|
Items in cart [0] |
Questions? Call 888-624-8373 |
| [ Top of Page ] [ Home ] [ Contact Us ] [ Help ] [ The National Academies Home ] | ||
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 149
5
GEOGRAPHY AND DISPARITIES IN
HEALTH CARE
Thomas C. Ricketts, ITI
This paper examines how health status, access to health care,
and health outcomes vary by geographic location. It also examines
which aspects of location appear most to affect health care access,
services, and utilization. There are clear geographic differences in
health status that vary according to the level of aggregation. At the
national level, overall mortality rates are much higher in the Southeast,
the Appalachians, and parts of the Intermountain West (Pickle et al.,
1996~. That pattern changes for Black mates to include very high rates
in the urban East and Midwest. For White females higher rates cluster
in the Midwest and Mississippi Valley. There are likewise differences
among states that mirror regional patterns. Within states, differences
are associated with areas with lower incomes, higher numbers of
minority populations, and cultural and historical risk factor patterns
that contribute to higher rates of morbidity and mortality. The same
gradients can be seen within cities and counties where neighborhoods
and census tracts reflect similar patterns of health disparities. These
differences are both apparent and persistent when subjected to
statistical controls and comparisons (Geronimus et al., 1999~.
5-~. GEOGRAPHY
Geography is often thought of as the generation and
interpretation of maps that describe the physical world. Geography is
far more than that, but the physical description of boundaries has a
great deal to do with how we view communities and how we construct
society (Giddens, 1984~. The physical aspects of a community are
usually defined by boundaries that may have been developed for a
specific public purpose, but that often create gradients that separate
one population group from another. This can be apparent in zoning
149
OCR for page 150
1 50 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
rules or in the creation of jurisdictions that have different systems of
social support. Areas can also become different through social and
economic processes that create regions or communities whose
boundaries are essentially invisible.
When speaking of health, the domain of medical geography is
most often invoked. Medical geography, however, is more aligned
with the study of disease and disease diffusion without explicit
consideration of other aspects of human interaction. The structure of
health services and how people use health services in ways that reflect
and create disparities are factors that span the human and the medical
parts of geography. The discourse of the geographer involved in
describing health care delivery and health status has become
controversial within the discipline itself. While space and place in
health care delivery are important, their structure and interpretation
are, to some, irrelevant to practical decision making because they are
the result of overwhelming social forces and power relationships. To
others, a point of view that includes spatial and landscape perspectives
can be useful for local purposes and for broader policy development
(Mohan, 1998~.
Nevertheless, the power of geographic comparisons and
boundary setting is real in the policy world, and the application of
policy is very sensitive to location and scale. As one leading
researcher has observed:
There is no agreement about how to best define a
geographical area in terms of socioeconomic position or
about which area-based measures of socioeconomic
position are most informative, especially across multiple
kinds of health outcomes (Krieger, 2002~.
This paper does not contradict that conclusion, but does
recognize that there are options for understanding the geography of
health disparities as well as for implementing solutions. For example,
regions, states, and localities are different in several ways. Regional
differences show that history, environment, culture, and politics have
combined to create disparities that cross state boundaries. Those
regional differences--apparent in the Southeast, Appalachia, portions
of the Tntermountain West, and selected parts of the Southwest--point
OCR for page 151
5: GEOGRAPHY AND DISPARITY IN HEALTH CARE
151
to the need for interstate collaboration or federal coordination and
sharing of resources. Urban-rural comparisons do not reveal consistent
patterns of dispanty, but rural and inner city conditions tend to
magnify differences associated with other social, economic, and health
system characteristics. There are variations in rates of illness and
access to appropriate care that reveal themselves in comparisons
across states. These consistent variations imply that there are state-
level policy levers that can be used to reduce disparities. Town, city,
and county boundaries may describe communities that can develop
solutions using local government or social, religious, or external
systems.
The small area geographies used most often to depict health
status are appropriate for identifying and verifying health status
disparities. They include units of census geography such as tracts and
block groups, counties, ZIP code areas, and clusters of ZIP codes.
These can be used to construct service or market areas that contrast
health outcomes and utilization for primary care, general hospital care,
and tertiary care. But the level of intervention appropriate to specific
patterns of disparity is not always coterminous with those boundaries.
While we may identify disparities in rates using zIP code areas or
census tracts, it is not easy to mobilize an intervention based on those
boundary sets. People do not feel a sense of "membership" or
citizenship to such areas, and neither government nor the health care
system is structured to act at those levels unless the boundaries
identify real neighborhoods or communities.
There is no consensus on a fundamental unit of geography to
use in measuring health and health care in the United States or
elsewhere. There are many reasons for this, including the problems of
relating individual events to population rates. However, the most
important reason lies in the way in which health data are reported
(Meade and Earickson, 2000~. Data are compiled according to the
political and administrative organization of governments and, to a
lesser extent, society. Denominators in rates are most often expressed
as the population of some political unit such as a state. It would be
more clinically useful to express rates in terms of gender, age, or even
occupation. Those relate more directly to health care delivery, to
health status, and to outcomes for individuals.
