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A Priority Rating System
for Public Health Programs
DOUGLAS VILNIUS, MS, MPA
SUZANNE DANDOY, MD, MPH
The authors are with the Utah Department of Health. Mr. Vilnius is
Director, Division of Community Health Services, and Dr. Dandoy is
Executive Director of the Department. She is also Adjunct Professor,
Department of Family and Preventive Medicine, University of Utah.
The authors are indebted to George E. Pickett, MD, MPH, Univer-sity of Michigan, who initially developed the Basic Priority Rating
(BPR), and Denise Basse, Utah Department of Health, who suggested
the application and adaptation of the model.
Tearsheet requests to Douglas Vilnius, Division of Community
Health Services, Utah Department of Health, P.O. 16660, Salt Lake
City, Utah 84116-0660.
When resources are limited, decisions must be made
regarding which public health activities to undertake. A
priority rating system, which incorporates various data
sources, can be used to quantify disease problems or
risk factors, or both.
The model described in this paper ranks public
health issues according to size, urgency, severity of the
problem, economic loss, impact on others, effective-ness, propriety, economics, acceptability, legality of
solutions, and availability of resources. As examples of
how one State can use the model, rankings have been
applied to the following health issues: acquired immu-nodeficiency syndrome, coronary heart disease, injuries
from motor vehicle accidents, and cigarette smoking as
a risk factor. In this exercise, smoking is the issue with
the highest overall priority rating.
The model is sensitive to the precision of the data
used to develop the rankings and works best for health
issues that are not undergoing rapid change. Cost-ben-efit and cost-effectiveness analyses can be incorporated
into the model or used independently in the priority-set-ting process. Ideally, the model is used in a group set-ting with six to eight decision makers who represent the
primary agency as well as external organizations.
Using this method, health agencies, program directors,
or community groups can identify the most critical
issues or problems requiring intervention programs.
PUBLIC HEALTH AGENCIES, like all governmental
services, never have adequate resources to address the
needs of all constituents. Over time, the resource pen-dulum may swing, but most who pursue public health
funding through the political process would agree that
major distinctions between the good and bad times are
based on relative degrees of "lean," "leaner," or
"devastating.'" Such is the environment in which
scarce public resources must be competed for among
vast and growing social needs.
The competition for resources mandates that public
health decision makers seek methods and apply skills
that produce efficient and effective outcomes. State leg-islators, local boards of health, city and county com-missioners, and taxpayers occasionally demand and
certainly deserve public health programs and services
which maximize cost-effective and cost-beneficial pub-lic health outcomes. What methods and tools are avail-able to public health administrators and managers that
enable them not only to do things right but, even more
important, to do the right things?
There seems to be reasonable consensus within the
public health community that prolonging productive life
is a societal value that has been adopted as part of the
public health mission. The reduction of pain and suffer-ing is another generally accepted goal of public health.
However, further clarification of the mission and goals
may become clouded by politics, ethics, economics,
and public opinion. Life satisfaction, quality of care,
confidentiality, access to care, blaming the victim, the
right to die, and cost containment are issues tied to
societal values that affect health decision making in the
1990s. What, if any, effect do these issues have on
public health's mission, and how are their implications
translated into information upon which decisions and
priorities can be based?
A Decision Making Model
There is no "one best way" to set public health pri-orities. What is essential, however, is that a process or
method be adopted that is systematic, objective, and
allows for a standardized comparison of problems or
alternatives that incorporate the scrutiny of science and
the realities of the environment. One approach to this
challenge is a methodology which attempts to consoli-Soptomber-October 1990, Vol. 105 No. 5 463
Table 1. Problem size ratings for selected health problems on a
scale of 1-10
Problem Rate, Scale Rate' Scale BPR score
AIDS .......... 11.2 2 3.9 0 1
CHD .......... 3,058 6 313.4 4 5
MVI .......... 176 4 18.0 2 3
Smoking ....... 10,006 8 44.1 2 5
I per 100,000 population.
