Page County Virginia

Page County Virginia Health Needs Assessment Part 2 Health Status Assessment October, 2001 Compiled and Printed by Blue Ridge Area Health Education Center James Madison University

Page County, Virginia Health Needs Assessment Part 2 October, 2001 Health Status Assessment Compiled and Printed by Blue Ridge Area Health Education Center James Madison University MSC 4001 Harrisonburg, VA 22807 (540) 568-3011 David E. Cockley Dr.PH Principal Investigator The preparation of this document was financed in part through a grant from the Virginia Department of Health, Center for Primary Care and Rural Health. Agreement Number: CPCRH-0006

2 ACKNOWLEDGEMENTS The author wishes to thank those individuals who extended extra time in data collection, review of drafts and preparation of this section of the Community Needs Assessment. Of particular note are James Madison University students Meghan Cyphert, Kirstin Dawson, and Matthew Calone. In addition, Kristen Nolen provided exceptional assistance contributed in the verification of data, final editing and preparation of the Needs Assessment.

3 Table of Contents List of Tables......................................................... 4 List of Figures......................................................... 5 Executive Summary.................................................... 6 Introduction........................................................... 7 Data Methodology...................................................... 8 Natality............................................................. 10 Birth Data......................................................10 Birth Risk Data................................................. 12 Teen Pregnancy Data.............................................13 Mortality..............................................................14 Mortality Rates..................................................14 Morbidity............................................................ 18 Hospitalization Utilization................................................20 References.......................................................... 21

4 List of Tables Table 1 Page County Population Data..................................... 7 Table 2 Page County Socio-Economic Data, 1999........................... 8 Table 3 Birth Data for Page County, 1999.................................10 Table 4 Birth Data for Page County, 1995 1999........................... 10 Table 5 Averaged Birthrates for Page County, Planning District 7, and the Commonwealth of Virginia, 1996 1999...............................11 Table 6 Prenatal and At-Risk Data for Page County, 1996 1999............... 12 Table 7 Averaged Prenatal and At-Risk Data 1996 1999.....................13 Table 8 Averaged Teen Pregnancy Data 1995 1999....................... 13 Table 9 Teen Pregnancies in Page County 1995 1999......................14 Table 10 Averaged Age-Adjusted Mortality Rates for 1995 1998.............. 15 Table 11 Age-Adjusted Mortality Rates for Page County, Planning District 7, and the Commonwealth of Virginia, 1999..............................17 Table 12 Cases and Age-Specific Incidence Rates for Reported Cancer, 1994 1998.................................................... 18 Table 13 Hospital Inpatient Discharge Data for Page County Residents, 1997 1999..................................................... 20

5 List of Figures Figure 1 Averaged Birthrates for Page County, Planning District 7, and the Commonwealth of Virginia, 1996 1999..............................11 Figure 2 Age-Adjusted Cancer Rates for Page County and Virginia, 1994-1998.....................................................19

6 Executive Summary Page County is a rural area in northwestern Virginia within the Shenandoah Valley. The county consists of 311 square miles set between the Blue Ridge Mountain on the east and the Massanutten Mountain on the west. Page County had a 2000 census population of 23,177. It has an older age cohort demographic than the state as a whole. The population density in Page County is 74.5 people per square mile. Page County economic data show a lower socioeconomic status than the Commonwealth of Virginia. The per capita personal income for Page County residents was $19,337 in 1999. This ranks Page County s per capita income at only 65% of the state per capita income rate. Fifteen percent of the population is below 100% of the federal poverty guidelines. Over thirty-five percent is below 200% of the federal poverty level. Over the last five years, Page County exhibited an average birthrate lower than regional or state rates. An average of 250 births per year occur for Page County residents. Teen pregnancy rates were higher than regional counties or the Commonwealth of Virginia. A slightly lesser percentage of pregnancies have early prenatal care and over a third (37%) of births were non-marital births. Despite these risk factors, the percentage of low birth weight births was lower for Page County residents than state or regional comparisons. Page County exhibits a higher than expected age-adjusted mortality rate for Unintentional Injuries (including injuries for automobile accidents) and Septicemia. The age-adjusted mortality rates for Malignant Neoplasms, Diabetes Mellitus, Nephritis and Nephrosis and Alzheimer s Disease, however, were lower than in Virginia or the northwest Virginia region. The incidence of cancers reported to the Virginia Cancer Registry was below state incidence rates for all years between 1994 and 1998 except one. The five-year average incidence rate for reported cancers in Page County residents was 86.3% of the Virginia state incidence rate. Page Memorial Hospital, the only hospital located within the county, is a 54-bed facility in Luray. Over the last three years, Page County residents utilized Page Memorial Hospital for 54 percent of their in-patient hospitalizations.