OCR for page 152
1 52 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
5-2. INTERSTATE GEOGRAPHY
Interstate geography includes several different units
commonly used to analyze health care delivery and service and to
formulate health care policy. The following is a brief overview of two:
regions and rural-urban areas.
Regions
Regional systems and structures have been developed to cope
with health problems across state borders. They include the health care
system development of the Tennessee Valley Authority (TVA) and the
Appalachian Regional Commission (ARC) as well as work in the
Tower Mississippi Delta. The ARC remains active in this field and
supports work that illustrates disparities in health status and access
through the University of Kentucky (www.mc.uky.edu/RuraTHealth
/ARC_AHPAC/ahpac.htm). There are regional initiatives in the
Mississippi Delta through various organizations and governments. A
regional study of asthma supported by the Trust for America's Health
is illustrative (health-track.org/reports/msO420/~. The Health
Resources and Services Administration (HRSA) announced a program
to improve health care by supporting rural hospitals in the Delta region
in late 2001. Similar cross-state efforts such as the U.S.-Mexico
Border Health Commission are underway along the U.S.-Mexico
border (www.borderhealth.gov/~. These regional initiatives are
supported through affiliations of state governments such as the
Southern Governors' Association or the Southern Growth Policies
Board or ad hoc groups of governors or state agency heads.
Rural-Urban Areas
One view of the geographic structure of the nation contrasts
how the population is distributed between cities and rural areas. There
are more than 60 million people classified by the U.S. Bureau of the
Census as "rural" and 55 million living in "nonmetropolitan" counties
in 2000. This is a population group comparable in size to the United
Kingdom. Rural America would be among the top 20 nations in
population. The structure of the Congress, which gives equal
representation to states in the Senate, means that the rural issues that
OCR for page 153
5: GEOGRAPHY AND DISPARITY IN HEALTH CARE
153
are important in sparsely populated western states such as Idaho,
Wyoming, Montana, and North and South Dakota are given careful
consideration in Congress. The political as well as physical geography
of the U.S. makes rurality an important concept.
The two most common designations of rurality used in
describing populations are those of the U.S. Bureau of the Census and
the U.S. Office of Management and Budget (OMB). "Urbanized
areas" are defined by the U.S. Bureau of the Census according to a
complex set of characteristics that takes into consideration the
economic nature of a place, transportation patterns, and the number of
people living in a fixed area. That definition is undergoing revision
and a final rule is expected to be published soon. For the 2000 census,
rural areas are considered places outside urbanized areas. Urbanized
areas are composed of "core census block groups or blocks that have a
population density of at least 1,000 people per square mile and
surrounding census blocks that have an overall density of at least 500
people per square mile" (www.census.gov/geo/www/ua/ua_2k.htmI).
This delineation has not been used often to determine effects on health
and health care. More often the OMB Metropolitan-Nonmetropolitan
classification of counties is used for comparisons.
The OMB designation classifies counties as metropolitan or
nonmetropolitan based on whether the county has a large city and a
number of suburbs. It also takes into account a functional element that
measures the extent to which peripheral counties are economically
integrated with their surrounding metropolitan counties. A
Metropolitan Area (MA) must contain either a place with a population
of at least 50,000, or a census-defined urbanized area and a total MA
population of at least 100,000, or reflect the economic activities of
such a place. Various attempts to subclassify the counties within the
metropolitan and nonmetropolitan categories exist, and they have been
used to examine health care resource use and distribution and health
status. In 2001 the National Center for Health Statistics (NCHS)
included a rural-urban comparison in its Healthy People series. The
NCHS report found that:
.
Residents of counties on the borders of large metropolitan areas
generally are ranked highest on health indicators.
OCR for page 154
OCR for page 156
OCR for page 157
OCR for page 158
OCR for page 159
OCR for page 170
OCR for page 171
OCR for page 172
OCR for page 173
OCR for page 174
OCR for page 175
OCR for page 176
OCR for page 177
OCR for page 178
OCR for page 179
OCR for page 180
Representative terms from entire chapter:
care disparities
1 54 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
Indicators of health, health care use, and health care resources can
differ by level of urbanization.
Regions do vary, which is reconfirmed by data.
· Nationally, residents of the most rural counties have the highest
death rates for children and young adults, the highest death rates
for unintentional and motor vehicle traffic-related injuries, and the
highest mortality for ischemic heart disease and suicide among
men (Eberhardt et al., 20011.
