This report is provides an example of the types of graphics used, the software programs needed, and a set of conclusions that can be drawn from a careful community health assessment. The community was the 17 cities and counties in south central Virginia. Look at the health attributes analyzed. Also, look at the recommendations. What proportion of the recommendations to improve health rely on medical technology and which rely on public health skills?
Health System Analysis - Southside AHEC Area of Interest
Physical Health Problems
Overview
The introductory section describes the geographic area of interest for the Southside AHEC. It comprises 4 cities and thirteen counties in 1990 (Figure 1( NOTE: the figures referred to are fond in the original report. If there is enough interest the entire report could be placed on the web )), the year for which the data analysis starts. The City of South Boston in Halifax County had its city status removed in 1995. However, from 1990-1994 it was an independent jurisdiction. South Boston data was kept as a separate data set in the files of the Virginia Department of Health. Data used for this analysis has been collected by county, city, census tract and zip code and obtained from the VDH, the Census Bureau.
Figure 2 shows population distribution in the AHEC in 1990. Petersburg had the greatest population, over 38,000, followed by Halifax, Mecklenburg and Prince George Counties with almost 30,000 people each. Hopewell had over 22,000 people.
Figure 3 shows the major highways. A circle of 20 miles diameter around Blackstone represents the maximum travel distance to obtain primary care services, as recommended by studies at the Institute of Medicine (IOM) & HRSA.
The charts on population show an uneven distribution across the jurisdictions in the AHEC, both by total and age group, Figures 4-7. The population in each decile starts to decrease after people reach 24 years of age when outward migration in search of non agricultural jobs begins. The second wave of population decrease occurs after 54 years of age when deaths start having a significant effect on population size. I chose the population segments based on data available, but more importantly by the age groups in which particular health problems predominate. The age group from 0-13 has the lowest death rates except immediately post natal ( the first month after birth.) From 14 through 34 one finds the awakening from adolescence through early adulthood with the associated problems of sexual awakening, seeking sexual partners and competition for leadership and dominance which often leads to violence . From 35 to 54 there are fewer health problems, other than the early signs of chronic diseases making this age group the one for which secondary prevention is most valuable. From 54 onward death rates increase significantly, as personal behaviors developed during the prior forty years start taking their toll. Whichever age group is examined, differences between individual jurisdictions shift little over time.
The section on economics describes economic capability and educational status of the population based on the 1990 Census. This is followed by a section of primary care resources, a major focus of the AHEC. Following are sections on death data, infectious disease prevalence, infant deaths, and perinatal issues. This data describes the physical health status of the region. I have provided no data on social and mental health because the data is poorly defined and measurements cannot be validated.
Economics & Education:
Mecklenburg, Petersburg, Hopewell and South Boston have the highest dollar sales in the AHEC Figure 8.and 9, shows income distribution by households.
Data from the 1990 Census shows that the population falls into three main groups:
1} households with incomes less than twice the poverty level (approximately $30,000 for a family of four (based on 1995 federal standards)
2) households with incomes from twice the poverty level to less than $50,000.
3) and a smaller proportion that make more than $50,000 per year.
Figure 10 shows the low income population in 1990. Those below poverty (about $15,000 for a family of four in 1995) are eligible for Medicaid, unless they are males over 18 or non pregnant females without infants, also over 18.
Studies by the “Commission on Health Care for All Virginians” found that families with incomes below twice the poverty level have little capability to purchase health insurance. Also, most of these individuals work for businesses that do not provide insurance to their employees. They are often part time employees in laboring or fast food jobs. These people need help to achieve and maintain optimal health as they cannot pay for disease care.
Census data also show, like other studies for rural areas, a low proportion of the total 1990 population who were over 25 years of age stating they had graduated from high school. However many people who are now over 65 did not need a high school education to earn a living years ago, Figure 11. Except for Petersburg and Prince George counties no more than 12% of the total 1990 population over 25 years of age graduated from college, Figure 12). The Census Bureau considers 25 as the age by which the majority of people attending college graduate. Commerce, business (large & small), and industry need more highly trained technical staff. Health status rises with income and education.