7 Introduction: Page County is a rural area in northwestern Virginia within the Shenandoah Valley. The county consists of 311 square miles set between the Blue Ridge Mountain on the east and the Massanutten Mountain on the west. The South Fork of the Shenandoah River flows northward through the county. The George Washington National Forest and Shenandoah National Park surround the entire length of Page County and together constitute 43 percent of the county s land area. Luray, the county seat, joins the towns of Stanley and Shenandoah as localities with greater than 1000 population. Page County had a 2000 census population of 23,177 (U.S. Census Bureau, 2000) (Table 1). This was a 6.9 % increase since the 1990 census. This is a slower rate of growth than the 14.4 % growth for Virginia population since 1990. The population density in Page County is 74.5 people per square mile compared to 178.8 people per square mile across Virginia. Of significance to the health status measures reviewed in this report, Page County has a larger elder cohort than Virginia as a whole. 15.7 percent of Page County residents (2000) were age 65 or older. This compares to 11.2 percent for the entire Commonwealth (U.S. Census Bureau, 2000). Table 1: Page County Population Data Page County Virginia Population (1990) 21,690 6,187,358 Population (2000) 23,177 7,078,515 Population per square mile 74.8 173.8 Percent Population Age 65+ 15.7% 11.2% Source: U.S. Census Bureau, 1990; 2000 Page County economic data show a lower socioeconomic status than the Commonwealth of Virginia. The per capita personal income for Page County residents was $19,337 in 1999 (Bureau of Economic Analysis, 2000). This compares to $29,794 for the Commonwealth of Virginia (Table 2). This ranks Page County s per capita income at only 65 percent of the state level. Fifteen percent of the county s population is below 100% of the federal poverty guidelines. 37.7 percent is below 200% of the federal poverty level (Center for Primary Care and Rural Health, 2000). A greater percent of

8 Page County s population is in these low economic categories than Virginia citizens as a whole. Virginia has only 10.5 percent of its total population below 100% of poverty, and 27.1 percent below 200% of poverty. 8.4 percent of the Page County population is enrolled in Medicaid (See Table 2). More than one quarter of Page County students (28.3%) receive free school lunches (1998) (Center for Primary Care and Rural Health, 2000). Table 2: Page County Socio-Economic Data 1999 Page County Virginia Per capita income $19,337 $29,794 % below 100% poverty level 15.0% 10.5% % below 200% poverty level 37.7% 27.1% Students Receiving Free Lunch 28.3% 31.7% Source: Center for Primary Care and Rural Health, 2000 Data Methodology: Health statistics data for this section of the Health Needs Assessment were taken mainly from secondary health data compiled by the Virginia Department of Health. These include natality, mortality and age-adjusted disease-specific mortality rates. Demographic data were derived from U.S. Census Bureau reports plus calculated estimates for interim years. The 2000 census reports were available for gross population determinations. Age-adjusted mortality rates for the top causes of mortality were taken from the Virginia Department of Health, Center for Health Statistics Annual Vital Statistics for Virginia. Prior to 1999, age-adjusted weights were based on the 1940 U.S. census. Beginning in 1999, the age-adjusted weights were compared to the 2000 U.S. census age distribution (Anderson, Minino, Hoyent, & Rosenberg, 2001). This discontinuity of reference population limits accurate trend analyses for adjusted population data across this period. In addition, the World Health Organization updated the Ninth Revision of the International Classification of Diseases (ICD-9) to the Tenth Revision (ICD-10). Beginning in 1999, ICD-10 codes were utilized by the Virginia Department of Health and other state and national health statistics centers for cause of death classification and coding. While most of the leading causes of mortality remained unchanged, there were

