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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. synopsis ..................................... 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 incidencelprevalence mortality 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 = bpr 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 data. 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: problem rating aids .... 3 chd ....1 mvi .....2 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 total average 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 this factor. 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 case basis. 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 applied. cost estimates by case for each study problem, using a scale of 0-5, would be problem aids................ chd ................ mvi................. smoking ............. case cost per year $50,151 8,700 45,500 643 rating 5 2 5 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 the lowest. 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 least impact. problem rating aids .... 5 chd ....1 mvi .....3 smoking .....2 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 smoking. 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 infor
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