These general comparisons are plagued by the problem of
aggregation of widely divergent nonmetropolitan populations and
communities into large, gross classifications that are meant to be
consistent across the nation. There are regional patterns of rural
disadvantage that are highly discernible. For example, there is higher
infant mortality in the rural Southeast. Those conditions are clearly
related to the income and educational differences between those rural
regions and other parts of the nation. Geographic patterns of morbidity
and mortality vary by race and ethnicity (Albrecht et al., 1998), and
these differences are sometimes reinforced by rural location. Blacks
and Whites living in nonmetropolitan counties have higher death rates
from diabetes (Ricketts, 2001) and heart disease (Slifl
5: GEOGRAPHY AND DISPARITY IN HEALTH CARE
Access to Care in Rural Areas
155
Access to health care services in rural versus urban areas has
been explored by health services researchers for decades. Rural
residents are, on average, poorer, older, and, for those under age 65,
less likely to be insured than persons living in urban areas (American
College of Physicians, 1995; Hartley et al., 1994; Braden and
Beauregard, 1994; Schur and Franco, 1999~. Rural Americans also
report more chronic conditions and describe themselves in poorer
health than urban residents. Further, injury-related mortality and the
number of days of restricted activity are higher in nonmetropolitan
areas. The degree to which Tower levels of access affect health
outcomes and utilization for rural persons is at issue, however, given
the conclusions drawn by Me6PAC in its Report to Congress
(Me6PAC, 2001~. It is easy to challenge its flat assertion that an access
gap does not exist. The analysis did not always include controls for
health status, and the risk adjustment for prior use may have made the
analyses inaccurate. The access study also did not differentiate
between underserved and adequately served communities and did not
reveal whether there was an independent rural or travel effect for the
measures of access. But most importantly, the sample was drawn with
the assumption that rural places compose a homogenous sample
stratum. While the wide variation in access in urban systems is
accepted and comparisons within and between metropolitan areas are
usual in national surveys, this is not feasible for rural places given the
current construction of these surveys (Schur et al., 1998~.
Race, Ethnicity, and Rurality
The interaction of race and ethnicity and rurality has been
examined in a review of studies of six conditions highlighted by the
U.S. Department of Health and Human Services (DHHS) in its
disparities initiative. The conditions are infant mortality, cancer
screening and management, cardiovascular disease, diabetes, HIV
infection, and child and adult immunizations (Slifkin et al., 2000~. The
review found that rural minorities are further disadvantaged compared
to their urban counterparts in cancer screening and management,
cardiovascular disease, and diabetes. The gaps between Whites and
minorities appear to be greater for these conditions in rural places, but
1 56 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
the studies that made up the review did not carefully control for many
variables that might describe problems with access to care. Likewise,
comparisons did not include controls for regional effects. There are
clear limitations to drawing inferences from geographical
classifications at the county level.
In sum, there is credible evidence that being in a rural place
has a strong and relatively consistent negative effect on one's
economic chances. However, there is some difficulty in creating a
strong claim that rurality has an independent and significant impact on
people's health. The problem, it seems, is that the definitions of what
are rural and nonmetropolitan are more closely tied to factors related
to population and its density. These have a consistent economic effect,
but an inconsistent health effect. Unfortunately, a definition of medical
rurality is not at hand. Instead, various measures of medical
underserv~ce, health professional shortages, and vulnerability are
available. While those measures are place specific and tend to be more
rural, they are also applicable to highly urbanized areas. The search for
a perfect measure of rurality that will capture its health effects may be
a useful exercise, but will require a careful analysis of the effects of
distance, culture, occupational context, and the spatial characteristics
of technology and information diffusion. Such a metric will have to
overcome the strong bias in favor of existing, well-documented, and
relatively consistent systems of classifications of rurality. To do so, it
will have to have a transparent application to populations and health
care systems as well as a clear application to policy.
Distance as a Proxy for Rurality
Distance to health care is one of the most important
geographic features that may affect health status and health outcomes
and that may contribute to disparities. The effects of distance on
access to health care services have been a subject of research for some
time. For example, Weiss examined how distance to a hospital
combined with social class determines patterns of use (Weiss and
GreenTick, 1970~. Conner and colleagues examined studies of distance
to care to attempt to find standards for access (Conner et al., 1994~.
While they found evidence of distance decay in use and some
indication that quality of care suffered when care was provided to
5: GEOGRAPHY AND DISPARITY [N HEALTH CARE
157
people who lived at some remove from services, they were unable to
develop clear guidance for what would be a fair standard for physical
accessibility. Nor were they able to develop clear guidance on how to
measure it. They were able to contrast units of analysis classifying
areas as "town/community/ZIP"; county; "market-share defined"; and
national. However, they made no recommendations concerning their
ability to detect differences that might reflect disparity. There is
evidence that underserved populations are located at a greater physical
distance from services in rural communities. Low-income populations
in urban areas are often adjacent to a high density of health care
resources (Bohland and Know, 1989~.
5-3. INTRASTATE GEOGRAPHY
There are several geographic units that are often used to
analyze health care delivery and services and to develop health care
policy. The following briefly examines states, communities, local
health department jurisdictions, census and postal geography, and
market areas.
States
In the U.S., states are the fundamental polities for the support
and regulation of most local health care delivery. When the federal
government chooses to provide support for nationwide public health
programs, each of its three major options involves the states:
Grants-in-aid to states based on their populations, or so-
called block grants;
· Formula grants that take into consideration some factors
of need, with the Medicaid program an example of such a
system; and
.
Program or project grants that involve states either as
umbrella applicants or as passive reviewers, with
community health centers an example.
1 5 8 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
State public health systems and their mtal and health statistics
reporting systems provide much of the data on health care dispanties.
