United 2020: Measuring Impact Health The Institute for Urban Policy Research At The University of Texas at Dallas Kristine Lykens, PhD
United 2020: Measuring Impact Health Overview In the Dallas area, nearly 25 percent of individuals have no regular health care provider; as a result, many of them turn to the emergency room for primary care. Consequently, less than 18 percent of emergency room visits across the region are for true emergencies, while the remaining 82 percent of emergency room visits are either treatable or preventable in a primary care setting. i With a lack of insurance, low-income individuals are even more likely to depend on emergency services for primary care, and other vulnerable populations, such as low-income seniors, disabled persons, and domestic abuse victims are at an elevated risk for not receiving adequate health care and related services. ii United 2020 Goal: To improve health and quality of life across the metropolitan Dallas service region. 2010 Baselines Access to Care / Prevention: 82.2% of emergency room visits were for non-emergency or preventable conditions. Healthy Lifestyles: 36.1% of youth, and 63.1% of adults were overweight or obese. As part of United 2020, the United Way of Metropolitan Dallas has established a community-wide goal to improve health and quality of life across the metropolitan Dallas service region. Strategies embraced by the United Way for this purpose include expanding access to primary care for children and adults, promoting healthy lifestyles through health information, education, and programming, as well as focusing on prevention and early intervention through regular screening and monitoring. Measurement Measuring improvement in the health of our community is a complex endeavor. Much as a physician considers many signs and symptoms to diagnose and treat an individual patient, for community health we also consider a number of signs and symptoms. Physicians consider indicators such as blood pressure, body temperature, areas of physical pain and many more. For the population, we consider indicators such as insurance status, preventable hospitalizations, risk behaviors and many others. Once problems with health have been identified, communities, like physicians, initiate interventions to improve health. Physicians prescribe drugs, diets, exercise or surgery. Communities promote policy changes, fund programs, and promote healthy lifestyles. As physicians who monitor the progress of their patients through re-assessing symptoms and re-testing, communities monitor indicators to assess the progress towards alleviating health problems. The sections below describe the indicators (and how they are measured) that will be used by the United Way of Metropolitan Dallas to monitor improvements in community health targeted by the strategies of expanding access to health care, promoting healthy lifestyles through health information, education and training, and focusing on prevention and early intervention through screening and monitoring. P a g e 2
Expanding Access to Health Care Since existing programs and policies are different for children and adults, the impact of this strategy will be measured and monitored separately for each group. Children have greater access to health insurance coverage through the State Medicaid Program (Medicaid) and the State Children s Health Insurance Program (SCHIP). The primary indicator selected for children s access to care is the number and percentage of uninsured children (18 years or younger) in the service area. As depicted in Figure 1 and Figure 2, the overall number of uninsured children for the four UWMD counties was estimated to be 241,515 (21.1 percent) in 2007. iii This information is available from Census data. A secondary measure of progress for this strategy is the number of children in the service area who are enrolled in Medicaid and SCHIP. This information is reported at the county level by the Texas Health and Human Services Commission, and is presented below in Table 1. iv Once children are enrolled in either of these insurance programs, comprehensive health benefits are available to them. Adult access to health care is somewhat more complex to measure. Medicare coverage provides financing for care for close to all elderly adults (65+ years). Lack of health insurance is not a strong indicator because non-elderly uninsured adults do have some access to care through a patchwork of providers and programs such as safety-net hospitals, community health clinics, community mental health centers, and other specialized programs. Thus increased access to health care for non-elderly adults will be measured by three primary indicators. 