Primary Care Resources:
Figures 11 and 12 describe the distribution of Primary Care Resources. In the not too distant past primary care was that care delivered by family physicians and GPs. Until the American Board of Family Physicians started to certify its members in the late 1960s family medicine was not considered a medical specialty. Family medicine is a specialty that focuses on continuity of care as the point of access for initial and continuing care. It is concerned with providing a comprehensive range of care, rather than depth of care for a limited range of diseases from a particular organ. The family physician also focuses on the dynamics of families living within a community. Family physicians, while using hospitals ( although less than in the past) are more likely to locate themselves where there is a large enough population, within reasonable travel distance, to support a 2-3 physician practice financially. A three doctor practice needs a population base of about 7500. Pediatricians, Internists and OB-Gyns are more likely to practice in a community with a hospital. . This is clear when Figure 13 is compared with Figures 14 through 16, and by review of Figure 18. Tables 1 and 2 show the distribution of the 176 primary care providers in the AHEC region by type and city or county.
Studies have shown that the general internist has a patient panel that is very similar to that of the family physician, but does not see infants and children and does no deliveries. The internist usually has more patients with cardiac and pulmonary disease than the family physician
The pediatrician deals with a smaller range of problems, He or she increasingly follows children into early adulthood. While pediatricians had large numbers of children with infectious diseases in to care for in the past, immunization eliminated many serious childhood infections other than ENT problems. As a result more pediatricians subspecialize rather than remaining generalists.
Table 3 shows the distribution of physicians below 55, as well as those moving into an age where they start to consider retiring or cutting back on hours. Almost 27 per cent are over 55 years old with many in their sixties, these 47 individuals will have to be replaced within the next ten years.
While the 6 hospitals in the region are located on the periphery, community health centers and health departments are located throughout the area. The number and distribution of primary practices is such that everyone in the region is accessible to a physician with no more 20 to 30 minutes driving time. There are no major mountain or river barriers similar to those seen in the Shenandoah Valley or Southwest Virginia. The Blackstone Family Practice training site is located in the region where travel distances to hospitals is greatest. It is a major asset to the Region and AHEC.
Tables 4 & 5 show the number of common reasons people visit doctors offices, by number and percentage, as well as the resulting diagnoses made by their physicians. The data comes from the 1983 NAMCS survey, the latest data available at the time of this report.
Mortality Data
Mortality Data has been used to assess health status for more than 200 years. It is compiled from death certificates forwarded to the Virginia Department of Health. It is only as accurate as its recorders. Certificates are coded and data compiled based on underlying causes of death. For example, the immediate cause of death could be acute myocardial infarction. This might be secondary to generalized atherosclerosis which in turn is secondary to diabetes mellitus. The underlying cause would be diabetes. Ward clerks, physicians, office staff and funeral directors’ staffs who fill out death certificates are rarely well trained in Nosology ( the art of completing vital data certificates). This death would most likely be coded as a myocardial infarction but should have been coded as diabetes. Another example would be a death certificate coded with the underlying cause of death as tobacco and lung cancer as the immediate cause. For effective primary and secondary prevention interventions we must know the underlying causes. For older people who, increasingly, die outside hospitals, the cause of death on the death certificate may not be the true underlying cause but only an informed guess.
Despite all the reservations about accuracy and timeliness of vital records we find remarkable consistency from year to year, even though popular labels crop up at times. Outside large urban areas, the relatively few deaths vary from year to year by number and cause. Three to five year aggregates of causes of death are best used to examine trend data to plan interventions to reduce untimely deaths.