States have the primary responsibility for the protection of public
health. As part of that responsibility, states have developed a
coordinated system of data collection and repotting. They have also
developed programmatic interventions that vary. State governments
vary in the degree of support for public health and health care deliverer,
and there are differences in the structures of their health care delivery
systems that are due to their respective populations, cultures, and
histones. The states vary as markedly in investment in health as they
do in health outcomes. Figure 5-1 describes a potentially close
relationship between per capita health spending and years of potential
life lost (YELL).
FIGURE 5-1 Variations among States in Life Years Lost and Per Capita
Spending for Health
Health Spenciing vs~ Life Years Lost:
Wide Variations in State Performance
'term ~rort' I - ~~.J Years of =~tia: Bite ~ q~013 OD]
2000
~~i
- tODC .
(~;~~ ~ ~ ~~ o; -~~~-~~~~~-~~~~~~~~~~~~~~-~~$~~~---~~~~-~~~~-~~~~~~~~-~~~~~~~-~-~1Ga $1 ,E30
{in Frorr, P'edi>~.ted Poi Ca pit`: He,alth Spend'ng (~01.3~.)
blote. Fle;altf. sper,dirl~ yard c. Ii[e Ic's~il0D,Ct,30 are d - onions
frt=`'9il~t't'.~lr.i Alp ,p=~;b~.~' Irk pot splat '''`~-r;~.
Is ~8lc£lI3t~1frol~14lChl~ 'CFA data
tle`~a .. *,
;~4Sk~
.
- 10.3t,0
4'
.*
~ LC~ Island
a.
~~ -
~ I/~3SOth03>'ttS
.
LICE=
* r~~i<.D~
SOURCE: (Conover, 1998. Reprinted with the author's permission.)
Key to the identification of a substantial difference in health
status or access between geographically defined populations or
population segments is the degree to which the boundaries separate or
include the population that is negatively affected or the degree to
which the nature of the area itself affects health and health care. Maps
of the United States at the state level show strong and important
5: GEOGRAPHY AND DISPARITY IN HEALTH CARE
159
differences in mortality, morbidity, and access to care measures. There
are different ranking and ratings systems that reveal health disparities
at the state level, including those distributed by the UnitedHealth
Group (UnitedHealth Group, 2000), Morgan Quitno (Morgan and
Morgan, 2001), the National Conference of State Legislatures (Siegel,
1998), AARP (Lamphere et al., 1999), and the Urban Institute (Liska,
et al., ~998~. The National Center for Vital and Health Statistics of the
Centers for Disease Control and Prevention (CDC) does not explicitly
rank states, but data it distributes can easily be ranked and grouped.
Those rating systems are criticized for their inaccuracy and the
inclusion of subjective judgments of what constitutes a summary
measure of health (Gerzoff and Williamson, 2001~.
There are other compilations of state-level data that allow for
comparisons, but that do not specifically rank or rate states. These
include the Kaiser Family Foundation "50 State Comparisons" web
site (www.statehealthfacts.kif.org), state-level data that are compiled
by the Maternal and Child Health Bureau in the Health Resources and
Services Administration (HRSA) to track Title V progress
(www.mchdata.net/), and a series of health profiles for states compiled
by HRSA that covers a
wide range of indicators
(stateprofiles.hrsa.gov/StateProf~lesIndex.htmI). State agencies and the
public pay close attention to these rankings systems, and they are
sometimes used to guide policy decisions. The UnitedHealth Group
rankings are circulated widely and commented upon regularly. The
indicators used in that ranking system have been modified slightly for
use as a performance measuring system for the state of Nebraska.
States have attempted to lead in the implementation of
comprehensive programs to improve health status and the coordination
of services either through overt political refonm or through
administrative emphasis on health (Nelson, 1994~. The degree of
variation in state efforts to improve population health is illustrated by
the variation of their policies. For example, the Robert Wood Johnson
Foundation's State Coverage Initiative and its tracking of insurance
coverage by states illustrates the range of coverage decisions and the
potential for state-level policy to influence how health care is paid for
(www. statecoverage.net/matrix.htm).
1 70 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
for assessments of the adequacy of access and guidance for allocating
resources. The review did not support the idea of access as a unifying
concept that would lead to a consensus definition of an appropriate
geographic unit. The general geographic size of places where access
was most effectively measured was at the local level, usually
consisting of small counties or clusters of ZIP areas. It was closely
associated with the system that was meant to affect or provide access
to primary care. In these areas, the fit between a measurable disparity
in access closely approximated the area in which a solution could be
achieved either through the enhancement of availability (for example,
creating a clinic) or modifying some factor that reduced access (for
example, developing a subsidy for care). However, many of the studies
they reviewed made note of, but seldom measured, important effects
and influences on the programs and projects from adjacent areas or
state systems.
