Last year, The Center for Health Affairs (CHA) asked

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1 Planning & Action February By Mark Salling, Ph.D., and Michele Egan Health Needs Analysis, Assessment Looks at the Region Last year, The Center for Health Affairs (CHA) asked Community Solutions to undertake an analysis of health conditions in the Northeast Ohio region that is served by CHA member hospitals. With the report completed, CHA and its members are considering its implications and how to respond to the challenges it identifies. Over the next year, CHA will be working to engage the health care community in developing collaborative approaches to improving health conditions and health care delivery in the region. 1 The report provides statistical information and a descriptive analysis and assessment of health conditions and issues. It documents and illuminates the range of health issues, problems, and needs of the community, and is intended to assist CHA, its member hospitals, and others involved in regional health care issues to better identify significant health needs and to marshal relevant resources conducive to improving the quality of life in the community. Although the report has been prepared with funding support from the CHA, the data and analyses are intended for use by the region s broader public health community. Furthermore, it is hoped that the report as a snapshot of current and recent conditions will be used as a base-line set of information that will lead to policies, actions, and future assessments of progress. The assessment has three purposes: to describe the state of health of the region s population, including access to, and utilization of, resources; to promote identification of major factors contributing to poor health; and to facilitate the identification of actions needed to address these issues. An individual s health is mainly affected by the following: physical environment in which one lives, such as the quality of the air and water; social and economic environment, because income and racial and ethnic disparities can affect access to care, quality of care, risk behaviors, and risk factors; It is hoped that the report behavior and lifestyle factors, such as smoking, drinking, drug use, and obesity; and family genetics and individual biology. This report does not address factors associated with family genetics, and, regrettably, only one environmental factor is included (ozone action alert days). But the report does include data and analyses on a wide assortment of important indicators of the health of the region s population, including those in the list of the Healthy People 2010 Leading Indicators published by the U.S. Department of Health and Human Services. 2 The Healthy People 2010 Leading Indicators are: Physical Activity Overweight and Obesity Tobacco Use Substance Abuse Responsible Sexual Behavior Mental Health Injury and Violence Environmental Quality Immunization Access to Health Care The indicators in this report are organized into chapters as described below: Demographic/Socio-Economic Profile: Knowing basic demographic and socio-economic information about the population is vital to (1) knowing what specific services the region and its communities need and (2) helping public health agencies and service providers more efficiently and effectively plan for and deliver services. Access to Health Care: Access to health care is both an economic and geographic issue. The indicators presented here are vital to understanding the availability of health care services to the region s population. Health Status and Conditions: What are the significant health conditions of the region s population? These indicators help provide a basic knowledge of the overall health of the population and allow public health agencies as a snapshot of current and recent conditions will be used as a base-line set of information that will lead to policies, actions, and future assessments of progress.