Looking at deaths by age group, Figure 20, there are relatively few deaths until 55 years of age. Table 8 shows the number of deaths among the population over 54 years of age, the age at which most chronic disease occurs. Other than violence and genetic or developmental problems of infants few people’s behaviors cause sufficient damage to impair their health until their mid fifties, when they pay the consequence of their actions. The exception are deaths due to violence and substance abuse, found among adolescents and young adults. When we look at numbers of deaths we find considerable variation from place to place. When we adjust for population size, using death rates, the variability is reduced but still not comparable among jurisdictions. The places with largest populations do not necessarily have the highest death rates.
When comparing deaths by major cause, Figures 21 & 22, variability is diminished when adjusted for population differences (e.g. using rates.) However, the major causes still stand out. There are proven prevention interventions available to combat all these deaths. While some techniques are clinical, such as blood pressure checks and Pap smears, others are behavioral such as stopping smoking and changing diet. Table 4-page 30 describes the reasons for which people visit offices of primary care physicians. Many of these visits are for problems which reduce longevity if untreated.
Since 1965 cardiac deaths have declined almost 45% and stroke 60%. While improved medical technology has played a role, increased exercise, blood pressure & weight reduction, as well as reduced smoking and stress, have also played a significant part. Influenza and pneumonia deaths are preventable by immunizations but many people do not get the vaccines. Most chronic lung disease can be avoided by stopping smoking and reducing weight. Arteriosclerosis can be reduced by control of diabetes, blood lipids, and blood pressure which can be controlled by diet.
Lung cancer can be reduced 90% by stopping smoking. Breast cancer deaths can be reduced by early detection using mammography, specially for high risk individuals. Pap smears have almost eliminated death from cervical cancer. Better early identification of Human Papilloma Virus and more frequent pap smears may minimize the type of surgery needed to control cervical cancer when it does occur. We are still debating how to prevent colon cancer by early detection.
Death data is only a snapshot of the outcome of many years of deleterious behaviors. Other data that assist in developing “health” strategies can be obtained from the CDC/state Behavioral Risk Factor Survey which is performed in Virginia by the VCU Center for Public Service, Survey Laboratory.. Other useful data, that examine health services use and disability, can be obtained from the NCHS Health Interview and Health Examination series of documents (Series 10 & 11). A similar survey was conducted in Virginia in 1979. A partial replication was conducted in Richmond in 1991 by VCU Center for Public Service. Additionally, the National Ambulatory Medical Care Survey (NCHS Series 22) shows data on visits by cause to doctors offices and therapy provided.(e.g. Page 31) This data for types of diagnoses made in primary care physician’s practices have remained similar for the last 25 years.(not including Visits to OB-Gyns)
All these data confirm that just as a relatively small number of problems lead to early death, a small number of problems ( less than 25) are responsible for half the visits for ambulatory care. The prevention strategies available are rarely used because current health (medical) insurance does not pay for prevention activities
.Infectious Diseases:
Among the commonly reportable diseases, the most prevalent, other than sexually transmissible diseases, are those spread by fecal contamination. These are mainly Salmonellosis and Shigellosis, with some Campylobacteriosis, Hepatitis-A and Giardiasis (Page 38-40). All except the last are commonly spread through contaminated, poorly prepared and maintained food products while the last is most commonly spread through contaminated water supplies. In rural areas all these bacteria and viruses can be spread from water contaminated by animal and human feces. Poor disposal of single use diapers and poor sanitation of child care facilities also contribute to their spread. These outbreaks are preventable through use of frequent hand washing and careful disposal of human and animal waste.
While meningococcal infections often cause media hysteria the occurrence of such diseases is rare, Table 12. Page 40. The cause of intermittent outbreaks is not well understood.
Improved childhood immunization has resulted in rare outbreaks of communicable disease. School surveys continue to show that none of Virginia’s communities meet acceptable population immunization levels for children reaching their second birthday. Nearly all the common childhood infectious diseases are preventable by immunization. This is more true since Hemophilus influenza, Hepatitis-B & A, and Chickenpox immunization have become available. Improved record keeping, linkage and recent improvements in immunization tracking systems could lead to near 100 per cent coverage and protection of children from common communicable diseases within the next 3-5 years.