Technical Problems with Community Indicators
The determination of small area rates and indices describing
the health status and health care resources available to populations is
subject to varying degrees of error. In creating these rates and
indicators, analysts rely on a largely dispersed and cooperative system
of reporting that is based on local and state rules and laws, although
the standards and guidelines are centrally agreed upon. Mortality rates,
overall, are generally considered accurate, but there is evidence that
cause of death is often miscoded on death certificates that are the
source of mortality data (Kircher, 1985; Goodman and Berkelman,
1987~. The accuracy of health care resource data is not often called
into question, but for secondary data analysis there are problems with
national data sources that may skew a picture of a county or
community. The American Medical Association (AMA) Masterfile is
the most frequently used source for national estimates of physician
supply down to the county level, but it has been shown to have a
degree of error due to reporting lags and the high mobility of
physicians (Cherkin and Lawrence, 1977; Grumbach et al., 1995;
Williams et al., 1996~. For rural areas, the difference between the
number of physicians reported in the Masterfile and the actual, locally
verified number is striking in many places (Konrad et al., 2000;
Ricketts et al., 2000~. At the state level, license and survey data
5: GEOGRAPHY AND DISPARITY IN HEALTH CARE
171
indicate that the Masterfile may overestimate primary care physician
supply by as much as 20 percent. Data for nurses, pharmacists, and
other health professionals are far less accurate when drawn Dom
national sources because of the lack of a national inventory system
(Kresiberg et al., 1976; Osterweis et al., 1996~.
Geographic Information Systems as Savior?
GIS has been proposed by some as an all-purpose answer to
problems of community characterization. It is touted as capable of
solving resource allocation problems as well as of being an essential
part of the field epidemiologist's armamentarium. The widespread use
of GTS in public health came relatively late in the development of
computer-assisted cartography and geographic analysis largely due to
the lack of useful data to attach to geographic coordinates (Rushton et
al., 2000~.3 Healthy People 2010 includes the goal of increasing "the
proportion of all major national, State, and local health data systems
that use geocoding to promote nationwide use of geographic
information systems (GIS) at all levels" from a baseline of 45 percent
to 90 percent (Office of Disease Prevention and Health Promotion,
2001, pp. B234~.
Geographic information systems carry the strong promise of a
new, liberating technology and are often advertised to have the
capacity to allow complex information to be displayed clearly and
transparently, making both problems and solutions apparent. However,
GTS is not really a new technology, but an expansion and
intensification of older technologies. The expansion of the use and
capacity of computers has facilitated collection of data by using
remote sensing or by tapping into administrative, statistical, or clinical
datasets. However, the massive amount of data that is now available
has not immediately led to marked improvements in health care, the
identification of health problems, or the formulation of health
solutions because the volume of data has outpaced our ability to
understand it.
3 However, some of the first applications of automated cartography were used
to address health services problems.
1 72 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
GIS, however, has renewed interest in the use of spatial data
as well as of statistical data of all types to explore questions, and to
conduct surveillance of health systems and communities. The power of
a map or data displayed in reference to space cannot be
underestimated. The ability to quickly depict data in maps and graphs
using GIS has made many problems seem more tractable because they
can be understood in a context that is shared by analysts, policy
makers, and stakeholders. At the same time, the classical errors of the
mapmaker are repeated, and the ability to "lie with maps" is
increasingly recognized as a threat to the validity of analysis on the
order of more standard statistical misapplications (Monmonier, 1991~.
5-5. CONCLUSION
Geographers who examine the relationship between place and
health believe that it is formed less by the intrinsic nature of fixed
places than by how people interact across space to make a particular
place more or less healthy. The relationship between HIV infection
and interstate highway locations represents a perfect example of a
health consequence that is literally in motion and dependent upon
place only to facilitate transmission. The consequences are felt at a
distance. Injury prevalence is dependent on risks that are tied to
geography: higher rates of trauma in rural areas are due to factors
related to exposure and behavior (snowmobile use, chainsaws, tractors,
higher highway speeds, Tower seatbeTt use) that reflect the interaction
between human activity and space and places. These are disparities in
risks are related to geography. Paradoxically, urban places tend to be a
bit safer in terms of trauma. There are more guns in rural places, and
firearm injury rates are higher. Also, the urban-rural differential in
drug and substance abuse is no longer so great as to create clear
contrasts in the net health effects of crime. There are obvious
structural and physical differences between the decaying inner city of
Scranton, Pennsylvania and of the "cotton trail" area of South
Carolina. However, the health disparities
in access, services, and
quality are fundamentally the same and described in the same terms.
Across geographies there is a convergence of human health status and
of how we deal with it.
5: GEOGRAPHY AND DISPARITY IN HEALTH CARE
173
While geographic location is associated with wide variations
in access, health care use, and health status, two core geographic
elements and their relationship to health disparities are not well
understood. They are distance (time and topography fit under this
heading as well) and weather. Measuring distance often involves the
use of rough estimations that mask actual geographic patterns of use.
In many studies of the effects of distance, populations are described by
some geographic entity such as a ZIP code or county, and the
"average" distance to some location of care using the center of the
geographic unit is calculated. This means that the variation or disparity
due to differences in distance that exist within this geographic unit is
lost to the analysis. The option is then to examine the relationship
between an individual's distance to care and health status or outcomes.