NOTE: AIDS = acquired immunodeficiency syndrome; CHD = coronary heart dis-ease; MVI = motor vehicle injury requiring hospitalization.
date these factors into a process having a quantifiable
outcome. That model, Basic Priority Rating (BPR),
(1, 2) applies a defined problem or issue to a set of cri-teria that rate the size and seriousness of the problem,
the effectiveness of potential interventions, and a reality
test of miscellaneous items. The resulting process pro-duces a quantifiable value for each problem being ana-lyzed, thus providing a basis for priority setting. The
BPR formula is as follows:
[(A+B) C]÷3xD =
where A equals the size of the problem, B the serious-ness of the problem; C the effectiveness of intervention,
and D equals propriety, economics, acceptability, and
legality, known as "P.E.A.R.L." We shall now
describe the model and its use with specific examples.
Defining the problem. Decision makers who engage in
problem solving can conserve considerable energy by
constructing clear statements of problems. Many frus-trating hours and lost opportunities have resulted from
an imprecise definition of a problem. Is the problem a
dysentery outbreak or a contaminated water supply? Is
the problem that people are dying from heart failure at
an old age or prematurely, or is the problem better
defined by lifestyle practices that lead to heart disease?
A clear statement of the problem will not only provide a
consensus for direction among those engaged in the pri-ority-setting process, but it will also establish a basis
for concise objective setting if, and when, the problem
is identified as a priority for which planning, interven-tion, and evaluation are necessary.
If the link between risk factors, health status condi-tions, and mortality is recognized, each risk factor or
each cause of illness may be considered as a problem.
Four potential problems-the incidence of acquired
immunodeficiency syndrome (AIDS), motor vehicle
injuries requiring hospitalization (MVI), coronary heart
disease (CHD), and cigarette smoking (smoking)-will
be analyzed to illustrate the application of BPR. The
nature of priority setting and decision making often
involves choices among a variety of conditions requir-ing a public health response, thus further complicating
the decision making process. Consequently, care should
be taken to arrange problems by category, such as dis-ease and accidents, risk factors, and target populations,
before the analysis begins. In our example, we will, for
illustration only, be comparing three direct causes of
morbidity and mortality (AIDS, MVI, and CHD) and
one risk factor (smoking), using both national and Utah
Size of the problem. The size of a health problem is
most often represented by incidence or prevalence rates
in 100,000 population segments. These rates are spe-cific to disease and nondisease conditions, such as 176
motor vehicle injuries per 100,000; 10,006 cigarette
smokers per 100,000; 11.2 AIDS cases per 100,000;
3,058 heart disease cases per 100,000.
Disease specific morbidity data are often difficult to
obtain compared with the relative ease of acquiring
cause of death information. Most information on dis-ease incidence emanates from hospitals and physicians
as a record of treatment and payment. Few States have
a morbidity registry that provides a centralized source
for disease and injury data, unless the diseases are con-sidered communicable. Therefore, finding reliable data
to compare relative problem incidence-prevalence may
prove to be a difficult task. Lifestyle risk factor data, on
the other hand, are being collected on a regular basis by
the majority of States through the Behavioral Risk Fac-tor Survey (3).
Mortality rates may also be applied to the process of
rating the problem size and, like the incidence and
prevalence rates, are presented per 100,000 population,
for example, 313.4 CHD deaths per 100,000. These
data are easily obtained from State health department
offices of vital records and traditionally play a major
role in determining public health priorities.
The BPR model suggests the following scale for
scoring relative rate ranges:
Incidence or prevalence per 100,000 population Score (1)
50,000 or more ............... 10
5,000 to 49,999 ............... 8
500 to 4,999 ............... 6
SOto 499 ............... 4
S to 49 ............... 2
0.5 to 4.9 ............... 0
Depending on the magnitude of problems being consid-ered, the scale may require adjustment to compensate
for lower incidence or prevalence rates.
In table 1 we apply this rating scale to the four prob-lem conditions being analyzed. Smoking and CHD war-rant the highest ratings for problem size, while AIDS
scores the lowest.
464 Public Halth Reports
Seriousness of the problem. A health problem's
seriousness is defined by four factors in the BPR model:
(a) urgency, (b) severity, (c) economic loss, and
(d) impact on others. Each factor should be evaluated
on a per case basis only. Readily identifiable and acces-sible data sources are not available for ranking problem
seriousness. The analysis of each seriousness factor will
require a considerable degree of investigation in order
to obtain quantifiable data. Some factors related to the
problem under consideration may require literature
searches, while other factors may require the decision
making group's best guess.
As each seriousness factor is applied, it is important
to keep its analyses independent of the other factors,
both within the seriousness category as well as the other
categories. For example, when assessing the severity of
AIDS, the analysis should be undertaken without regard
for the size or economic loss of the AIDS problem .