9 significant changes in the coding and classification of several causes of mortality. This further impedes direct trend analysis across the pre-1999 and post-1999 reporting periods. Comparability ratios to recalculate age-adjusted mortality rates prior to 1999 for trend analysis subsequent to 1999 are being prepared by the National Center for Health Statistics but are not yet available (Kochanek, Smith, & Anderson, 2001). In lieu of verified comparability ratios, this report presents the four-year average ratios for Page County compared to Planning District 7 and the Commonwealth of Virginia from 1995 through 1998. Trends in mortality statistics are based on this period. The 1999 ageadjusted mortality rates are also presented but are not included in the trend analysis. Economic data are summarized from the U.S. Department of Commerce, Bureau of Economic Analysis. These included county, state and regional data on per capita income up to 1999. In addition, the percent of population below 100% and 200% of the federal poverty guidelines are listed based on calculations from the Virginia Department of Health, Center for Primary Care and Rural Health. Cases of reported cancers were taken from the Virginia Department of Health, Virginia Cancer Registry. Data from 1994 1998 at the county and state levels are presented. These are cancer cases conveyed by physicians and health care providers. Ageadjusted cancer rates are presented as a per 100,000 population rate. Virginia Cancer Registry data reflects a conservative description of cancer incidence in Virginia. Not all health care providers report cancer data to the state registry. Rural areas have been found to exhibit lower incidence rates because reporting is less complete. Hospital Utilization data were obtained from Virginia Health Information. This information is based on hospital inpatient discharge data for Page County residents reported to Virginia Health Information annually. It includes hospitalizations for Page County residents wherever they were actually hospitalized. Data from years 1997, 1998, and 1999 are included and are used to show the distribution of hospitals utilized by county residents. Because of the relatively low population number in Page County, population-based data for the county tend to be volatile. A slight numerical change in natality, mortality or disease incidence can change the population-based rates significantly. Therefore, where available, multi-year averages have been presented.

10 Natality: Birth Data Page County exhibits a lower natality rate (birthrate) than either Planning District 7 1 or Virginia as a whole (see Table 3). In 1999 the number of births for Page County residents was 256 for a birthrate of 10.9 / 1,000 population. This was 88.6% of the regional rate and 78.4% of the state rate. Table 3: Birth Data for Page County, 1999 Vital Event Page County Planning District 7 State of Virginia Total Live Births 256 2,228 95,207 Birth Rate / 1,000 Population 10.9 12.3 13.9 Source: Center for Health Statistics, 1999 As noted above, the low population numbers in Page County make multi-year trend data more appropriate for a county like Page than single year figures. In Table 4 the birthrates for Page County are tracked from 1995 1999. The county population has seen a fairly consistent number of births per year (averaging 250.2) over the last five years. The calculated birthrate has also remained steady, averaging 10.9 births per 1,000 population. Table 4: Birth Data for Page County, 1995 1999 1995 1996 1997 1998 1999 5 Year Average Estimated Population 22,607 22,812 22,835 23,056 23,165 22,895 Number of Births 230 269 251 245 256 250.2 Birthrate (Births / 1,000 Population) 10.1 11.7 10.9 10.5 10.9 10.9 Source: Center for Health Statistics, 1995-1999 1 Planning District 7 is a Regional Health Planning District and incorporates the northwest Virginia counties of Frederick, Clarke, Warren, Shenandoah, and Page plus the city of Winchester. Regional references throughout this report denote Planning District 7.