The latter analytical approach is feasible, but the former is far less
expensive. Much of what we know about the effects of distance on
health is based on the former type of studies. The degree to which true
effects of distance are missed by this ecological approach is not well
understood. Similarly, analysts and researchers often ignore
differences in weather and environment and their effects on access,
especially in the United States. We are constrained by our boundaries
in such a way that we may not be able to completely understand how
geography does affect disparities.
The relationship of neighborhood residence to health may be
considered a form of pure geographic effect since neighborhoods are a
combination of topography and social interaction. However, a reliable
definition of neighborhood is elusive, and bringing some form of
consistency to its measurement may be antithetical to a concept that
strives to reflect the variety of human interaction. Measuring true
geographic disparity has been difficult, and summary approaches that
compare populations often mask evidence of disparity. We may have
to begin to think of geography in the study of health disparities as
more of an individual characteristic as opposed to a way to organize
population analysis.
1 74 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
Reference List
Albrecht, S.L., L.L. Clarke, and M.K. Miller. 1998. Community, family, and
race/ethnic differences in health status in rural areas. Rural Sociology 63
(2~:235-52.
American College of Physicians. 1995. Rural primary care. Annals of Internal
Medicine 122 (5~:380-90.
Bindman, A.B., K. Grumbach, D. Osmond, M. Komaromy, K. Vranzian, N.
Lurie, J. Billings, and A. Stewart. 1995. Preventable hospitalizations and
access to health care. JAMA 264 (4~:305-11.
Blakely, T.A., K. Lochner, and I. Kawachi. 2002. Metropolitan area income
inequality and self-rated health a multi-level study. Social Science &
Medicine 54 (1~:65-77.
Bohland, J., and P.L. Know. 1989. Grown of proprietary hospitals in the
United States: a historical geographic perspective. In Health Services
Privatization in Industrial Societies, ed. J. L. Scarpaci. New Brunswick,
NJ: Rutgers University Press.
Braden, J.J., and K. Beauregard. 1994. Health Status and Access to Care of
Rural and Urban Populations. Rockville, MD: Agency for Health Care
Policy and Research.
Brasure, M., S.C. Stearns, E.C. Norton, and T.C. Ricketts. 1999. Competitive
behavior in local physician markets. Medical Care Research arid Review
56 (41:395-414.
Cherkin, D., and D. Lawrence. 1977. An Evaluation of the American Medical
Association's Physician Masterfile as a Data Source One State's
Experience. Medical Care 15 (91:767-69.
Conner, R.A., J.E. Kralewski, and S.D. Hillson. 1994. Measuring geographic
access to health care in rural areas. Medical Care Review 5 1 (31:337-77.
Conover, C.J. 1998. "Do States Matter?" Online. Available at
http ://www.hpolicy. duke. edu/cyberexchange/StateGov/slides/st 1 -2d.html
[accessed May 3O, 20024.
Dartmouth Medical School. 1998. The Dartmouth Atlas of Health Care 1998.
Ed. J. E. Wennberg. Chicago: American Hospital Publishing, Inc.
5: GEOGRAPHY AND DISPARITY IN HEALTH CARE
175
Diehr, P., K. C. Cain, W. Kreuter, and S. Rosenkranz. 1992. Can small-area
analysis detect variation in surgery rates? The power of small-area
variation analysis. Medical Care 30 (6~:484-502.
Diehr, P., K. Cain, F. Connell, and E. Volinn. 1990. What is too much
variation? The null hypothesis in small-area analysis. Health Services
Research 24 (6~:741-71.
Diez-Roux, A.V. 1998. Bringing context back into epidemiology: variables
and fallacies in multi-level analysis. American Journal of Public Health
88 (2~:216-22.
Dorch, J.S., L.A. Bailey, and M. Stoto, eds. 1997. Improving Health in the
Community. A Role for Performance Monitoring. Washington, DC:
National Academy Press.
Duncan, C., K. Jones, and G. Moon. 1998. Context, composition, and
heterogeneity: using multi-level models in health research. Soc Sci and
Medicine 46 (1~:97-117.
Eberhardt, M.S., D.D. Imgram, D.M. Macuc, E.R. Pamuk, V. M. Freid, S.B.
Harper, C.A. Schoenorn, and H. Xia. 2001. Urban and Rural Chartbook.
Health United States, 2001. Washington DC: U.S. Government Printing
Office.
Epling, P.J., S.E. Vandale, and G.W. Steuart. 1975. Beyond the individual for
the practice of social medicine: household networks as etiologic-
diagnostic units. In Topics and Utopias in Health. Policy Studies, eds.
S.R. Ingman and A.E. Thomas. The Hague: Mouton.
Galper, J. 1998. An exploration of social capital, giving, and volunteering at
the United States county level. Washington, DC: The Urban Institute.
Geronimus, A.T., J. Bound, and T.A. Waidmann. 1999. Poverty, time, and
place: variation in excess mortality across selected US populations, 1980-
1 990. Journal of Epidemiology and Community Health 53 (6~:325-34.
Gerzoff, R.B., and G.D. Williamson. 2001. Who's number one? The impact of
variability on rankings based on public health indicators. Public Health
Reports 116 (2~: 158-64.
