Why Don't We Know More Precisely What To Do?

By David A. Kindig, MD, PhD

As much as I admire and support last week’s NRC-IOM report on the U.S. Disadvantage, I have been reflecting on the authors’ strong call for better data and research investments. Unfortunately, the report’s policy recommendations don’t seem on par with the extreme challenges presented.

The report’s recommendations include:

• “Intensify efforts to achieve established national health objectives”
• “Organize a comprehensive media and outreach campaign” to “stimulate a national discussion”

These are reasonable things to do, but why don’t we know more precisely what to recommend to policy makers to close these gaps?

Two quotes come to mind, including Victor Fuchs ( 1974):

“How much, then, should go for medical care and how much for other programs affecting health, such as pollution control, fluoridation of water, accident prevention and the like. There is no simple answer, partly because the question has rarely been explicitly asked.”

And another from my own Association for Health Services Research (AHSR) Presidential Address (1996):

“Now that we are in a time when attention is turning to fundamental health outcomes, when performance and value purchasing are becoming discussed by business coalitions, when there is serious discussion of a new connection between medicine and public health, we find that our research community has not invested nearly enough in the knowledge and understanding we need to guide policy.”

And now this report, presenting this massive information on our poor performance, has to call for “a coordinated portfolio…of research devoted to understanding the factors responsible for the US health disadvantage and potential solutions including lessons that can be learned from other countries.”

What is wrong here? It is true that going beyond simple description of differences to finding causal pathways is extremely complicated. Methods and data sets to explore these relationships are limited, and so far there are few studies even showing associations of factors producing health disparities, and even fewer on the relative cost effectiveness of policies across determinants like health care and behaviors and the social determinants of health.

However, I believe we can find answers to these important questions. I do find it possible that our national focus on clinical care and health care technology has diverted resources from understanding the contributions from other sectors that are even more critical for producing health. The wide variation in health outcomes among communities has to result largely from different levels of financial and nonfinancial policy investments over time; these natural experiments should offer investment and policy guidance for a business model for improving population health. However, little such guidance exists because of lack of comparable investment information across small units of population like communities or counties. My colleague, Tim Casper, and I examined the availability of such data in a sample of Wisconsin counties for per capita expenditures in selected categories of health care, public health, human services, income support, job development, and education. We found that even this well-resourced state is challenged by the difficulty in locating useable data, a lack of resources among public agencies to upgrade information technology systems for making data more usable and accessible to the public, and a lack of enterprise-wide coordination and geographic detail in data collection efforts.

So this is why the NRC-IOM report has to repeat the 1974 Victor Fuchs’ call for better information. Perhaps the worsening results will pose enough of a threat to national productivity and even security to prompt greater action and investment. More national conversations are taking place; last month Academy Health held a planning session to develop a strategy for population health research and policy to become one of three new objectives for the organization going forward. The Robert Wood Johnson Health and Society Scholars program leaders are discussing ways that a population health research and policy “community” can be created and supported.

As the report indicates, there are many things that we can do now, and waiting will delay for generations the health improvement we need and can achieve. I’m extremely hopeful that this report and several others over the past two years will be some kind of Sputnik wake-up call where we find the will to address these knowledge and policy challenges much more aggressively so that future generations don’t ask “Why didn’t they do it then?”

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. Follow him on twitter: @DAKindig.

References:

1. Fuchs, Victor. 1974. Who Shall Live? Basic Books, New York.
2. Kindig, D. 1999. AHSR Presidential Speech: Beyond Health Services Research. HSR: Health Services Research 34:1 (April 1999, Part II). pp 205-214.
3. Casper T,  Kindig DA. Are Community-Level Financial Data Adequate to Assess Population Health Investments? Prev Chronic Dis 2012;9:120066.

Comments

[Ed Donovan]

Scientific methods for testing health improvement hypotheses at the population level are not well developed. Thus, the current evidence base relies heavily on often poorly controlled, retrospective, cohort, comparative designs. Many refer to U.S. States as potential laboratories of experimentation providing sufficient homogeneity and sample size to make more rigorous studies possible. Many population-level interventions now devolve to States. Medicaid is one example. With balanced randomization (or quasi-randomization), population-level interventions could be tested with 25 assigned as intervention States and 25 as controls. Large within-State populations would provide relatively precise estimates of effect so an overall sample size of 50 might provide more useful information than currently available. Feasible? Worth a try?

[Sarah Gollust]

Thanks for this post. I'm also intrigued by the policy recommendation that implies that "stimulating a national dialogue" will naturally bubble up into policy action, the hopeful assumption of many similar reports (including 2012's IOM report on obesity prevention).