cost

Ab-1 SUMMARY S-1 The Imperatives S-3 The Vision S-11 The Path S-13 Actions for Continuous Learning, Best Care, and Lower Costs S-19 Achieving the Vision S-27 References S-29 PART I: THE IMPERATIVES

Health promotion in later life: it's never too late.

The clinical and epidemiological rationale for the health improvement benefits of health promotion in the later years of life are provided in this article. The authors review the emerging scientific consensus concerning the utility of lifestyle interventions for health improvement in the context of a narrowed definition of health promotion. Governmental initiatives for testing health promotion among Medicare beneficiaries are also discussed. Major research findings are reviewed and implications for health promotion practioners are also provided.

Diabetes and physical activity

A t no time has the need been more apparent for effective community-wide initiative on behalf of the health of Americans. As much of the nation’s attention has been drawn to the fact of public health as the frontline of defense against terrorism, an epidemic of subtle but compelling urgency and lethality has been sweeping the nation. And, as with terrorism, the twinned epidemics of sedentary lifestyles and diabetes cannot be contained without the concerted efforts of informed leadership in our communities using proven approaches to counter the threat. Nearly 16 million Americans have diabetes, one third of whom are as yet undiagnosed.1 Diagnosed diabetes in adult Americans increased from 4.9% in 1990 to 6.5% in 1998,2 and 1999 data from the Behavioral Risk Factor Surveillance System reveal that the prevalence increased by 6% in just 1 year.3 In 1990, only four states reported that greater than 6% of residents were diagnosed with all types of diabetes, but just a decade later, the number of states reporting levels that high rose to 42 in the year 2000.4 Coincidences abound in the midst of rapid changes, but it is no coincidence that the incidence of diabetes has risen in tandem with the prevalence of sedentary lifestyles and obesity in our country. In the 6-year period from 1994 to 1999, the number of U.S. states in which greater than 15% of the population was overweight climbed from 17 to 44.5 Despite these alarming statistics, we know there are ways to turn the trend. Last year, the Diabetes Prevention Program announced the results of a large clinical trial indicating that at least 10 million Americans at high risk for type 2 diabetes would be able to reduce their level of risk by 58% through diet and exercise.6 Those who achieved this reduction had engaged in walking or other moderate-intensity exercise for 30 minutes each day and reduced their body weight by 5% to 7% — a 5% weight loss yielding a nearly 60% reduction in risk for diabetes! How then can we translate the success achieved within the controlled environment of a clinical trial to practical, real-world circumstances? This supplement to The American Journal of Preventive Medicine offers important guidance in this respect. The Task Force on Community Preventive Services is a crucial partner in this effort. Launched in 1996 under the auspices of the Department of Health and Human Services, the Task Force is charged with the comprehensive review of the science base in support of various community-based interventions, and the development of recommendations for their application in health promotion and disease prevention. The Task Force publishes its recommendations in the Guide to Community Preventive Services. In the area of diabetes, the lineage and relationship of the work of the Task Force on Community Preventive Services with that of the U.S. Preventive Services Task Force is especially apt, as perhaps with no other disease is the importance of the link between clinical and community interventions so clear. The potential for gain against the toll from diabetes is great, but only if we pair aggressive clinical interventions with equally aggressive community action fundamental to broad lifestyle changes. The articles in this supplement show that we have learned much about the effectiveness of individual approaches, location-specific initiatives and community-wide interventions, both for improving management of diabetes and for increasing physical activity. Recommendations presented here should be helpful for state and local health departments, policymakers, healthcare systems, managed care organizations, researchers, funders of public health programs, and other interested audiences. Even beyond our shores, the findings will help better alert and equip our colleagues and cousins in other nations, for whom the magnitude of our travails may be serving as a harbinger of some of the problems looming large on their horizons. We in The Robert Wood Johnson Foundation welcome the recommendations of the Task Force, as both a call and a blueprint for the sort of action that works. Among our goals over the years for reducing chronic disease among Americans has been a commitment to reducing the avoidable burden imposed by diabetes. The Foundation continues its work in this field, with From The Robert Wood Johnson Foundation, Princeton, New Jersey Address correspondence to: J. Michael McGinnis, MD, Senior Vice President and Director, Health Group, The Robert Wood Johnson Foundation, P.O. Box 2316, Princeton, NJ 08543-2316. E-mail: mmcginn@rwjf.org.

Public policy and healthy eating

Abstract This paper highlights a range of health policy applications, or levers, that stem from use of the Dietary Guidelines for Americans as a policy document and require strengthening in order to improve health prospects of the American people. The discussion draws on broad public policy interventions, many of which emerged during the conference.

A vision for health in our new century.

