Slide 1 Ongoing Disparities in Rural Health 1 Slide 2 Source: Singh and Siahpush, Widening Rural-Urban Disparities in Life Expectancy, U.S., 1969-2009. American Journal of Preventive Medicine, 2014; 46(2):e19-e29. Slide 3 All-Cause Mortality: US vs. Appalachia All-cause annual mortality rates, ages 15-64, by region (1999-2015) * Diseases of despair annual mortality rates, ages 15-64, by region (1999-2015) * Rates are presented as deaths per 100,000 population. Rates are age adjusted. *For all years, the Appalachian rates is significantly different from the non- Appalachian U.S. rate, p 0.05 Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html Rates are presented as deaths per 100,000 population. Rates are age adjusted. *In all years except 1999, the Appalachian rate is significantly different from the non- Appalachian U.S. rate, p 0.05 Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html 3
Slide 4 Slide 5 Slide 6 Overdose Deaths: Appalachia Overdose mortality rates for males, ages 15-64, by age group and region (2015) Overdose mortality rates for females, ages 15-64, by age group and region (2015) * Rates are presented as deaths per 100,000 population. Rates are age adjusted. *Appalachian rates are significantly different from the non-appalachian U.S. rate for the same age group, p 0.05 Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html Rates are presented as deaths per 100,000 population. Rates are age adjusted. *For all age groups, Appalachian rates is significantly different from the non- Appalachian U.S. rate, p 0.05 Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html 6
Slide 7 Social Determinants of Health The social determinants can be classified into five domains: 1) Economic stability Poverty, employment, food security, housing stability 2) Education High school graduation, enrollment in higher education, language and literacy, early childhood education and development 3) Social and community context Social cohesion, civic participation, perceptions of discrimination and equity, incarceration/institutionalization 4) Health and health care Access to health care, access to primary care, health literacy 5) Neighborhood and built environment Access to healthy foods, quality of housing, crime and violence, environmental conditions Healthy People 2020 Framework. http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health 7 Slide 8 Social Determinants of Rural Health Rural residents tend to be poorer than urban residents Average median household income is $42,628 for rural counties ($52,204 for urban counties) (2013) The average percentage of children living (ages 0-17) living in poverty is 26% in rural counties (21% urban) (2013) Unemployment (2014) Nationally, the average unemployment rate in rural counties is 6.4% compared to 6.9% in urban counties Rural residents educational attainment (2009-2013) - Averaged across counties 16.5% have < high school education (14.7% urban) 36.3% have only a high school diploma (31.9% urban) 17.4% have a Bachelor s degree or higher (24% urban) Source: http://www.ers.usda.gov/data-products/state-fact-sheets/state-data.aspx#.vfpos_nf91y Slide 9
Slide 10 Examination of Trends in Rural and Urban Health: Establishing a Baseline for Health Reform CDC published Health United States, 2001 With Urban and Rural Health Chartbook No urban/rural data update since 2001 Purpose of this study: Update of rural health status ten years later to understand trends Provide baseline of rural/urban differences in health status and access to care prior to ACA implementation 10 Slide 11 Methods Replicated analyses conducted in 2001 using most recent data available (2006-2011) Used same data source, when possible: National Vital Statistics System Area Resource File (HRSA) U.S. Census Bureau National Health Interview Survey (NCHS) National Hospital Discharge Survey (NCHS) National Survey on Drug Use and Health (SAMHSA) Treatment Episode Data Set (SAMHSA) Applied same geographic definitions, although classifications may have changed since 2001: Metropolitan Counties: large central, large fringe, small Nonmetropolitan Counties: with a city 10,000 population, without a city 10,000 11 population Slide 12 Mortality: Children and Young Adults Death rates for all causes among persons 1 24 years of age by rurality 12