2 10 Planning & Action February 2008 and service providers to better understand the range of services needed. Health Care Utilization: Understanding how health care resources are utilized, combined with an understanding of access to those resources, can foster better planning and delivery of health care to the region. Maternal and Infant Health: Adequately addressing the needs of mothers and their infants will contribute to better health outcomes for the population now and in succeeding years because poor maternal and infant health are frequently associated with poorer health (as well as socioeconomic) outcomes that continue into later life. Mothers and their infants are also among the more vulnerable in regard to health conditions. Mortality: Clearly, mortality rates by cause of death are indicators of some of the most serious health conditions and issues faced by the population. Health Risk/Prevention Factors: The health of the region s population is highly dependent on behaviors and factors that increase the risk for disease and other health problems. Calls for Health-Related Services: An important and insightful measure of the health of the region s population is provided by calls to the local 211 agency. Data Sources The report includes data and descriptive analysis that, wherever possible, compare the region to the nation and/ or state. Data sources include the following: 1. Census data provide a variety of demographic (e.g., age, sex, race, ethnicity, and household and family composition), socio-economic (e.g., poverty), and health (e.g., disabilities) factors. 2. Birth and death records provide many indicators on maternal and infant health (e.g., teen birth rate, prenatal care, low birth weight, and tobacco usage), causes of mortality (e.g., cancer, heart disease, stroke, suicide), and years of life lost. 3. Data on patient admissions from the Ohio Hospital Association (OHA) provide specific information about diagnosed health conditions. The OHA data provide patient demographics, diagnoses, admission source, payer, outcome, etc. 4. The Ohio Family Health Survey (OFHS) of and the Cuyahoga Family Health Survey (CFHS) of 2001 provide information about access to care and perceived health conditions of the population. OFHS and CFHS data include estimates of health insurance coverage, health status, and health care access and use, including usual source of health care, problems obtaining health care, hospital emergency room use, medical visits, dental care, and quality of care. The data permit county-level analysis for the whole region (and comparison with the state) and city-level analysis for Cleveland, Akron, and Lorain/Elyria. 5. The 211 First Call for Help (211-FCFH) provides data on calls for various types of service and thereby indicates relative need in the community. The data are limited to Cuyahoga County and some adjacent communities. 6. Mental health data from county mental health boards are also presented. Study Area The study area is based on CHA member hospitals share of hospital patients. We defined primary and secondary counties for the study (see Map 1). These areas, which include 13 urban, suburban, and rural counties, account for 29 percent of Ohio s population. When we divide counties into urban, suburban, and rural types, we ascertain that CHA members received 90 percent of the suburban patient shares, 78 percent of the urban patient shares, and 26 percent of the rural patient shares. The study resulted in three products: (1) a full report, 407 pages in length, which includes 79 indicators in eight chapters and with text, tables, and graphics; (2) summary extracts with highlights of each of the eight chapters; and (3) an overall assessment which focuses on comparison of the region to the nation and state and on issues of geographic, racial/ethnic, and economic disparities. These documents are available at: home/cha/publications and com (See Projects & Targeted Issues/Research on the left navigation bar.) An Example of Findings The full report includes, for example, an indicator on asthma noting that about 111,000 children, or 13.1 percent in the study area, reported having been told they had asthma; that rate was almost identical to the state of Ohio as whole. Children in Trumbull County had the highest rate of asthma, 22.0 percent, and children in Medina County had the lowest, 6.1 percent. Inner cities Lorain/Elyria and Akron had higher rates than their suburbs, but Cleveland s rate was similar to that for the suburbs of Cuyahoga County at 14 percent. Using data on hospital discharges we can see in Map 2 that the rates for bronchitis and asthma were highest in Cleveland, and parts of Lorain, Huron, Geauga, Summit, and Trumbull counties. Overall Assessment In addition to the detailed data on the specific indicators, the study presents an overall summary of the major health care issues in the region. These issues are addressed by three questions:

3 Planning & Action February Map 1: Study Area Primary and Secondary Service Areas for CHA Member Hospitals 1. How does the region s health compare to other areas, with the nation or state providing the standard to which we compare the region? 3 2. What is the variation within the region in regard to its central cities, suburban communities, and urban and rural counties? 3. What are the racial/ethnic and income disparities in regard to health? When examining these questions for each indicator, we find some with clear answers and others that are less obvious. Not surprisingly, the assessment concludes that the region s health conditions are often associated with high poverty rates, especially among the most vulnerable populations such as female-headed families, those with low levels of educational attainment, and older persons. These economic and social conditions increase many of the health problems of these populations and challenge the region s health care system to address them. When we consider data related to access to care, we find that the region as a whole fares well in comparison to the nation or state. The national issue of health care insurance coverage is less severe in Northeast Ohio probably at least partly because of the dominance of unionized labor in the manufacturing sector, which is disproportionately represented in the region. The region is similar to the state in regard to most of the other measures of access to care we examined, including Medicaid and Medicare enrollment rates, access to a medical home, and ER visits. The population also perceives that it has the same degree of access to care as others in the state. It is also noted that low-income and minority populations that are concentrated in central city neighborhoods or in rural areas have shortages of available health care resources. Further, lack of equity in access to care within the region is apparent in regard to each of the indicators considered. Without exception, problems with access to care are worse in central cities than suburbs and for minorities and the poor. Rural problems with access to care exist in regard to health insurance, ER usage, and perception about having greater unmet health care needs. We also find no apparent, important differences between the region s and state s health status and conditions as reported in the Ohio Family Health Survey; nor between the region and nation in regard to census data on disabilities. Only in regard to syphilis (worse nationally) and gonorrhea (worse regionally) is there any notable difference for the region. Child maltreatment rates in Cuyahoga