Our vision of good health is changing. Extraordinary progress was made over the course of the 20th century—life expectancy at birth increased by nearly 30 years and scientific insights revealed that our health fates are determined by interacting factors within each of the five major health domains. As life expectancies extend far beyond customary notions of old age, attention shifts from survival and toward improving the quality of life. Our beliefs about what makes for a healthy life are reorienting around a vision of new possibilities, in which we take full advantage of what we know about getting each child off to the right start; providing all the opportunity for lifelong vitality borne of healthy lifestyles; designing safe and nurturing physical environments for our communities; assuring that all have access to the kind of medical care they need; protecting the isolated or estranged from the illness or injury that often accompanies their condition; and providing comfort and choices for all at the end of life.

Diabetes and physical activity: Translating evidence into action

A t no time has the need been more apparent for effective community-wide initiative on behalf of the health of Americans. As much of the nation’s attention has been drawn to the fact of public health as the frontline of defense against terrorism, an epidemic of subtle but compelling urgency and lethality has been sweeping the nation. And, as with terrorism, the twinned epidemics of sedentary lifestyles and diabetes cannot be contained without the concerted efforts of informed leadership in our communities using proven approaches to counter the threat. Nearly 16 million Americans have diabetes, one third of whom are as yet undiagnosed.1 Diagnosed diabetes in adult Americans increased from 4.9% in 1990 to 6.5% in 1998,2 and 1999 data from the Behavioral Risk Factor Surveillance System reveal that the prevalence increased by 6% in just 1 year.3 In 1990, only four states reported that greater than 6% of residents were diagnosed with all types of diabetes, but just a decade later, the number of states reporting levels that high rose to 42 in the year 2000.4 Coincidences abound in the midst of rapid changes, but it is no coincidence that the incidence of diabetes has risen in tandem with the prevalence of sedentary lifestyles and obesity in our country. In the 6-year period from 1994 to 1999, the number of U.S. states in which greater than 15% of the population was overweight climbed from 17 to 44.5 Despite these alarming statistics, we know there are ways to turn the trend. Last year, the Diabetes Prevention Program announced the results of a large clinical trial indicating that at least 10 million Americans at high risk for type 2 diabetes would be able to reduce their level of risk by 58% through diet and exercise.6 Those who achieved this reduction had engaged in walking or other moderate-intensity exercise for 30 minutes each day and reduced their body weight by 5% to 7% — a 5% weight loss yielding a nearly 60% reduction in risk for diabetes! How then can we translate the success achieved within the controlled environment of a clinical trial to practical, real-world circumstances? This supplement to The American Journal of Preventive Medicine offers important guidance in this respect. The Task Force on Community Preventive Services is a crucial partner in this effort. Launched in 1996 under the auspices of the Department of Health and Human Services, the Task Force is charged with the comprehensive review of the science base in support of various community-based interventions, and the development of recommendations for their application in health promotion and disease prevention. The Task Force publishes its recommendations in the Guide to Community Preventive Services. In the area of diabetes, the lineage and relationship of the work of the Task Force on Community Preventive Services with that of the U.S. Preventive Services Task Force is especially apt, as perhaps with no other disease is the importance of the link between clinical and community interventions so clear. The potential for gain against the toll from diabetes is great, but only if we pair aggressive clinical interventions with equally aggressive community action fundamental to broad lifestyle changes. The articles in this supplement show that we have learned much about the effectiveness of individual approaches, location-specific initiatives and community-wide interventions, both for improving management of diabetes and for increasing physical activity. Recommendations presented here should be helpful for state and local health departments, policymakers, healthcare systems, managed care organizations, researchers, funders of public health programs, and other interested audiences. Even beyond our shores, the findings will help better alert and equip our colleagues and cousins in other nations, for whom the magnitude of our travails may be serving as a harbinger of some of the problems looming large on their horizons. We in The Robert Wood Johnson Foundation welcome the recommendations of the Task Force, as both a call and a blueprint for the sort of action that works. Among our goals over the years for reducing chronic disease among Americans has been a commitment to reducing the avoidable burden imposed by diabetes. The Foundation continues its work in this field, with From The Robert Wood Johnson Foundation, Princeton, New Jersey Address correspondence to: J. Michael McGinnis, MD, Senior Vice President and Director, Health Group, The Robert Wood Johnson Foundation, P.O. Box 2316, Princeton, NJ 08543-2316. E-mail: mmcginn@rwjf.org.

The role of patient education in achieving national health objectives

Accomplishments in health promotion and disease prevention during the past decade underscore the vital role of education in helping individuals develop behaviors conducive to better health. The growing body of scientific evidence linking personal health practices with premature morbidity and mortality justifies support for health education as a primary mechanism for improving the Nation’s health.