11 Page County s average birthrate over the past four years (1996 1999) consistently ranked lower than either the regional or state rates (Table 5, Figure 1). With a four-year average Birth Rate per 1,000 population of 11.3, Page County s rate was 91.8% of the regional rate and only 81.3% of the state birth rate. Table 5: Averaged Birthrates for Page County, Planning District 7, and the Commonwealth of Virginia, 1996 1999 Vital Event Page County Planning District 7 State of Virginia Average Number of Births 255 2,193 93,275 Birth Rate / 1,000 Population 11.3 12.3 13.9 Source: Center for Health Statistics, 1996-1999 Figure 1: Averaged Birthrates for Page County, Planning District 7, and the Commonwealth of Virginia, 1996 1999 16.0 14.0 Birthrate / 1,000 Population 12.0 10.0 8.0 6.0 4.0 2.0 0.0 Page County PD7 Virginia

12 Birth Risk Data Early prenatal care is a strong predictor of healthy birth outcomes. The percentage of pregnancies in Page County (from 1996 1999) that received prenatal care beginning in the first thirteen weeks of pregnancy was 84.3% (Table 6). This is a lower percentage of pregnancies receiving early prenatal care than the four-year mean for the northwest Virginia region (88.1%), but comparable to the state mean percentage (84.4%) (Center for Health Statistics, 1996-1999). In addition, the percent of non-marital births is another predictor of poor birth outcomes. Over a third of the births in Page County are non-marital births (37.0 % averaged from 1996 1999). The percentage of non-marital births in Page County is over seven percent higher than the regional non-marital birth rate and eight percent higher than the state non-marital rate (Table 6). Despite these heightened risk factors for Page County births, the county fails to exhibit a higher percentage of low weight births. The percent of births in Page County that were low weight births (< 2500 grams) was only 6.8%. This is lower than both the regional (7.0%) and state (7.8%) rates for this same period (Center for Health Statistics, 1996-1999) (Table 7). Table 6: Prenatal and At-Risk Data for Page County, 1996 1999 1996 1997 1998 1999 Average Estimated Population 22,812 22,835 23,056 23,165 22,895 Percent Prenatal Care in First Trimester Percent Low Weight Births (<2500 grams) Number of Non-Marital Births Percent Non-Marital Births 82.2% 86.1% 86.2% 83.2% 84.3% 5.6% 8.4% 6.5% 6.6% 6.8% 106 89 95 90 90.6 39.4% 35.5% 38.8% 35.2% 37.0% Source: Center for Health Statistics, 1996-1999

13 Table 7 displays the comparison of averaged prenatal at-risk data for Page County, Planning District 7, and the Commonwealth of Virginia. Table 7: Averaged Prenatal and At-Risk Data 1996-1999 Vital Event Page County Planning District 7 State of Virginia Percent Prenatal Care in First 84.3% 88.1% 84.4% Trimester Percent Low Weight Births 6.8% 7.0% 7.8% (<2500 grams) Percent Non-Marital Births 37.0% 30.8% 29.4% Teen Pregnancy Data Source: Center for Health Statistics, 1996-1999 Over the years 1995 1999, the pregnancy rate for teens in Page County (ages 10 19) was 36.8 per 1,000 population ages 10 19. This was greater than either the comparable rate for Planning District 7 or the rate for the Commonwealth of Virginia (see Table 8). Page County s teen pregnancy rate averaged 119% of the regional teen pregnancy rate and 106% of the state rate. Table 8: Averaged Teen Pregnancy Data 1995-1999 Vital Event Total Teen Pregnancy Rate (per 1,000 Females 10 19) Page County Planning District 7 State of Virginia 36.8 31.0 34.7 Pregnancy Rate (<15 Years) 1.8 0.9 1.9 Pregnancy Rate (15 17 Years) 44.1 38.5 43.2 Pregnancy Rate (18 19 Years) 118.8 98.9 98.2 Source: Center for Health Statistics, 1995-1999 There is also a correlation of high teen pregnancy rates (especially for teen mothers less than 15 years of age) with poor birth outcomes. When teen pregnancies are sub-divided into those for teen mothers less than 15 years old, mothers 15 17 years old, and mothers 18-19 years old, the heightened pregnancy rates of Page County teens are upheld. Page County s teen births are 200% of the regional rate for teen mothers less than 15 years of age; 115% for mothers 15 17 years of age; and 120% for mothers 18 19 years of age. Although the numbers of teen pregnancies each