200,000 150,000 100,000 50,000 Figure 1 Figure 2 Table 1. S-CHIP and Medicaid Enrollment by, December 2010 SCHIP Medicaid Enrollment Enrollment Collin 9,507 37,029 Dallas 59,424 325,884 Researchers have gathered strong evidence that Denton 9,377 35,580 non-elderly adults without adequate access to Rockwall 1,147 4,713 outpatient physician or clinic care for physical Total 79,455 403,206 ailments are much more likely to be admitted to hospital emergency departments and inpatient care for conditions which can be effectively treated in an ambulatory setting. A list of diagnoses associated with these conditions has been developed. v Examples of these conditions are pneumonia, asthma, chronic obstructive pulmonary disease, diabetes, and congestive heart failure. These conditions are identified as ambulatory care sensitive conditions. Studies have shown a strong correlation between admissions for these conditions and a lack of access to adequate outpatient care. vi,vii,viii 30% 25% 20% 15% 10% 5% 0% Number of Children Age 18 and Under Uninsured by, 2007 0 23,353 Collin 10% 181,544 Dallas 26% 32,519 Denton 4,099 Rockwall Percent of Children Age 18 and Under Uninsured by, 2007 Collin Dallas 18% 18% Denton Rockwall P a g e 3
To monitor progress in reducing hospital emergency department and inpatient admissions for these conditions the Institute has obtained all inpatient admissions for the service area from the Texas Health Care Information Commission (THCIC), ix a state agency that collects this required data from most sizeable hospitals in Texas. Total non-elderly adult inpatient admissions will be determined for patients from the service area. Admissions and visits for ambulatory care sensitive conditions will be extracted and admission proportions will be calculated annually. A reduction in this proportion will be the primary indicator of progress in improving access to care for non-elderly adults. Two additional indicators of adult access to health care will be monitored regarding mental health and dental care. Mental health care will be monitored by obtaining the proportion of adults who experienced serious psychological distress in the past year who also experienced at least one major depressive episode. Reduction in this proportion will be the indicator of improved access to mental health care. This indicator is obtained from the Substance Abuse and Mental Health Administration (SAMHSA), National Survey on Drug Use and Health. This survey data is aggregated for Texas Region 3a, which includes Dallas, Collin, Denton, Ellis, Hunt, Kaufman, Navarro, and Rockwall counties. x The most recent estimate for the service area is based on annual averages from the 2002, 2003, and 2004 surveys, and estimates that 8.59 percent of adults age 18 or older, have experienced serious psychological distress. Access to adult dental health care will be measured from responses to the Behavior Risk Factor Surveillance System (BRFSS) Survey to the question Have you visited a dentist or dental clinic in the past year for any reason? This data is available from the Center for Disease Control and Prevention, aggregated for the counties of Collin, Dallas, Delta, Denton, Ellis, Hunt, Kaufman, Navarro, and Rockwall (the Dallas-Plano-Irving Metropolitan Division). xi In 2008, the BRFSS estimate for the region was 65.9 percent visiting the dentist for any reason. Increases in the proportion of respondents who said yes to this question will be the indicator of improved access to adult dental care. Finally, in addition to a reduction in inpatient admissions for ambulatory-care sensitive positions, progress toward increasing access to care will be tracked through the percentage of major hospital emergency room visits that were for non-emergency or preventable conditions. The information is reported annually in the Community Health Checkup produce by the Dallas Fort Worth Hospital Council, and is based on an algorithm developed by New York University. The algorithm classifies most visits in one of four categories: non-emergent (not an emergency), emergent but treatable in a primary care setting, emergency but preventable with access to primary care, and emergency but not preventable or treatable. In 2007 in the Dallas Fort Worth Combined Metropolitan Statistical Area (CMSA), 17.8 percent of emergency room visits were for emergent, non-treatable, non-preventable conditions, while the remaining 82.2 percent represented a combination of non-emergency or preventable conditions. xii Prevention and Early Intervention Similar to the strategy to increase access to health care, another strategy was selected focusing on prevention and early intervention through screening and monitoring. Thus two primary indicators of progress for this strategy have been selected by the United Way of Metropolitan Dallas. The first of these indicators is the percentage of mothers who receive care in the first trimester of their pregnancy. Early prenatal care is recognized by physicians and public health practitioners as critical to good birth outcomes. The Healthy People 2020 report lists the following objective: Increase the proportion of pregnant women who receive early and adequate prenatal care. xiii To measure this indicator the Institute has obtained data from the Department of State Health Services (DSHS) birth certificate data file. The numbers of pregnant women and percent receiving care starting in the 1 st trimester of P a g e 4