Over the last 5-10 years Tuberculosis has started to climb to levels we last saw 25 years ago, Table 13, page 41. This is partially due to closure of sanitariums, but more due to placing alcoholics and other mentally ill people on the streets, as well as the increased prevalence of HIV infection which increases susceptibility to TB in young people. This is mainly a problem of urban areas. It is a problem in Petersburg and Sussex in this AHEC.
Sexually transmissible diseases are common throughout the AHEC (Pages 42-44.) The major STDs reported are Gonorrhea and Chlamydia. The prevalence is highest in Petersburg ( the AHEC’s most urban area.) The incidence is highest among young people from 15-29. It is 99%+ preventable by either delaying sexual activity, having a single sexual partner within marriage, or through consistent use of condoms.
With the vastly improved protection of blood supplies we no longer see new cases of HIV infection from tainted blood products. HIV, like other STDs, is spread mainly through unprotected sex with multiple partners. Because the disease has a long incubation period young people rarely associate their behaviors as leading toward such infection. The other major method of transmitting HIV is through using needles when sharing injectable illegal drugs (which also increases transmission of Hepatitis-B and syphilis). This disease is also 99%+ preventable. If one considers teen pregnancy an STD then STDs are the major preventable disease of teens. They are preventable through education and development of appropriate shared sexual values. Data is becoming increasingly consistent showing that teens are not usually made pregnant by other teens but by older males, in their twenties
Pregnancy Related Problems
Infant mortality.
Data for the AHEC show that although rates for the region are not as high as in urban areas the AHEC’s population has infant mortality rates that are twice as high for non-whites as for whites. In some counties the rates are many times higher for non-whites (Figure 23 & 24). Even after aggregating data for five years, to reduce wide annual swings in rates due to the small numbers of infant deaths, the problem is still significant.
This is largely due to poor prenatal care. Some women fail to go to physicians or local health departments. There is significant difference between localities. Crater and Southside had the lowest death rates until 1994. Crater has a great difference between white and non-white infant deaths. This may well be more due to the large number of low income women in Petersburg, although Petersburg has shown a continual reduction in IDRs over he last 5 years.
Prenatal Care by Trimester.
Starting prenatal care in the first trimester occurs for 70-80% of pregnant women, although the Southside Health District jurisdictions show the lowest rate of starting care in the first trimester(Figure 25).
Fertility.
Fertility rates are highest among non-white females. This may be related more to lower education levels, poverty and lack of support by two parents in the young mother’s household, than to other factors (Figure 26).
Teen Pregnancies.
The majority of teen pregnancies take place in the Southside Health District, Petersburg & Hopewell. This is another side of the outcome of unprotected and indiscriminate sexual activity (as well as the inability of teens to say NO to older male friends.) Figure 27 & Table 17
Abortions.
While pregnancy is one outcome of unprotected sexual activity another outcome is abortion. The teen abortion rate across the district (Page 49 and Figures 28 & 29), hovers around 30% of pregnancies. While the abortion rate is slightly higher for non whites than whites there is no significant difference. Abortions are clearly an expression of unwanted pregnancies. They could be avoided by better planning and acceptance of responsibility for giving birth to children. Currently society places too much emphasis on female responsibility and not enough on male responsibility. The issue of teen pregnancy and abortions is one of value systems and community expectations.
Low Birth Weight.
Another measure of effectiveness and/or access to prenatal care is weight of infants at birth Figure 30 and Table 18. However, current data is based on using 2500 grams as minimal normal birth weight. There is good evidence that non-white women, except for Hispanic females, may have a normal low birth weight of 2250 Grams.
Births.
See Figures 31 and Table 19
Recommendations:
The Board should develop strategic plans for imminent changes in the health care system.
These strategies should focus on changes that have the greatest effect on long term improvement of health status. When a strategy also leads to short term benefits it will be easier to sell to the communities within the region.