Slide 13 Mortality: Working-Age Adults Death rates for all causes among persons 25-64 years of age by rurality 13 Slide 14 Mortality: Seniors Death rates for all causes among persons 65 years of age and over by rurality 14 Slide 15 Mortality: Chronic Obstructive Pulmonary Diseases Death rates for chronic obstructive pulmonary diseases among persons 20 years of age and over by rurality 15
Slide 16 Risk Factors: Adolescent Smoking Cigarette smoking in the past month among adolescents 12-17 years of age by rurality 16 Slide 17 Risk Factors: Adult Smoking Cigarette smoking among persons 18 years of age and older by rurality 17 Slide 18 Mortality: Suicide Suicide rates among persons 15 years of age and over by rurality 18
Slide 19 Mortality: Suicide Suicide rates among persons 15 years of age and over by region and rurality, 2008-2010 19 Slide 20 Risk Factors: Obesity Obesity among persons 18 years of age and older by rurality 20 Slide 21 Health Care Access and Use: Physician Supply Patient care physicians per 100,000 population by rurality 21
Dentists per 100,000 population Slide 22 Health Care Access and Use: Dentist Supply Dentists per 100,000 population by rurality 90.0 83.2 80.0 71.5 70.0 60.0 50.0 40.0 30.0 20.0 10.0 61.7 60.6 56.5 49.8 40.2 41.3 30.4 29.0 1998 2007 0.0 Large central Large fringe Small metro Micropolitan Non-core 22 Slide 23 Regional Mortality Study Purpose: To examine the impact of rurality on mortality and to explore the regional differences in the primary and underlying causes of death. 23 Slide 24 Methods Mortality data pulled from National Vital Statistics System (NVSS) Years 2011-2013 Data are Grouped by: 2013 NCHS Urban-Rural Classification Scheme for Counties (Large Central, Large Fringe, Small/Medium Metro, Micropolitan, Non-core) HHS Regions Age Gender Cause of Death Top 10 Nation-wide causes of death for each age group 24
Slide 25 HHS Regions 25 Slide 26 Mortality: Heart Disease Males, 25-64 yrs 26 Slide 27 Mortality Index: Lower Resipratory Disease Females, 25-64 yrs, HHS Region 7
Slide 28 Regional Differences in Mortality: Males; 25-64; Region 7 Michael Meit, Co-Director of the Walsh Center Meit-Michael@norc.org 301-634-9324 Slide 29 Regional Differences in Mortality: Females; 25-64; Region 7 Michael Meit, Co-Director of the Walsh Center Meit-Michael@norc.org 301-634-9324 Slide 30 Index Top 10 Causes: Select Age Range
Slide 31 Index: Select Age, Sex, Region Slide 32 Resources Slide 33 Evidence-Based Models Toolkit Series Conducted on behalf of the Health Resources and Services Administration (HRSA) Federal Office of Rural Health Policy (FORHP) A compilation of evidence-based practices and resources that can strengthen rural health programs New toolkits each year on different topics that target FORHP grantees, future applicants, and rural communities Applicable to organizations with different levels of knowledge and at different stages of implementation Hosted by the Rural Health Information Hub on the Community Health Gateway 33
Slide 34 Organization of Toolkits Module 7: Program Clearinghouse Module 1: Introduction to Topic Area Module 2: Program Models Module 6: Dissemination of Best Practices Module 3: Implementation Considerations Module 5: Evaluation Considerations Module 4: Sustainability Strategies 34 Slide 35 www.ruralhealthinfo.org Slide 36 Toolkits in Progress Transportation Aging in Place Food Security Suggestions for new toolkits? 36
Slide 37 https://walshcenter.norc.org https://www.ruralhealthinfo.org 37 Slide 38 The Future of Rural Public Health Slide 39 Analyzing LHDs by Rurality Rural: Multiple definitions: By county By Census tract By ZIP Code Multiple grades of rural Micropolitan Frontier Federal government uses 74 definitions of rural, including 16 primary definitions Approximately 20% of residents live in rural areas 39