176 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
Gesler, W.M., and M.S. Meade. 1988. Locational and population factors in
health care-seeking behavior in Savannah, Georgia. Health Services
Research 23 (3):443-62.
Giddens, A. 1984. The Constitution of Society. First paperback edition ed.
Berkeley, CA: University of California Press.
Goodman, R.A. and R.L. Berkelman. 1987. Physicians, vital statistics, and
disease reporting. JAMA 258 (3~:379-81.
Grumbach, K., S.H. Becker, E.H. Osborn, and A.B. Bindman. 1995. The
challenge of defining and counting generalist physicians: an analysis of
Physician Masterfile data. American Journal of Public Health 85
(10): 1402-07.
Halverson, P.K. 2000. Performance measurement and performance standards:
old wine in new bottles. Journal of Public Health Management and
Practice 6 (5~:vi-x.
Halverson, P.K., R.M. Nicola, and E.L. Baker. 1998. Performance
measurement and accreditation of public health organizations: a call to
action. Journal of Public Health Management and Practice 4 (4~:5-7.
Hartley, D.L., L. Quam, and N. Lurie. 1994. Urban and rural differences in
health insurance and access to care. Jrnl Rur Health 7 (4~: 357-79.
Irwin, M., C. Tolbert, and T. Lyson. 1997. How to build strong home towns.
American Demographics 19 (February):42-48.
Jencks, S.F., T. Cuerdon, D.R. Burwen, B. Fleming, P. M. Houck, A.E.
Kussmaul, D.S. Nilasena, D. L. Ordin, and D. R. Arday. 2000. Quality of
medical care delivered to Medicare beneficiaries: A profile at state and
national levels. JAMA 284 (13~:1670-76.
Johnston, R.J., D. Gregory, G. Pratt, and M. Watts, ed. 2000. The Dictionary
of Human Geography. 4th ed. Oxford: Blackwell Publishers Ltd.
Kawachi, I., B.P. Kennedy, K. Lochner, and D. Prothrow-Sti~. 1997. Social
capital, income inequality, and mortality. American Journal of Public
Health 87 (9): 1491-98.
5: GEOGRAPHY AND DISPARITY IN HEALTH CARE
Kircher, T., J. Nelson, and H. Burdo. 1985. The autopsy as a measure of
accuracy of the death certificate. NEngl JMed 313 (20~: 1263-69.
Konrad, T.R., R. Slifkin, C. Stevens, and J. Miller. 2000. Using the AMA
Physician Masterfile to measure physician supply in small towns.
Journal of Rural Health 16 (2~: 162-67.
Kresiberg, H.M., J. Wu, E. Hollander, and J. Bow. 1976. Methodological
177
approaches for determining health manpower supply and requirements.
Volume I. Analytical Perspective. In Health Planning Methods and
Technology Series. Rockville, MD: National Health Planning
Information Center.
Krieger, N. 1992. Overcoming the absence of socioeconomic data in medical
records: validation and application of a census-based methodology.
American Journal of Public Health 82 (5~:703-10.
Krieger, N. 2002. Researcher tries to accurately measure socioeconomic
differences and health disparities. Harvard School of Public Health,
January 12, 2001. Available at
www.hsph.harvard.edu/ats/Janl2/janl2_03.html "accessed February 21
2002].
Krieger, N., D.R. Williams, and N.E. Moss. 1997. Measuring social class in
U.S. public health research: concepts, methodologies and guidelines.
Annual Review of Public Health 18:342-78.
Kwok, R.K., and B. C. Yankaskas. 2001. The use of census data for
determining race and education as SES indicators: a validation study.
Annals of Epidemiology 11 (3~: 171-77.
Lamphere, J., N. Brangan, S. Bee, and K. Griffin. 1999. Reforming the Health
Care System: State Profiles 1999. Washington, DC: AARP Public Policy
Institute.
Liska, D.W., N.J. Brennan, and B.K. Bruen. 1998. State-Level Databook on
Health Care ,4ccess and Financing. Washington, DC: The Urban
Institute Press.
Mays, G P., and P.K. Halverson. 2000. Conceptual and methodological issues
in public health performance measurement: results from a computer-
assisted expert panel process. Journal of Public Health Management and
Practice 6 (5~:59-65.
178 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
Meade, M.S., and R.J. Earickson. 2000. Medical Geography. 2nd ed. New
York: The Guilford Press.
MedPAC. 2001. Report to the Congress: Medicare in Rural America.
Washington, DC: Medicare Payment Advisory Commission.
Mellor, J.M., and J. Milyo. 2001. Re-examining the evidence of an ecological
association between income inequality and health. Journal of Health
Politics, Policy and Law 26 (3~:487-522.
Mohan, J.F. 1998. Explaining geographies of health care: a critique. Health &
Place 4 (2~: 113-24.
Monmonier, M. 1991. How to Lie with Maps. Chicago: University of Chicago
Press.
Morgan, K.O'L., and S. Morgan, eds. 2001. Health Care State Rankings,
2001. Lawrence, KS: Morgan Quitno Press.
Morrisey, M.A. 1993. On defining small areas. Medical Care 31 (5
Suppl):YS89-95.