The major goal of the AHEC is to enhance entrance to the health professions
Three complementary goals are
1 Education for development of a healthy population.
2.Improvement in access to primary care services
3.Retain current providers in the region.
The first goal requires five to ten years to measure a change in outcome. If you encourage additional young people to want to be primary care doctors when they leave high school you will see a result in ten years!
. A nurse practitioner or health educator will show up in five to six years, a pharmacist, physical therapist, nurse or PA in four years, an AA degree nurse in 2-3 years.
Provide incentives for any of these graduates to locate in the region. You can start seeing results in one to two years.
Starting or improve coordination among programs to improve health behaviors. You can identify results within two to three years.
Keeping current providers in the community. This has an immediate result.
Rather than focusing only on enticing more individuals to enter the health related professions you can improve health status and services more rapidly by enticing health professionals to come and live in your region. There is an oversupply of doctors in the US and in Virginia. As the HMOs and other third party payers reduce incentives to carry out high priced, often ineffective or unproved services, suburban physicians will look for places to practice, even if they need retraining.
A third of the physicians will be retiring in the next five to ten years and need replacing. Training new physicians by enticing high school graduates to enter medical training will not be fast enough.
Offer scholarships for short course to retrain specialists as generalists.
Plan locations and incentives for Graduates of the Blackstone Family Practice residency training program. If you keep all of them in the region you will meet 80% of your need over the next 10 years.
There is little evidence of current physician shortage at present. However, good data on who practices what kind of medicine how many hours a week is not available. This conclusion are based on the assumption that all the physicians identified in practice are practicing full time. If this is not the case then you need to start enticing additional primary care physicians into the AHEC now. By integrating services among hospitals, schools, health departments, primary care physicians, so that all the groups supplement direct medical services with health education programs you may not need as many physicians in ten years. Studies show that 75-80 per cent of primary care activities can be carried out safely and with high quality by nurse practitioners and physician assistants. Presently, we do not produce enough extenders to meet the need of all the primary care physicians. Also, as there appears to be an excess of total physicians in the state it makes little sense to keep training more physicians who can only handle specialized problems working out of a hospital base.
There is no adequate regional or state plan to link primary care services together effectively, or to entice new physicians to medically short areas.
The AHEC should develop a regional plan to link primary care services in the region.
The AHEC should fill the vacuum in development of the “Healthy Communities” process recommended by the National Civic League (NCL), in most of Virginia..
The NCL provides training classes for community representatives and has manuals for community use that are available from the national headquarters in Denver. It trains leaders in the community to develop plans to improve health status using traditional; and non traditional links. Mr. Robert Bobb, the Richmond City Manager, is a senior officer of the NCL and can provide contacts in Denver for you.
Studies by the “Joint Commission on Health Care” found that families with incomes below twice the poverty level have no capability to purchase health insurance. Also, most of these individuals work for businesses that do not provide insurance to their employees, often as part time employees in laboring or fast food jobs. These people must be helped to achieve and maintain optimal health as they cannot pay for disease care.
The Board must consider how the poverty and distribution of income in the AHEC influence the development of primary care services.
Is an absolute increase in the number of health care personnel needed, and if so, what kind? Consider how primary care practices and clinics can be supported by health care changes in nutrition education, public health home visiting, electronic consultation & communications, coordinated health education through school into junior college, and health education in doctor’s office and hospitals and community centers. Also, consider how linkages between the various providers & educators can be developed and how to evaluate effectiveness of health promotion by the various entities. For example; should health departments place WIC and PHN staff in physicians’ offices? Should the hiring of health educators be given a priority in health departments, doctor’s offices and hospitals? How can we ensure providers are reimbursed for cost-effective health education? Do you need to start legislative action or studies?
The data on death, disease and pregnancy suggest more specific actions rather than system wide changes..