14 Mortality: year are numerically small in Page County, the low population count accentuates these rates. On average, Page County has one birth each year for a teen mother less than 15 years old, 22 births for teen mothers 15 17 years old, and 33 births for teen mothers 18 19 years old (See Table 9). Mortality Rates Table 9: Teen Pregnancies in Page County 1995-1999 Total Teen Births Teen Mothers < 15 Years Teen Mothers 15-17 Teen Mothers 18-19 1999 53 1 24 28 1998 48 1 14 33 1997 50 2 15 33 1996 68 0 26 42 1995 60 1 30 29 5-Year Average 55.8 1.0 21.8 33.0 Source: Center for Health Statistics, 1995-1999 Due to the older population cohorts prevalent in Page County, the gross mortality data for Page County is much higher than regional or state total mortality rates. However when this older population distribution is accounted for through ageadjustment, the total mortality rate for Page County is actually slightly below both the mortality rates for the region and the Commonwealth of Virginia. The Age-Adjusted Disease-Specific Mortality Rates for Page County residents (averaged over 1995 1998) appear in Table 10. These population-based mortality data are compared to comparable rates for Planning District 7 and the Commonwealth of Virginia. When the age-adjusted mortality rates for the top causes of mortality are compared, Page County has a rate comparable with the regional and state rates for mortality from Diseases of the Heart, Cerebrovascular Disease, and Suicide. Deaths due to Diseases of the Heart and Malignant Neoplasms account for over half of all mortalities in Page County. These primary causes of mortality are the same for both the region and the Commonwealth as a whole. Page County residents are slightly more likely to die from Chronic Obstructive Pulmonary Disease or Pneumonia and Influenza than residents of the region or

15 the Commonwealth as a whole. Page County residents are seventeen percent more likely to die of Chronic Obstructive Pulmonary Disease than citizens in Virginia. The mortality rate due to Pneumonia and Influenza is 146% of the regional rate and 111% of the state rate. Those disease-specific causes of mortality consistently greater than regional or state rates include Unintentional Injuries and Septicemia. Unintentional Injury includes deaths from motor vehicle accidents plus other non-vehicular accidents. The Page County resident mortality rate for Unintentional Injury was 42% higher than the comparable rate for the northwest Virginia region and 35% higher than the Commonwealth of Virginia. Septicemia includes deaths from bacterial infection. The four-year mortality rate for Page County from Septicemia was 21% higher than the regional rate and 52% higher than the state rate. Table 10: Averaged Age-Adjusted Mortality Rates for 1995-1998 2 Vital Event Page Planning Virginia County District 7 Total Deaths / 100,000 Pop 468.2 480.7 494.2 Diseases of the Heart 133.0 136.1 132.2 Malignant Neoplasms 111.1 130.7 130.0 Cerebrovascular Disease 27.6 27.4 28.7 Chronic Obstructive Pulmonary Disease 24.0 22.0 20.5 Unintentional Injury 39.1 31.9 27.6 Pneumonia & Influenza 14.7 10.1 13.3 Diabetes Mellitus 6.8 9.8 12.0 Suicide 11.5 12.7 11.0 Septicemia 7.8 5.1 6.4 Nephritis and Nephrosis 2.7 4.0 5.7 Alzheimer's Disease 0.8 5.2 3.2 Chronic Liver Disease 6.4 7.3 6.0 Homicide & Legal Intervention 5.9 2.9 7.6 HIV & AIDS 9.0 5.3 9.8 Source: Center for Health Statistics, 1995-1998 2 Age-Adjusted weights are from 10-year age groupings from the 1940 U.S. Census (endorsed by the National Center for Health Statistics) for comparisons between jurisdictions and states.

