Health status varies by county: Where patients live matters

A report detailing the first-ever county breakdown in each state finds wide disparities in health standings and notes factors contributing to those rankings.

By Doug Trapp — Posted March 1, 2010

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Physicians can't treat unemployment, violent crime or dirty air, but these are a few of the many environmental factors that affect patients' health.

Residents of rural counties are especially challenged by high poverty and a lack of access to primary care, according to a set of rankings released Feb. 17 by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. The report is the first-ever county-level analysis of people's health status and factors affecting it.

"These rankings demonstrate that health happens where we live, learn, work and play. And much of what influences how healthy we are and how long we live happens outside the doctor's office," said Risa Lavizzo-Mourey, MD, the Robert Wood Johnson Foundation's president and CEO. The rankings can be accessed online.

The report grouped the healthiest county from each of the 50 states and each state's least-healthy county. It found wide disparities between these groups. For example, residents of the 50 least-healthy counties are 60% more likely to be admitted to a hospital for preventable conditions than are people in the healthiest counties.

The report also found that 80% of the least-healthy counties are rural, said Patrick Remington, MD, MPH, report co-author and associate dean for public health at the University of Wisconsin School of Medicine and Public Health. People in healthier counties generally are better educated and more likely to have jobs, as well as access to health care, healthy foods, and parks and recreational areas.

The analysis is modeled on a University of Wisconsin Population Health Institute project that has ranked the health of the state's 72 counties since 2003. That project was inspired by "America's Health Rankings," an annual comparison of states' health published by the United Health Foundation since 1990.

"It's very powerful to have county-level data," said Judith Monroe, MD, Indiana's health commissioner.

Driving changes

The county-level report is designed to spur local officials into action, as have the rankings in Wisconsin. "We see the county health rankings not as a final report, but as a first step," Dr. Remington said.

For years, Juneau County was ranked as one of Wisconsin's least-healthy counties. The smoking rate for pregnant women there was twice that of the state average, for example. This ranking prompted the county health department and local leaders to focus on educating pregnant women about the dangers of smoking, among other efforts, leading to improvement in Juneau County's health numbers.

Dr. Remington said the project's leaders realize that state and local budgets are tight. But even improving communication between entities can lead to new ideas.

Efforts to contain influenza A(H1N1) have helped local leaders, including from local government, schools and hospitals, find new ways to improve access to health care, said Elizabeth Walker, project director of the Center for Safe and Healthy Schools at the National Assn. of State Boards of Education.

"This has to be a team sport -- community health improvement," said Andrew Webber, president and CEO of the National Business Coalition on Health. The rankings should provide tremendous motivation to reduce health disparities, he said.

The view from the ground

Physicians cautioned that the rankings do not mean the healthiest counties are perfect.

Yuma County -- in the southwest corner of Arizona -- is the healthiest of the state's 15 counties, but the report ranks it 13th for factors that influence health. Its unemployment and childhood poverty rates are higher than the state average.

Public health improvement is a priority in the county, said Roberto T. Garcia, MD, a solo-practice family physician in the city of Yuma. For example, a local program sends physicians to businesses to talk with workers about the importance of maintaining an ideal weight and getting screened for diabetes, he said.

But Yuma County also attracts at least 100,000 winter residents each year, which could be pushing the county's health ranking higher, suggested Mark Ivey Jr., MD, a family physician and past president of the Arizona Medical Assn.

Dr. Ivey practices in Gila County, ranked the state's least healthy, but second for clinical care, a measure of access to preventive care. The county, northwest of Phoenix, has a good hospital system, Dr. Ivey said.

More than 1,300 miles to the northwest, Tom Machala, MPH, RN, public health director for Jefferson County, Ore. -- the least healthy of that state's 33 counties -- questioned the value of some of the ranking criteria. Some of the health status measures used to make comparisons between counties are self-reported by patients, rather than based on other factors that might be more accurate, he said.

Jefferson County also ranks last in Oregon for factors influencing health care. Unemployment is high, as is the percentage of uninsured residents, according to the report. "Those things make a big difference in health outcomes," said Gary Plant, MD, a family physician in Jefferson County.

Benton County -- Oregon's healthiest -- benefits from jobs provided by Hewlett-Packard and Oregon State University. The area also embraced public smoking bans, including in bars, more than 10 years ago, said David Grube, MD, a family physician who has practiced there for 33 years.

Benton County was "making changes 15 to 20 years ago that are just now coming to Jefferson County," Machala said.

An adopted bond issue is bringing a new community college to Jefferson County, Dr. Plant said. A better-educated work force probably will improve the county's health more than any physician could, he said.

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Counties' health varies widely

Residents of the least-healthy counties in each state are much more likely to smoke, have preventable health conditions and die prematurely than people living in the healthiest counties in each state.

Least-healthy Healthiest Ratio
Premature death rate 12,368 4,904 2.5-1
Self-reported health status of fair or poor 20% 9.5% 2.1-1
Adults who smoke 26% 16% 1.6-1
Preventable hospital stays 95 61 1.6-1
Children living in poverty 30% 9% 3.5-1

Note: Premature death rate is calculated as the years of potential life lost before the age of 75 per 100,000 people. Preventable hospital stays are calculated as per 1,000 Medicare beneficiaries.

Source: "County Health Rankings," Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, February (link)

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Health care only part of being healthy

Counties were ranked both by measures of health outcomes and by factors that influence people's health. Outcomes had five criteria while health factors relied on 23 measurements.

Health outcomes

Mortality (50%): Years of potential life lost before age 75
Morbidity (50%): Rate reporting fair or poor health, or physically or mentally unhealthy days; low birth weight rate

Health factors

Health behaviors (30%): Rate of adult smoking, obesity, binge drinking, motor vehicle crash deaths, chlamydiosis, teen births
Clinical care (20%): Rate of uninsured adults, diabetic screenings, hospice care use, hospitalizations for ambulatory-sensitive conditions; ratio of primary care physicians to the population
Social and economic factors (40%): High school graduation rate; number of college graduates; rates of unemployment, poverty, income inequality, social and economic support, single-parent households; violent crime or homicide rate
Physical environment (10%): Air quality, access to healthy foods, liquor store density

Source: "County Health Rankings," Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, February (link)

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External links

Interactive map of county health rankings prepared by Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute (link)

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