Cardiovascular Mortality and Morbidity. Cardiac deaths have declined nationally almost 45% and stroke 60% in the last 15 years. While technology has played a role, data from the Framingham and Veteran’s Administration studies show that increased exercise, blood pressure & weight reduction, as well as reduced smoking and stress, have all played a significant part. Arteriosclerosis can be reduced by control of diabetes, blood lipids, and blood pressure. Over the next few years invasive surgery for cardiovascular disease is likely to decrease.
Lung Diseases & Death: Influenza and pneumonia deaths are preventable by immunizations but many people do not get the vaccines. Most chronic lung disease can be avoided by stopping smoking and reducing weight.
Cancer of Cervix. Better early identification of Human Papilloma Virus and more frequent pap smears may minimize the type of surgery needed to control cervical cancer.
Breast Cancer. Many women still fail to get mammograms ,despite the willingness of all insurers to pay for them. There is no question that longevity from this disease has improved. The data on reduction in deaths is suggestive but not proven. This certainly speaks to improved quality of life.
Control of these diseases requires intervention for a relatively small number of problems. Effective interventions are available and reduce premature death and improve health status. Office visits for antecedents of these problems are responsible for half the visits for ambulatory care. Yet, although the service is provided, many patients refuse to follow the advice given.. The prevention strategies available may not be provided because current health (medical) insurance does not pay for prevention activities.
The AHEC should coordinate programs to reduce chronic diseases.
Communicable disease community health education aimed at child and day care centers can reduce transmission of diseases of fecal origin. Improved record keeping, linkage and recent improvements in immunization tracking systems can lead to 100 per cent coverage and protection of children from common communicable diseases within the next 3-5 years. This will not occur if the community is poorly informed about the value of immunizations and their availability
The AHEC should become a partner of the Virginia Immunization Project and coordinate programs to spread disease from improperly disposed feces
The population group of most significance ( other than those over 54 years old) is the young people from 6-17 who have the most potential for behavioral changes that will promote their future health. They should be taught to abstain from harmful drugs, including tobacco. They should be taught proper nutrition( for which school meals may not be good models), the value of exercise, how to handle stress, appropriate amount of sleep and the value of education.
The AHEC should provide leadership to link information provided in school with information and activities provided by community organizations and parents,
Equally important to young children as they approach and pass through puberty and adolescence is how to handle interpersonal conduct including sexual activity. Sexually related diseases including Hepatitis B, Gonorrhea and HIV infection are increasingly common. If the AHEC Board believes that births should occur within intact families, and that children should be nurtured by both mother and father, appropriate behaviors must be taught and modeled. Teen births then meet the criteria to be labeled a sexually transmitted disease.. Such teaching is also important if the Board feels that pregnancy should be delayed until children complete high school and are sufficiently educated to form self sustaining family units..
The AHEC should take a leadership position in recommending techniques to avoid self destructive sexual behavior.
Having just discussed sexually transmitted diseases, abortions are clearly an expression of inappropriate pregnancies. They could be avoided by better planning and acceptance of responsibility for giving birth to children. Currently society places too much emphasis on female responsibility and not enough on male responsibility. The issue of teen pregnancy and abortions is one of value systems and community expectations. Abortions and ‘right to life’ cannot be discussed in a vacuum but as part of the issue of sexual responsibility.
Once pregnancy occurs and is carried to delivery of a live infant the issues of genetic abnormalities such as Tay Sachs disease, PKU and Sickle Cell disease have to be managed as well as the problems of developmental abnormalities, which depending on how you measure and label them can affect 40% of births. Early identification and intervention through blood testing is essential, as is education during pregnancy for care of a child.
The AHEC, in cooperation with community organizations, should take a leadership role in developing and coordinating access to programs on child development and care for all adolescents and pregnant females.
In summary, the AHEC is the only regional organization, which has the opportunity to develop the healthy community concept and ensure access to and coordination of health and medical services. Every other organization focuses on its own field of expertise rather than community organization. Community groups focus on facilities and payment or treatment for specific diseases rather than community standards and behaviors that enhance health, prevent disease and extend healthy years of life for older people..