16 Mortality rates in Page County were significantly lower than the regional and state rates for deaths due to Malignant Neoplasms, Diabetes Mellitus, Nephritis and Nephrosis, and Alzheimer s Disease. Page County mortality rates for various cancers were only 85% of the regional or state average rates. It should be noted that deaths from Diabetes Mellitus, Nephritis and Nephrosis, and Alzheimer s Disease are categorized as underlying causes of mortality although another cause of mortality (i.e. Heart Attack) may be listed as primary. These conditions are listed as the underlying cause of death when the death of the patient is a long-term consequence of these conditions even though the specific cause of death may be for another cause. All these causes of mortality seem under-represented in the Page County resident data. The low apparent incidence of mortality in Page County from these underlying conditions may be due to differential reporting criteria used in completing the death certificates. Care should be taken in inferring population characteristics or health needs relative to these rates. Malignant Neoplasms, on the other hand, is the second greatest cause of mortality for citizens in the state and in Page County. However the age-adjusted disease-specific mortality rate for Malignant Neoplasms is only 85% of the comparable rate in either Planning District 7 or the state of Virginia. The 1999 Age-Adjusted Mortality Rates for Page County residents appear in Table 11. This one-year reporting period shows deaths from Diseases of the Heart, Cerebrovascular Disease, Septicemia, Nephritis and Nephrosis, and Pneumonitis due to Solids and Liquids all to be above both regional and state rates. However, care should be taken to draw any conclusions from one year of data given the small relative population base in Page County.

17 Table 11: Age-Adjusted Mortality Rates for Page County, Planning District 7 and the Commonwealth of Virginia, 1999 3 Vital Event Page Planning Virginia County District 7 Total Deaths / 100,000 Pop 976.7 942.8 905.4 Diseases of the Heart 343.4 293.1 254.5 Malignant Neoplasms 199.3 224.3 214.2 Cerebrovascular Disease 82.7 71.9 69.6 Chronic Obstructive Pulmonary Disease 44.5 51.2 44.8 Unintentional Injury 33.6 30.8 33.4 Pneumonia & Influenza 19.7 22.2 27.5 Diabetes Mellitus 9.9 19.0 24.1 Suicide 8.6 14.3 11.9 Septicemia 28.5 13.7 18.1 Nephritis and Nephrosis 29.1 18.7 17.3 Alzheimer's Disease 7.0 22.5 16.0 Chronic Liver Disease 3.5 9.9 8.0 Homicide & Legal Intervention 5.1 5.3 6.2 Pneumonitis due to Solids & Liquids 15.1 10.9 8.4 Source: Center for Health Statistics, 1999 3 Age-Adjusted weights are from 10-year age groupings from the 2000 U.S. Census (endorsed by the National Center for Health Statistics) for comparisons between jurisdictions and states.

18 Morbidity: Morbidity data are notoriously difficult to obtain on a population basis. There are few required reporting mechanisms at either the federal, state or insurance company level for uniform morbidity data. One data source that is available is the Virginia Cancer Registry where all active cases of cancer are to be reported. From 1994 to 1998, reported cancer cases averaged 301.9 per 100,000 population in Page County. This compares to 349.8 per 100,000 population for the State (Table 12 and Figure 2). Table 12: Cases & Age-Adjusted Incidence Rates for Reported Cancers, 1994-1998 Year Page County Count Page County Rate (per 100,000) Virginia Rate (per 100,000) 1994 95 306.7 387.8 1995 81 271.1 344.1 1996 89 289.4 344.1 1997 113 350.9 331.4 1998 95 291.3 341.4 5-Year Average 94.9 301.9 349.8 Source: Virginia Cancer Registry, 1994 1998 Page County s age-adjusted incidence rate for cancers was markedly lower than the state rate each year between 1994 and 1998 except one. Only in 1997 when a relatively large number of cancer cases were reported did the Page County incidence rate exceed the state rate. Over this five-year period, the incidence of cancer reported in Page County was 86.3% of the state average. This corroborates the lower mortality rates for malignant neoplasms for county residents.

