A Population Health Opportunity Map

By David A. Kindig, MD, PhD

A commentary in the May 25 JAMA by Jonathan Fielding and Steve Teutsch caught my eye a couple of months ago. Both authors play influential roles in national population health policy, from their practice based experiences in the Los Angeles County Department of Public Health.

They begin by arguing that as we reform the health CARE system, complementary improvements are needed in community prevention programs and policies as well. The challenge for both national and local policy makers is to be able to “identify and implement those interventions that provide the greatest benefits and value,” including the relative effectiveness of both clinical and community prevention efforts. They suggest that a first step has to be a sound framework for “identifying and organizing” the universe of interventions which have been shown to have evidence of effectiveness.

The components of such a framework are proposed to be: 1) the ecologic model, which is generally consistent with the multi-determinant population health model we advocate in this blog, 2) the life course perspective, in which health at any point in time is the “product of a person’s behaviors and exposures superimposed on his or her underlying biology,” and 3) the evidence of effectiveness of any intervention in either the clinical or community spheres with enough scientific evidence to support its use.

These three components make up their proposed model, called An Opportunity Map for Societal Investment in Health, pictured below.

The horizontal axis reflects the life course, from wellness through illness to death. The vertical axis reflects the spectrum of intervention strategies from the individual to the societal level. The blue shading of the bottom half highlights individual clinical investments while the brown at the top reflects community wide programs and policies. The blending of colors in the middle implies that these exist on a continuum. Another figure shows (using diabetes as an example) how this model can be applied to issue-specific clinical and community prevention efforts.

The authors explain that when “individual interests and needs predominate, there is a slide to the lower right quadrant, where costs of medical care are high and health status is poorest.” They draw the conclusion that “attention to interventions in the upper left quadrant may yield greater health and economic efficiency,” including individual productivity and national global competitiveness.

I believe that private and public policy makers faced with making the program and policy investments in a resource limited world are likely to find conceptual models such as this should be helpful. I would like to see a third dimension added to reflect the estimated cost-effectiveness of each program and policy choice, both clinical and societal. While most population health advocates would agree with the authors’ call for more  resources in the upper left corner, each individual program or policy needs to be evaluated itself on some cost-effectiveness metric (such as quality adjusted life years gained per dollar invested). The addition of this dimension would reveal some very cost effective interventions in the lower right region of the figure and some very cost ineffective interventions in the upper left. In addition, attention must be given to relative cost effectiveness to improve health equity compared to improving overall population health; certain interventions will be more effective for one than for the other.

Will such broad “top down” conceptual models be helpful to local communities faced with making difficult decisions among dwindling resources? Next week I’ll try to address this question directly.  

David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Comments

[Amy Heydlauff]

Love the map as a visual for these important investments in health. It does make me wonder, though, if the pendulum has swung too far towards policy & systems. The individual still needs a role in our efforts. It's not just 'done to them' through health care (primary & tertiary) coming up to meet society (jobs, ag, justice, policy...). Individuals, families and local communities can, & often want to, intervene on their own behalf (think Paulo Freire). That's particularly true around primary prevention - which isn't well represented on this map. (Unless you think the only way primary prevention takes place is with primary care. That idea would be a real surprise to parents teaching their kids to eat f&v.)

[Geof Swain]

Perhaps, somewhat like a "cost-effectiveness" dimension, interventions could be mapped with regard to their "population reach." In this regard I also like Frieden's Health Impact Pyramid (Frieden TR, "A Framework for Public Health Action: The Health Impact Pyramid" AmJ Public Health. 2010;100:590–595), which shows the inverse correlation between "increasing population impact" and "increasing individual effort needed".

[Matt Stiefel]

I like the shading to depict the frontier between health care and the broader determinants. Although the horizontal axis depicts the journey from wellness through illness to death, it really doesn't provide much insight into that journey from the person's perspective, other than that it requires increasingly more resources. I think what's important to the person is how their health and functional status change over that journey, and how we might either slow the progression or make it more enjoyable along the way, as Joanne Lynn describes in her "Bridges to Health" model (http://www.milbank.org/quarterly/MILQ%2085.2%20Lynn%20et%20al..pdf).