4 12 Planning & Action February 2008 Map 2: Hospital Discharge Data Bronchitis and Asthma Discharges, Ages 0 to 17 Per 10,000 Persons Ages 0 to 17* 13-County Area, Ohio, 2005 Ohio by ZCTA and County With 13-County Outline County are actually lower than national rates. Like issues of access, income and racial disparities within the region are found for nearly all the indicators of health status. Central cities are the places where populations with poorer health are concentrated, yet rural parts of the region are also suffering from heart and circulatory disease, diabetes, and adult and child asthma. Notable, too, is that sexually transmitted diseases are apparently increasing in rural areas, and that health status is perceived to be relatively poor for children in rural areas. For most measures of health care utilization, the region is generally similar to the state. Exceptions are that the region s children are slightly more frequently hospitalized while its adults receive slightly more frequent dental care than others in the state. Yet, again disparities in utilization of health care resources within the region exist. Except for children s medical visits, central city residents apparently under-utilize these resources. Rural residents also underutilize many of these resources. Disparities for minorities and low-income populations are also present in regard to almost all of the utilization indicators. Only hospitalization of children is not associated with race. There is more variation between the region and the nation or state among the maternal and infant health indicators than with the other categories of the health assessment noted thus far. Positive comparative differences exist for maternal smoking (compared to the state s expectant mothers), teen births (lower in the region than the nation), and late or no prenatal care (the region s expectant mothers were more likely to get care). Yet, despite the early prenatal care, fewer of the region s expectant mothers continued to receive such care throughout their pregnancy than we find for the state s pregnant mothers. Unfortunately, but not surprisingly, the region s rate of infant mortality is substantially higher than the nation as a whole. Also not surprisingly, all these indicators of maternal and infant health are worse in central cities than the suburbs and worse for lower income persons. Pregnant mothers (and their chil-

5 Planning & Action February dren) in rural areas suffer higher smoking rates and poorer prenatal care during pregnancy. Disadvantaged minorities, while having comparable smoking and prenatal care rates to non-minorities, have higher rates of unmarried mothers, teen births, premature births, low-weight births, and infant mortality. The overall mortality rate is higher for the region than it is nationally. The region s mortality rate is comparatively high for heartand-coronary-related causes, lung and other cancers, and Chronic Obstructive Pulmonary Disease (COPD). On the other hand, the region s mortality rates for accidental deaths, motor vehicle deaths, and homicides are lower rural counties? than national rates, and years of potential life lost are fewer in the region than in the state. to health? Disparities in mortality rates exist for central cities versus suburbs, with suburban areas faring much better. Mortality rates in rural areas of the region are comparatively high for deaths caused by accidents, auto accidents, lung cancer, stroke, and COPD. Blacks and/or Hispanics suffer higher mortality rates for all noted causes except motor vehicle crashes and COPD (Whites have a higher rate). Suicide is higher for Whites as well, except for the high rates seen among young Blacks. Poverty is associated with all higher mortality rates for which adequate data is available. The effect of these disparities is that significant years of life are lost to disadvantaged minority and low-income persons. Among health risk behaviors and prevention factors, although adults in the region are more overweight than the national average, their rate of obesity is lower. Adolescents in the region exercise less, and they are more overweight than are those nationally. The region has higher rates of potentially adverse teen sexual behaviors and children with elevated blood-lead levels than the nation. With recently tightened standards, the region has been ordered by the U.S. EPA to come up with a strategy for reducing ozone alert days. Unlike the other major categories of health discussed in the report, there is less apparent association of risk behaviors with living in central cities and rural areas of the region. Sufficient data are not available on many of the indicators to conclude such associations exist. Among those indicators with sufficient information for assessment, adult smoking, obesity, teen sexual behavior, lack of adolescent exercise, and elevated blood-lead levels in children are more concentrated in central cities than in their suburbs. Obesity is also a concern for rural adults. White teens are disproportionately using tobacco, alcohol, and drugs compared to minority teens, and there is little evidence to suggest that such behaviors are income-related. For African Americans and the poor, teen sexual behavior and children with elevated bloodlead levels are the only two indicators with clearly higher rates. When we sum the various scores for the major community health dimensions, we find that, compared to either the nation or the state, the region while having substantial disadvantages in regard to demographic and socio-economic factors fares well overall in regard to access to care and maternal and infant health. The region does not compare favorably, however, in regard to indicators of health risk behaviors and prevention factors and mortality. As for overall health status and conditions and health care utilization the region appears to meet the norm. That said, our assessment concludes that geographic, racial, and socio-economic disparities within the region should be of great concern. The evidence is indisputable that health quality too often depends on where one lives, what one s race or ethnicity is, and what income one has. We believe that these are the important community health issues that the health care community should address. 1. How does the region s health compare to other areas, with the nation or state providing the standard to which we compare the region? 2. What is the variation within the region in regard to its central cities, suburban communities, and urban and 3. What are the racial/ethnic and income disparities in regard How the Indicators Can Be Used The report does not provide recommendations; it provides comprehensive information to be used to help set priorities for action and to ensure that scarce resources are allocated most effectively and efficiently.