19 Figure 2: Age-Adjusted Cancer Rates for Page County and Virginia, 1994-1998 Age-Adjusted Cancer Rate (per 100,000 Population) 500.0 400.0 300.0 200.0 Page County Virginia 100.0 0.0 1994 1995 1996 1997 1998 Source: Virginia Cancer Registry, 1994 1998

20 Hospitalization Utilization Page County is home to one private non-profit community hospital, Page Memorial Hospital, in Luray. This 54-bed facility provides primary and secondary acute care services including anesthesiology services, cardiopulmonary services, general and orthopedic surgery, home care, and therapy services. Despite its small size, Page Memorial Hospital provides over half (54.1%) of the in-patient hospitalizations for county residents (see Table 13). This means that 46 % of in-patient hospitalizations for Page County residents occur outside the county. Over 95 percent of hospitalizations for Page County residents (1997 1999 three-year average) were discharged from just four hospitals. These include Page Memorial Hospital, Rockingham Memorial Hospital (Harrisonburg), the University of Virginia Medical Center (Charlottesville), and Winchester Medical Center (Table 11). Warren Memorial Hospital (81 beds) and Shenandoah Memorial Hospital (95 beds), both located in adjacent counties, discharged only 2.3% of Page County resident hospitalizations. Another 2.4% of total discharges occurred in hospitals elsewhere. Table 13: Hospital Inpatient Discharge Data for Page County Residents, 1997-1999 Hospital 1997 1998 1999 3-Year Average 3-Year Average Percent Page Memorial Hospital 590 572 618 593.3 54.1 % Rockingham Memorial Hospital 232 204 213 216.3 19.7 % Univ. of Virginia Medical Ctr. 134 151 133 139.3 12.7 % Winchester Medical Center 115 91 82 96.0 8.8 % Shenandoah Memorial Hospital 24 14 11 16.3 1.5 % Warren Memorial Hospital 9 6 12 9.0 0.8 % Other Hospitals 32 28 19 26.3 2.4 % Total Hospital Discharges for Page County Residents 1136 1066 1088 1096.7 100.0% Source: Virginia Health Information, 1997-1999

21 References: Anderson, R.N., Minino, A.M., Hoyent, D.L., & Rosenberg, H.M. 2001. Comparability of Cause of Death Between ICD-9 and ICD-10: Preliminary Estimates. Department of Health and Human Services, Center for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics Report, 49, 2. Bureau of Economic Analysis, 2000. U.S. Department of Commerce, Regional Accounts Data, [www.bea.doc.gov/bea/regional/reis/drill.cfm] Center for Health Statistics. 1995; 1996; 1997; 1998; 1999. Annual Vital Statistics for Virginia. Richmond, VA: Virginia Department of Health. Center for Primary Care and Rural Health. 2000. Health & Resource Data Guide 2000. (Prepared by John B. Nezlek & Marilyn D. Groff, Applied Social Psychology Research Institute, College of William & Mary), Richmond, VA: Virginia Department of Health. Kochanek, K.D., Smith, B.L., & Anderson, R.N. 2001. Deaths: Preliminary Data for 1999. Department of Health and Human Services, Center for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics Report, 49, 3. U.S. Census Bureau, Census 1990, [www.census.gov]. U.S. Census Bureau, Census 2000, [www.census.gov]. Virginia Cancer Registry. 1994; 1995; 1996; 1997; 1998. Virginia Department of Health, 1500 East Main Street, Room 114, Richmond, VA 23219. Virginia Health Information, 1997; 1998; 1999. (Hospital Utilization Data), Virginia Health Information, 1108 E. Main Street, Suite 1201, Richmond, VA 23219