REPORT BRIEF NOVEMBER 2012 For more information visit www.iom.edu/valuingprevention An Integrated Framework for Assessing the Value of Community- Based Prevention Over the last century, the major causes of disease and death among Amer- icans have changed, shifting from predominantly communicable diseases spread by germs to chronic ailments. This shift has been accompanied by a deeper understanding about what keeps people healthy or leaves them vul- nerable to becoming ill. To get at the heart of the challenges to living a healthy life, we must increasingly emphasize factors that affect today?s causes of mor- bidity and mortality. Despite their importance to preventing illness, determining the value of community-based interventions has proven difficult. Preventing illness Despite their importance to pre- requires immediate investments with benefits that might not be realized for venting illness, determining the many years. Another complicating factor: Some people would remain healthy value of community-based inter- even in the absence of an intervention, but share its cost. ventions has proven difficult. In its new study, An Integrated Framework for Assessing the Value of Com- munity-Based Prevention, an Institute of Medicine (IOM) committee proposes a framework to assess the value of community-based, non-clinical prevention policies and wellness strategies. Sponsored by the California Endowment, the de Beaumont Foundation, the Robert Wood Johnson Foundation, and the W.K. Kellogg Foundation, the report aims to enhance intelligent decision making about which prevention activities and interventions are worthwhile. Essential Framework Elements For the purposes of its report, the IOM committee defines community-based prevention interventions as focused on populations with the aim of prevent- ing disease from occurring, increasing behaviors that improve health and well-being and?when disease does occur?slow- Second, the framework should consider the ing or stopping its progress, reducing or elimi- resources used and compare the benefits and nating negative consequences, and decreasing harms associated with those resources. To effec- disparities that result in inequitable distribution tively compare interventions, it is essential to of health. In its report, the committee concludes quantify the magnitude of benefits in relation to that a comprehensive framework for valuing the associated cost for each intervention. Third, community-based prevention programs and poli- the framework must take into account differ- cies should meet three major criteria. ences among communities that can affect the link First, the framework should account for ben- between interventions and outcomes. efits and harms in physical and mental health, Because none of the eight existing frame- community well-being, and community process. works that were analyzed met all of these criteria, The physical and mental health domain includes the IOM committee proposes a new framework to reductions in the incidence and prevalence of dis- assess the value of community-based prevention ease, declines in mortality, and increases in health- interventions. (See Figure.) related quality of life. The community well-being domain includes social norms, how people relate to each other and their surroundings, and their Taking a Comprehensive View willingness to invest in themselves and the people Selecting one community-based prevention pol- around them. The community process domain icy or program over another can be difficult, and encompasses elements that influence community this challenge can be further complicated by a participation in decision making, such as civic large menu of intervention options with a diz- engagement, development of local leaders, social zying array of desired outcomes. The committee support, and social networks. FIGURE: Framework for Assessing the Value of Community-Based Prevention Interventions Valuing?What Should Be Counted? Benefits Quality-Adjusted Life Years Health (QALYs) or Health-Adjusted Harms Life Expectancy (HALE) Benefits Community Community Well-Being Community Benefit Well-Being Harms Indicator Community Benefits Community Process Process Harms Indicator Value The Value of an Intervention Considers Its Benefits, Harms, and Costs Valuing?What Should Be Counted? Identification of Investments Savings Community Costs and Monetary Units (USD) Resources Costs 2 R es ources Us ed B enefits and Harms Because prevention can save money that otherwise would be spent treating illness, the commit- tee notes, it is important to assess changes that are expected to occur as a result of the intervention. recommends that decision makers weigh the ben- important to a different community. The value of efits and harms to health, community well-being, an intervention depends on the community?s per- and community process as they assign value to spectives, beliefs, and priorities. The value of an specific interventions. intervention also hinges on how, where, and how While changes to population health can be effectively it is carried out. documented by using quality-adjusted life years or In addition, the ultimate goal of the inter- health-adjusted life expectancy, well-defined data vention has an effect on the perceived value of sources for valuing community well-being and that intervention. A community-based preven- community processes still need to be developed. tion action may improve the overall health of a For that reason, the committee recommends that community, for example, but may achieve more the Centers for Disease Control and Prevention strikingly positive results among citizens with a create an expanded inventory of data sources and certain income level or occupation, exacerbating needs for community-based prevention