This principle of independent assessment within criteria
and factor should be applied throughout the process.
Each of the four problems is rated according to the four
factors that define seriousness in the model.
1. Urgency. Some problems require a rapid response
in order to prevent the spread of the problem or death
as, for example, in a spill of radioactive waste, con-taminated food, or a rabies outbreak. In BPR we use a
0-5 scale for each factor within the seriousness cate-gory. Since there is no clearly defined data source for
these ratings, one must rely on a combination of scien-tific knowledge and public opinion. The four problem
areas under consideration and their relative urgency rat-ings, using a scale of 0-5, are:
AIDS .... 3
Smoking ..... 0
AIDS receives the highest urgency rating, while smok-ing rates lowest of the four problems.
2. Severity. Severity is a major factor which fre-quently drives public health programs. Hence, the
severity of a disease, injury, outcome, or event is often
the key to health program decision making. AIDS,
chronic obstructive pulmonary disease, diarrhea from
Salmonella, measles, spinal cord injuries, and low birth
weight babies present varying levels of severity. How
should one rate these conditions on a scale ranging from
1 to 5?
What factors determine severity? Certainly the case
fatality rate (CFR), which measures the proportion of
those with a disease who die from it, would be the ulti-Table 2. Problem severity ratings by averaging case fatality rate
(CFR) and years of potential life lost (YPLL) for selected health
problems, on a scale of 0-5
Problem CFR Rating YPLL per case Rating ratbng
AIDS ....... 1.00 5 35.0 5 5
CHD ....... .06 3 13.3 3 3
MVI ....... . 10 3 43.7 5 4
Smoking ... . .004 1 1.9 0 0.5
NOTE: AIDS = acquired immunodeficiency syndrome; CHD = coronary heart dis-ease; MVI = motor vehicle injury requiring hospitalization.
mate measure of severity. Rabies, for instance, has a
CFR of 100 percent.
An additional severity index important to priority-set-ting is based on deaths which are deemed premature,
that is, before age 65. Premature mortality is repre-sented by years of potential life lost (YPLL) for persons
dying before age 65 within a specific disease category
(4). Hence, motor vehicle fatalities generate more years
of potential life lost per case than heart disease because
motor vehicle deaths generally occur at younger ages.
For the purpose of severity assessment, consideration of
YPLL should be limited to its face value and not
include aspects of economics related to productivity, a
subject to be addressed at another juncture in BPR.
In addition to CFR and YPLL, there are certain
"'conditions" or "states of being" which warrant
severity consideration because they affect the quality of
life. Arthritis, blindness, and spinal cord injury would
be examples of such conditions. Because hard data to
measure the severity of a disability or condition are fre-quently nonexistent, the information and experience of
the decision making group and their personal assess-ments of the problem often determine the ranking of
Risk factors may also be considered legitimate meas-ures of severity. Considering the fact that the risk of
dying from lung -cancer is 23 times greater for males
who smoke 40 cigarettes per day than for male non-smokers (5), does cigarette smoking warrant a severity
rating? Is its rating higher because smoking is also asso-ciated with other cancers, chronic obstructive pulmo-nary disease, and vascular disease? How should one
rate smoking versus unsafe sex versus sedentary life-style?
Because quality of life conditions and risk factors are
difficult to quantify with respect to seriousness, we
have limited our severity ratings to CFR and YPLL
(table 2). Thus, AIDS is the most severe problem and
smoking the least severe.
A decision making group may choose to weight these
subfactors differently. Note that the scale considered for
September-October 1990, Vol. 105 No. 5 465
each subfactor can greatly influence the outcome of the
ratings. Should AIDS, with a CFR nearly six times that
of CHD, proportionally establish the subfactor scale,
thus relegating all other problems proportional to AIDS
and resulting in CHD perhaps receiving a score of 0 or
1? The application of a scale with a range based more
on a pre-determined standard, versus relative com-parisons, as indicated previously, is another option.
There is no hard and fast rule as to what procedure to
follow. If the relative scale is used, it is possible to
achieve a total score for seriousness of 20 points. If the
problem size score warranted a 10, a seriousness score
of 20 implies that seriousness warrants twice the weight
of problem size, which may or may not be valid.
3. Economic costs. The economic aspects of a prob-lem should include the costs of medical expenses, pub-lic services, and prevention programs to the
community, to the person or the family or all three.