pregnancy and total live births by county have been determined and the proportion calculated for the service area. xiv In 2007, the most recent year for which data are available, there were 65,841 births in Collin, Dallas, Denton, and Rockwall counties. Of those, 36,258 (55.1 percent) of mothers reported prenatal care beginning during the first trimester. Figure 3 presents the 2007 information by county. Increases in this proportion will serve as an indicator of progress for this strategy. Percent of Births by Trimester During Which Prenatal Care Began by, 2007 Rockwall Denton 65% 66% Dallas 49% Collin 70% 0% 20% 40% 60% 80% 100% Percent of Births First Trimester Second Trimester Third Trimester No Prenatal Care Figure 3 The second indicator for the prevention and early intervention strategy is the percent of children that had well-child visits in the 3 rd, 4 th, 5 th, and 6 th years of life. This information is obtained from the Texas External Review Organization for Medicaid Managed Care and CHIP Annual Reports. The fiscal year 2008 data is the most current available, and indicates that 73.39 percent of children ages 3 through 6 received well-child visits. xv The indicator is aggregated for the Dallas region. Future annual reports from this organization will be used to monitor the progress of this strategy. Promoting Healthy Lifestyles The United Way of Metropolitan Dallas has developed a third strategy to improve the health of the community namely, to promote healthy lifestyles through health information, education and programming. Three primary indicators have been selected to monitor progress of this strategy. These are the percent of individuals who are overweight or medically obese, the percent of individuals who have used illicit drugs or alcohol within the past month, and the incidence of domestic violence. Overall progress in this area will be tracked in the same manner as access to care through a reduction in the percentage of emergency room visits for non-emergency or preventable conditions (see above). Overweight and Obese The Healthy People 2020 objectives include improving weight status of children, adolescents, and adults. One objective is to, [r]educe the proportion of children and adolescents who are overweight or obese. Additionally, another objective calls to [i]ncrease the proportion of adults who are at a healthy weight. xvi Indicators will be measured separately for youth and adults since the rates are very different by age (19 percent of youth compared to 37 percent of adults). Furthermore, data for youth and adults are P a g e 5
collected by separate surveys. Being obese for youth is defined as a weight greater than 95 percent of individuals in the same age and sex category, while being overweight is defined as having a weight greater than 85 percent of individuals in the same age range, but less than 95 percent. Data for youth are collected by the Center for Disease Control and Prevention in partnership with state and county public health agencies using the Youth Behavioral Risk Factor Surveillance System (YBRSS) Survey administered to a sample of 9 th through 12 th grade students. Dallas schools were included in the sample and aggregate data is available for Dallas. xvii The 2009 survey indicated that 19.2 percent of survey respondents were overweight, while another 16.9 percent were obese. Progress regarding this indicator will be monitored for decreases using future survey results. For adults, weight status is determined by an indicator called Body Mass Index (BMI). BMI is calculated based upon a formula which includes an individual s age, sex, weight, and height. Individuals with BMI between 25 and 29.9 are categorized as overweight and individuals with BMI of 30 or greater are categorized as medically obese. The Center for Disease Control and Prevention estimates the proportion of individuals in each category through the national Behavior Risk Factor Surveillance System Survey of adults. Responses are aggregated by state and some metropolitan areas. Aggregate estimates are available for the Dallas-Plano-Irving Metropolitan Division, which includes Collin, Dallas, Denton, Ellis, Hunt, Kaufman, Navarro, and Rockwall counties. xviii In 2009, the Dallas-Plano-Irving MD had an estimated 37.0 percent of the population overweight (with a BMI between 