and, after health disparities. If achieving health equity is at identifying data gaps, develop sources of informa- odds with improving overall community health, tion to fill those gaps. priorities will have to be determined. In addition, public and private sponsors, Decision makers should consult with the com- including the National Prevention, Health Pro- munity and other stakeholders to ensure that the motion, and Public Health Council, should sup- value of community-based prevention policies and port research that develops a single metric for wellness strategies reflect their preferences. Even community well-being, a single metric for com- if the appropriate decision makers are involved, munity processes, and a single metric for combin- they must be sure to make decisions in the right ing the community well-being and community way in order to gain legitimacy. The committee?s process indicators with health to create the single framework emphasizes the importance of trans- indicator of community benefit. One advantage of parency. Open and transparent assessments of this approach is to facilitate expressing the value the value of a given intervention can enhance its of community benefits per dollar spent. Because legitimacy among community members. prevention can save money that otherwise would To ensure transparency, the committee rec- be spent treating illness, the committee notes, it is ommends that analysts make public the evidence important to assess changes that are expected to used to value a prevention action and provide occur as a result of the intervention. estimates of the uncertainty of their results, and it counsels decision makers to make their rationales for decisions public. The Value of Transparency What is important to one community may not be 3 Committee on Valuing Community-Based, Non-Clinical Conclusion Prevention Programs The committee?s framework is just the first step. Robert S. Lawrence (Chair) F. Javier Nieto Center for a Livable Future Helfaer Professor of Public Additional efforts will be needed to build consen- Professor and Professor of Health, Professor of Population Environmental Health Sciences, Health Sciences and Family sus on the importance of its key outcomes?health, Health Policy, and International Medicine, University of Health; Director, Center for a Wisconsin School of Medicine community well-being, and community process? Livable Future, Johns Hopkins and Public Health, Madison Bloomberg School of Public Daniel Polsky in community-based prevention. Though much Health, Baltimore, MD Professor of Medicine and Kirsten Bibbins-Domingo Healthcare Management, remains to be learned, the framework represents Associate Professor and Perelman School of Medicine Attending Physician, University and the Wharton School, a valuable step toward realizing the elusive goal of of California, San Francisco University of Pennsylvania; appropriately and comprehensively valuing com- Laura K. Brennan Director of Research, Leonard President and Chief Executive Davis Institute of Health munity-based prevention. Officer, Transtria, LLC, Economics, Philadelphia St. Louis, MO Louise Potvin This framework has the potential to be used in Norman Daniels Professor, Social and Preventive many ways, years down the road: it might be for- Mary B. Saltonstall Professor Medicine, Faculty of Medicine, of Population Ethics and University of Montr?al, Institut de Recherche en Sant? mally incorporated into policy making; funders Professor of Ethics and Population Health, Harvard Publique de l?Universit? de Montr?al, Canada might require its use in impact assessments that University, Cambridge, MA Darrell J. Gaskin Nicolaas P. Pronk accompany legislative or grant proposals; or agen- Associate Professor, Deputy Vice President and Health Director, Center for Health Science Officer, HealthPartners, cies could be required to use the framework to Disparities Solutions, Minneapolis, MN Department of Health Policy Louise B. Russell evaluate their programs? output, strengthening the and Management, Johns Research Professor of Hopkins Bloomberg School of Economics, Institute for Health, evidence base. As a next step, however, communi- Public Health, Baltimore, MD Health Care Policy, and Aging Lawrence W. Green Research, Rutgers, The State ties and decision makers should begin to use and Professor, Department of University of New Jersey, New refine the framework, strengthening its value today Epidemiology and Biostatistics, Brunswick University of California, San Steven M. Teutsch and into the future. f Francisco Chief Science Officer, Los Robert Haveman Angeles County Department of Professor Emeritus of Public Public Health, California Affairs and Economics and Chapin White Faculty Affiliate, Institute for Senior Health Researcher, Research on Poverty, University Center for Studying Health of Wisconsin?Madison System Change, Jennifer Jenson Washington, DC Managing Senior Fellow, Partnership for Prevention, Washington, DC Study Staff Lyla M. Hernandez Angela Martin Study Director Senior Program Assistant Melissa French Rose Marie Martinez Associate Program Senior Director, Board on Officer Population Health and Public Andrew Lemerise Health Practice Research Associate Consultant Catherine M. Jones University of Montr?al, Canada Study Sponsors The California Endowment The de Beaumont Foundation The Robert Wood Johnson Foundation The W.K. Kellogg Foundation 500 Fifth Street, NW Washington, DC 20001 TEL 202.334.2352 FAX 202.334.1412 www.iom.edu The Institute of Medicine serves as adviser to the nation to improve health. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policy makers, health professionals, the private sector, and the public. Copyright 2012 by the National Academy of Sciences. All rights reserved.