6 14 Planning & Action February 2008 The analysis can help address some of the following questions: How many people are affected by a particular problem? What is the information telling you about equity? What is the impact on people s lives quality of life and years of potential life? Are there appropriate and effective interventions? Are the services adequate? Is there duplication in terms of treatment, prevention, or services for a particular age or disease? Does the health need coincide with national priorities is the local problem being addressed as part of a national strategy? Hospitals prompted this study because they were seeking an accurate description of the community, supported by data. This study enables them to ensure their current programming is on target and identify opportunities for new programs. Wellness issues and prevention, treating chronic disease, and issues related to access are all the focus of current efforts. Of course, hospitals are not the only organizations working to address community health. There are many stakeholders within the community working hard to meet many of the needs identified in this study. However, as the report demonstrates, tremendous opportunity still exists for organizations to work together to improve the health status of Northeast Ohioans. Over the coming months, area hospitals will be exploring opportunities to collaborate on additional efforts to tackle issues raised in this study. Working together and with other stakeholders creates an opportunity to capitalize on the strengths and resources of various organizations. While this report was initiated by hospitals, it is hoped that it can be used by many across the region as a tool to make a positive impact on the health of people who live and work in our community. Mark Salling, Ph.D., is Community Solutions Research director and Williamson Fellow. He is also director of the Northern Ohio Data & Information Service (NODIS), Maxine Goodman Levin College of Urban Affairs, Cleveland State University. He may be reached at Michele Egan is vice president, Corporate Communications, for The Center for Health Affairs. She may be reached at 1. Data assistance was also provided by the Northern Ohio Data & Information Service (NODIS) in the Maxine Goodman Levin College of Urban Affairs at Cleveland State University. 2. Healthy People 2010 was developed by the Healthy People Consortium an alliance of more than 350 national membership organizations and 250 state health, mental health, substance abuse, and environmental agencies. See 3. Unfortunately we are unable to compare the region to the nation on many of the indicators, since there is little comparative data on them. Our comparisons of the region to the state, therefore, should be understood in the context of how the state compares to the nation and other states. Community Solutions Endorses Health & Human Services Levy Community Solutions Board of Directors unanimously supports passage of the Cuyahoga County Health and Human Services Levy, which will appear as Issue 15 on the March 4, 2008, ballot. One of two county levies that support vital services, this proposed 4.8 mill levy would replace the current 4.9 mill levy. The Board of Cuyahoga County Commissioners believes the levy remains necessary because of the community s increasing need for basic safety net services. Levy revenue provides the base funding for the county s child welfare, public assistance, senior citizen, and homeless prevention agencies. The services it funds contribute to the maintenance and development of a safe, healthy community. More information on the levy or the services it supports: ,

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