25.0 and 29.9), and 26.1 percent of the population obese (with a BMI of 30.0 or more). Illicit Drug and Alcohol Use The second indicator that will be monitored for progress regarding this strategy is the percent of persons age 12 or over who have used illicit drugs within the past month, and the percent of high school students who have had at least one drink of alcohol during the past month. Measures of illicit drug used are provided by the Substance Abuse and Mental Health Administration National Survey of Drug Use and Health. Estimates are available aggregated for Texas Region 3a which includes Collin, Dallas, Delta, Denton, Ellis, Hunt, Kaufman, Navarro, and Rockwall counties. xix The most recent estimates for Region 3a, which represent the annual averages for the 2006, 2007, and 2008 surveys, report that 6.61 percent of respondents reported illicit drug use in the past month. Data regarding high school-aged use of alcohol is recorded by the Center for Disease Control and Prevention, in partnership with state and county public health agencies, using the Youth Behavioral Risk Factor Surveillance System (YBRSS) Survey administered to a sample of 9 th through 12 th grade students. Dallas schools were included in the sample and aggregate data is available for Dallas. xx In 2009, 39.7 percent of Dallas high school students responding to the survey reported having at least one drink of alcohol during the 30 days prior to the survey. Reductions in these measures will indicate progress toward the promoting healthy lifestyles strategy. Domestic Violence The third indicator that will be assessed regarding promoting healthy lifestyles is the incidence of family violence. The Healthy People 2020 Draft Objectives report lists three objectives related to domestic violence, [r]educe child maltreatment deaths, reduce non-fatal child maltreatment, and reduce violence by current or former intimate partners. xxi Domestic violence includes all ages: children, adults and elderly. Almost all domestic violence incidents involve physical assault. However this violence can include homicides and sexual assault. To measure this indicator the Institute obtained data from the Texas Department of Public Safety annual reports. xxii These reports include reported domestic violence crimes by jurisdiction. The number of crimes will be aggregated for the service area and Texas State Data Center estimates will be utilized to calculate the number of domestic violence incidents per P a g e 6
100,000 population. This will permit year to year comparisons that allow for population growth. The reduction in this indicator will be monitored to assess progress towards the promoting healthy lifestyles strategy. Table 2. Family Violence Incidents, Population, and Rate per 100,000 Population by, 2009 Number of Incidents 2009 Population Rate per 100,000 Population Collin 3,242 491,675 659.4 Dallas 19,859 2,429,276 817.5 Denton 1,924 657,876 292.5 Rockwall 382 81,267 470.1 Four Total 25,407 3,660,094 694.2 Summary The United 2020 goal for the Health impact area to improve health and quality of life across the service region can be measured according to three major features of health and quality of life: access to medical care, prevention and early intervention, and healthy lifestyles. While multiple strategies have been selected to maximize impact, one measure, representative of each strategy, is being used to establish a baseline and track progress: percent of children uninsured, percent of birth-mothers receiving prenatal care during the first trimester, and percent of adolescents and adults who are overweight or obese. Taken together, these measures illustrate the community s progress toward the United 2020 goal to improve health and quality of life in the metropolitan Dallas region. P a g e 7
Setting the Baseline In health, perhaps more so than in other areas of social policy, data is appreciably lagged. For many of the baselines established below, data is 3 to 5 years old. As with the other impact areas, the baseline data presented as estimates until such time as data for 2010 becomes available. At that time, the 2010 baseline will be set. Expanding Access to Care Indicator Year Geographic Reference Value Desired Target Percent of emergency room visits 2007 Dallas, Tarrant, Collin, Denton, 82.2 for non-emergency or preventable conditions Wise, Parker, Johnson, Ellis, Kaufman, Rockwall, Hunt, and Delta Counties Percent of persons age 18 and 2007 Collin, Dallas, Denton, and 21.1 under uninsured Rockwall Counties State Child Health Insurance December, 2010 Collin, Dallas, Denton, and 79,455 (SCHIP) Enrollment Rockwall Counties Medicaid Enrollment December, 2010 Collin, Dallas, Denton, and Rockwall Counties 403,206 Adult In-Patient Admissions for Ambulatory Care Sensitive Conditions Percent of Adults