Slide 40 Defining LHD Rurality by Rural/Urban Status RUCA Code LHDs coded as urban, micropolitan, or rural based on LHD zip code Micropolitan Includes census tracts with towns of between 10,000 49,999 population and census tracts tied to these towns through commuting. Rural Includes census tracts with small towns of fewer than 10,000 population, tracts tied to small towns, and isolated census tracts. Both micropolitan and rural categories are considered rural by the Federal Office of Rural Health Policy. 40 Slide 41 NACCHO Profile Small vs. Rural 41 Slide 42 Drivers of Change in Public Health State and Local Budget Cuts Reliance on Categorical Federal Funding State and Local Public Health Changing Environment a la Health Reform 42
Slide 43 Mean Percentage of LHD Revenues from Selected Sources, by Degree of Rurality Rural Urban 0% 20% 40% 60% 80% 100% Local State & Federal Medicare/Medicaid Clinical Analysis done by Dr. Kate Beatty, ETSU 43 Slide 44 Drivers of Change in Public Health State and Local Budget Cuts Reliance on Categorical Federal Funding State and Local Public Health Changing Environment a la Health Reform 44 Slide 45 Mean Percentage of LHD Revenues from Selected Sources, by Degree of Rurality Rural Analysis done by Dr. Kate Urban Beatty, ETSU 0% 20% 40% 60% 80% 100% Local State & Federal Medicare/Medicaid Clinical 45
Slide 46 Drivers of Change in Public Health State and Local Budget Cuts Reliance on Categorical Federal Funding State and Local Public Health Changing Environment a la Health Reform 46 Slide 47 S/LHDs at the Crossroads HDs may shift clinical services provision to partners or other health care entities Rural This may allow HDs Urban to increase focus on core public health activities and services (e.g., policy development/suppor t, assessment and surveillance, etc.) Mean Percentage of LHD Revenues from Selected Sources, by Degree of Rurality 0% 20% 40% 60% 80% 100% Local State & Federal Medicare/Medicaid Clinical 47 Slide 48 S/LHDs at the Crossroads HDs may expand their provision of clinical preventive services Rural Especially true in Urban areas where there are health provider shortages Also dependent on local ability to bill for services Mean Percentage of LHD Revenues from Selected Sources, by Degree of Rurality 0% 20% 40% 60% 80% 100% Local State & Federal Medicare/Medicaid Clinical 48
Slide 49 Slide 50 Performed by LHD directly Urban Micropolitan Rural Immunizations Adult 84.5 96.1 93.0** Childhood 80.2 96.3 93.3** Screenings HIV/AIDS 60.9 69.4 54.4** Other STDs 57.6 73.1 62.0** Tuberculosis 77.1 89.3 87.5** Cancer 31.3 45.6 33.7** Cardiovascular disease 25.4 31.8 27.1* Diabetes 33.1 35.6 31.2 Blood lead 52.7 67.9 62.0** Maternal and Child Health Family planning 38.1 70.5 57.7** Prenatal care 27.2 27.5 25.6** EPSDT 21.5 43.1 40.3** WIC 54.6 72.7 68.4** Other Health Services Comprehensive primary care 9.7 14 7.5** Mental health services 10.5 13.3 8.5* Substance abuse services 9.2 8.2 3.9** Analysis performed by Dr. Kate Beatty, ETSU Slide 51 Provided by others in community Urban Micropolitan Rural Immunizations Adult 55.5 51.5 50.1 Childhood 59.1 52.6 45.4** Screenings HIV/AIDS 70.1 59.3 54.7** Other STDs 64.9 56.4 58.1** Tuberculosis 51.6 53 38.1** Cancer 85.9 79.6 78.6** Cardiovascular disease 82.1 88.3 81.1* Diabetes 78.1 81.2 80.6 Blood lead 64.5 62.5 51.5** Maternal and Child Health Family planning 77.0 65.5 59.4** Prenatal care 82.1 87.2 67.8** EPSDT 62.6 62.8 45.8** WIC 40.6 33.9 29.3** Other Health Services Comprehensive primary care 89.2 90.7 93.0* Mental health services 90.5 94.7 88.2** Substance abuse services 90.1 96.7 85.0** Analysis performed by Dr. Kate Beatty, ETSU
Slide 52 Discussion Slide 53 Michael Meit, MA, MPH NORC at the University of Chicago 4350 East West Hwy, Suite 800 Bethesda, MD 20814 301-634-9324 meit-michael@norc.org Thank You!