Morrisey, M.A., F.A. Sloan, and J. Valvona. 1988. Defining geographic
markets for hospital care. Law and Contemporary Problems 51 (2~: 165-
94.
Nelson, H.. 1994. The states that could not wait: lessons for health reform
from Florida, Hawaii, Minnesota, Oregon, and Vermont. In Five States
That Could Not Wait, eds. D. M. Fox and J. K. Iglehart. Cambridge, MA:
Milbank Memorial Fund.
Norris, T., and M. Pittman. 2000. The healthy communities movement and
the coalition for healthier cities and communities. Public Health Rep 1 15
(2-3~: 118-24.
O'Keeffe, J., K.N. Lohr, and E.R. Brody. 2001. Community Capacity for
Improving Population Health: Feasibility and Design Study. Research
Triangle Park, NC: Research Triangle Institute.
Office of Disease Prevention and Health Promotion. 2002. Healthy People
2010. US Department of Health and Human Services 2001. Available at
http://www.health.gov/healthypeople/document/HTML/Volume2/23PHI.
htm [accessed February 21 2002~.
5: GEOGRAPHY AND DISPARITY IN HEALTH CARE
179
Osterweis, M., C.J. McLaughlin, H.R. Manasse, and C.L. Hopper. 1996. The
U.S. Health Wor~orce: Power, Politics and Policy. Washington, DC:
Association of Academic Heals Centers.
Pew Charitable Trusts. 1997. Trust and Citizen Engagement in Metropolitan
Philadelphia: A Case Study. Philadelphia: Pew Research Center for the
People & The Press.
Pickle, L. Williams, M. Mungiole, G.K. Jones, and A.A. White. 1996. Atlas
of United States Mortality. Hyattsville, MD: U.S. Department of Health
and Human Services.
Ricketts, T.C. 2002. Toward a new designation of underservice: final report
of proposed method, analysis of effects and commentary on related areas.
Chapel Hill, NC: Cecil G. Sheps Center for Heals Services Research,
University of Norm Carolina at Chapel Hill.
. 2001. Community Capacity to Improve Population Health: Defining
Community. Research Triangle Park: Research Triangle Institute.
Ricketts, T.C., L.G. Hart, and M. Pirani. 2000. How many rural physicians
are there? Journal of Rural Health 16 (3~: 198-207.
Rushton, G., G. Elmes, and R. McMaster. 2000. Considerations for
improving geographic information research in public health. URISA
Journal 12 (2~:31-49.
Schur, C.L., and S.J. Franco. 1999. Access to health care. In Rural Health in
the United States, ed. T. C. Ricketts. New York: Oxford University
Press.
Schur, C.L., C.D. Good, and M.L. Berk. 1998. Barriers to Using National
Surveys for Understanding Rural Health Policy Issues. Bethesda, MD:
Project HOPE Walsh Center for Rural Health Analysis.
Siegel, S. 1998. Access to Primary Health Care: Tracking the States.
Washington, DC: National Conference of State Legislatures.
Simpson, K.N., S. DesHamais, A. Jacobs, and A. Menapace. 1994. Methods
for defining medical service areas. In Geographic Methods for Health
Services Research, eds. T. C. Ricketts, L. A. Savitz, W. Gesler and D.
Osborne. Lanham, MD: University Press of America.
180 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
Slifkin, R.T., L.J. Goldsmith, and T.C. Ricketts. 2000. Race and Place:
Urban-Rural Differences in Health for Racial and Ethnic Minorities.
Chapel Hill, NC: Rural Health Research and Policy Analysis Program,
University of North Carolina at Chapel Hill.
Smeloff, E., and B.W. Kelzer. 1981. A geographic framework for
coordination of needs assessment for primary medical care in California.
Public Health Reports 96 (4~:310-14.
Stano, M. 1991. Further issues in small area variations analysis. Journal of
Health Politics, Policy and Law 16 (3~:573-88.
Teachman, J.D., K. Carvers and K. Paasch. 1997. Social capital and the
generation of human capital. Department of Human Development,
Washington State University.
Turnock, B.J. 2001. Public Health: What It Is arid How It Works. 2n~ ed.
Gaithersberg, MD: Aspen Publishers, Inc.
U.S. Bureau of the Census. 2002. Geographic Areas Reference Manual
[Accessed March 20,20023. Available from
http://www.census.gov: 80/geo/www/garm.html.
UnitedHealth Group. 2000. The UnitedHealth Group State Health Rankings,
2000 Edition. St. Paul, MN: UnitedHealth Group.
Weiss, J.E., and M.B. Greenlick. 1970. Determinants of medical care
utilization: the effects of social class and distance on contacts with the
medical care system. Medical Care 8 (6~:456-62.
Weissbourd, B. 2000. Supportive communities for children and familes.
Public Health Reports 1 15 (2~: 167-73.
Williams, P.T., M. Whitcomb, and J. Kessler. 1996. Quality of the family
physician component of AMA Masterfile. Journal of Am Board of Fam
Pract 9 (2~:94-99.