Experiencing Serious Psychological Distress in the Past Year Percent of Adults Visiting the Dentist Office for Any Reason in the Past Year June, 2009 United Way of Metropolitan Dallas Service Area 2002-2004 Dallas, Collin, Denton, Ellis, Hunt, Kaufman, Navarro, and Rockwall Counties 2008 Collin, Dallas, Delta, Denton, Ellis, Hunt, Kaufman, Navarro, and Rockwall Counties In Progress 8.59 65.9 Prevention and Early Intervention Indicator Year Geographic Reference Value Desired Target Percent of emergency room visits for non-emergency or preventable conditions Percentage of Mothers Receiving Prenatal Care During the First Trimester Percentage of 3 6 Year Olds Receiving Well Child Visits 2007 Dallas, Tarrant, Collin, Denton, Wise, Parker, Johnson, Ellis, Kaufman, Rockwall, Hunt, and Delta Counties 2007 Collin, Dallas, Denton, and Rockwall Counties 2008 Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, and Rockwall Counties 82.2 55.1 73.39 P a g e 8
Promoting Healthy Lifestyles Indicator Year Geographic Reference Value Desired Target Percent of 9 th through 12 th Graders 2009 Dallas 19.2 Overweight Percent of 9 th through 12 th Graders 2009 Dallas 16.9 Obese Percent of Adults Overweight 2009 Collin, Dallas, Delta, Denton, 37.0 Ellis, Hunt, Kaufman, Navarro, and Rockwall Counties Percent of Adults Obese 2009 Collin, Dallas, Delta, Denton, 26.1 Ellis, Hunt, Kaufman, Navarro, and Rockwall Counties Percent of Persons Age 12 and 2006-2008 Collin, Dallas, Delta, Denton, 6.61 Over Using Illicit Drugs During the Past Month Ellis, Hunt, Kaufman, Navarro, and Rockwall Counties Percent of 9 th through 12 th Graders 2009 Dallas 39.7 Reporting One Drink of Alcohol During the Past Month Domestic Violence Rate 2009 Collin, Dallas, Denton, and Rockwall Counties 694.2 Notes i Dallas 2008 Community Health Checkup. Dallas Fort Worth Hospital Council, 2009. ii The United Way of Metropolitan Dallas. 2010, March 5. Final Report to the Blue Ribbon Commission. iii Small Area Health Insurance Estimates, U.S. Census Bureau, 2007 iv CHIP Enrollment Date by and Month, Texas Health and Human Services Commission, CHIP Enrollment Statistics, December 2010; Medicaid Enrollment by and Month, Texas Health and Human Services Commission, Medicaid Point In Time Enrollment Statistics, December 2010. v Preventable Hospitalizations, 2005, Texas Department of State Health Services website, Center for Health Statistics, Texas Health Care Information Collection. vi Probst JC, Laditka JN, Laditka SB, Association between community health center and rural health clinic presence and county level hospitalizations rates for ambulatory care sensitive conditions: an analysis across eight US counties. BMC Health Services Research,2009, 9:134. vii Caminal J, Starfield B, Sanchez E, Casanova C, Morales M, The role of primary care in preventing ambulatory care sensitive conditions, European Journal of Public Health, 2004: 14: 246-251. viii Oster A and Bindman AB, Emergency department visits for Ambulatory care sensitive conditions, Medical Care, 2002, Vol. 41, No. 2, pp. 198-207. ix Texas Health Care Information Council, Texas Department of State Health Services, website. x National Survey on Drug Use and Health, 2004-2006, Department of Health and Human Services, Substance Abuse and Mental Health Administration website. xi SMART: Behavioral Risk Factor and Surveillance System, 2008 Dallas-Plano-Irving, Texas Metropolitan Division, Centers for Disease Control and Prevention website. xii Dallas 2008 Community Health Checkup. Dallas Fort Worth Hospital Council, 2009. xiii Healthy People 2020 Draft Objective, Department of Health and Human Services, 2009, www.hhs.gov. xiv Texas Health Data, Birth Data, 2005-2007, Department of State Health Services, Center for Health Statistics website. xv Annual Chart Book, Fiscal Year 2008, Texas Medicaid Managed Care STAR Quality of Care Measures, March 2010. xvi Healthy People 2020 Draft Objective, Department of Health and Human Services, 2009, www.hhs.gov. xvii Youth Behavioral Risk Factor Surveillance System Survey, 2009. Dallas. June 4, 2010, Vol. 59, No. SS-5. Center for Disease Prevention and Control website. xviii SMART: Behavioral Risk Factor and Surveillance System, 2008 Dallas-Plano-Irving, Texas Metropolitan Division, Centers for Disease Control and Prevention website. P a g e 9
xix National Survey on Drug Use and Health, 2004-2006, Department of Health and Human Services, Substance Abuse and Mental Health Administration website. xx Youth Behavioral Risk Factor Surveillance System Survey, 2009. Dallas. June 4, 2010, Vol. 59, No. SS-5. Center for Disease Prevention and Control website. xxi Healthy People 2020 Draft Objective, Department of Health and Human Services, 2009, www.hhs.gov. xxii Crime in Texas, 2009, Texas Department of Public Saftety website. P a g e 10