Although these costs can, and later will, be applied to
the aggregate problem as identified in problem size, at
this point the costs should be addressed on an individual
There is no one central source for average case costs,
although some publications provide cost information
that could be used in the absence of State or local data
(6-8). If at all possible, costs should be adjusted to a
given year's dollar value if cost data are based on dif-ferent years for different problems.
Both direct and indirect costs, if available, should be
Cost estimates by case for each study problem, using
a scale of 0-5, would be
Case cost per year
Again, the decision to use a standard versus a relative
scale arises. Based on the cost information considered,
AIDS and MVI warrant the highest rating and smoking
4. Impact on others. A basic principle upon which
public health was established is that society has legiti-mate concern over individual actions or conditions that
may affect many. Communicable disease control
remains an important agenda for public health today,
but the concept of effect on others has been expanded to
include water and air pollution, toxic waste spills, pas-sive smoking, and alcohol use by pregnant women.
Economic loss and the cost to society also may be
considered as impacts on others, even when the out-come of one person's disease or behavior may not
directly affect others. Legislation mandating use of seat
belts and motorcycle helmets has been passed partially
because of high insurance rates and increased Medicaid
costs for injuries.
The BPR attempts to capture the effect of health
problems on other persons in a quantifiable manner.
The decision maker is asked to consider the problem's
potential and its actual effect on others, as in the case,
for example, of the effect of suicide on a family, or the
transmission of AIDS, or drinking while driving.
Data for this category may be found in a variety of
sources, based on probability of infection per exposure,
such as, for example, measles exposure in an 80-per-cent immunized school population; the probability of
contracting lung cancer over time as a result of
exposure to cigarette smoke; or the probability of
spouse abuse in a given population of alcoholic men.
These data are not easily linked, however, in the midst
of a variety of public health problems and may require
considerable interpretation and assumption. Once again,
the process requires consideration of the problem on a
case basis. The preferred scale is 0-5, but the decision
maker may chose a standard or relative scale. The fol-lowing ratings, using a scale of 0-5, indicate that AIDS
has the greatest impact on others, while CHD has the
AIDS .... 5
Summary of seriousness criteria. The ratings of each
of the four factors comprising the seriousness category
are totalled in table 3. Based on the factors considered
in the process, AIDS is rated most serious, followed by
motor vehicle injuries, coronary heart disease, and
Effectiveness of interventions. Some public health
466 Public Halth Reports
problems seem more easily resolved than others, such
as, for example, measles versus AIDS, or smoking
versus obesity. The difficulty of educating intravenous
drug users, combined with the lack of a vaccine or
curative drugs, places AIDS in a less favorable inter-vention position than dental cavities, for instance. An
effective intervention, like measles vaccine, may not
eliminate a local disease outbreak if less than 80 percent
of the targeted child population receive the vaccine. A
proven worksite blood pressure control program may be
poorly attended if the workers have confidentiality con-cerns. Thus, the BPR model recognizes effectiveness of
intervention at two levels: (a) the overall success of the
method to be employed and (b) the degree to which the
targeted population will respond.
Locating information concerning effectiveness of
programs and receptivity of a target audience requires
an extensive literature search. Occasionally, reports or
journals present research summaries for select pro-grams, such as school health (9), smoking cessation
(5), or worksite health promotion (10). The pursuit of
Arriving in the mail over a period of weeks are taunting letters that end with a simple declaration, “Think of any number…picture it…now see how well I know your secrets.” Amazingly, those who comply find that the letter writer has predicted their random choice exactly. For Dave Gurney, just retired as the NYPD’s top homicide investigator and forging a new life with his wife, Madeleine, in upstate New York, the letters are oddities that begin as a diverting puzzle but quickly ignite a massive serial murder investigation.
What police are confronted with is a completely baffling killer, one who is fond of rhymes filled with threats and warnings, whose attention to detail is unprecedented, and who has an uncanny knack for disappearing into thin air. Even more disturbing, the scale of his ambition seems to widen as events unfold.
Brought in as an investigative consultant, Dave Gurney soon accomplishes deductive breakthroughs that leave local police in awe. Yet, even as he matches wits with his seemingly clairvoyant opponent, Gurney’s tragedy-marred past rises up to haunt him, his marriage approaches a dangerous precipice, and finally, a dark, cold fear builds that he’s met an adversary who can’t be stopped.
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