Guidance for the National Healthcare Disparities Report (2002) / Chapter Skim
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5 Geography and Disparities in Health Care
5 Geography and Disparities in Health Care
Pages 149-180
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From page 149... ...
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.
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From page 150... ...
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~.
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From page 151... ...
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.
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From page 152... ...
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)
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From page 153... ...
In 2001 the National Center for Health Statistics (NCHS) included a rural-urban comparison in its Healthy People series.
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From page 154... ...
· 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.
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From page 155... ...
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~.
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From page 156... ...
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~.
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From page 157... ...
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.
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From page 158... ...
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.
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From page 159... ...
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.
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From page 160... ...
23~. The relationship between socioeconomic characteristics and health in small areas has been described and validated in multiple studies at the census block group, census tract, and ZIP code levels
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From page 161... ...
They suggest that the validity of the construction of household networks can be determined by testing the hypothesis that there is greater similarity of health and disease episodes and behaviors within distinct social networks than between them. Social networks and social support are understood to be important in determining health status (Weissbourd, 2000~.
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From page 162... ...
These proxy measures then become community indicators rather than measures of individual family unit cohesion and are reflected in the extant measure of social capital. It might be, however, that there are strong ties within families, but weak connections to other families.
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From page 163... ...
Fifteen states have centralized systems with control over local health units exercised by a state health agency, and remaining states have some form of mixed or shared control. The population coverage for local health departments may be very small and local: one quarter of health departments are responsible for 14,000 people or less.
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From page 164... ...
Hospital Service Areas The determination of medical service areas became an important part of health policy considerations in the l980s due to the attention paid to legal and economic issues surrounding competition (Morrisey et al., 1988; Morrisey, 1993~. Geographic methods for health care service area construction were the subject of a comprehensive review in the context of geography (Simpson et al., 1 994~.
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From page 165... ...
Crossing those boundaries runs counter to the mutually exclusive nature of local government and its operations. The use of patient origins to create service boundaries usually aggregates smaller geographic units such as ZIP codes or census tracts into areas using an inclusion rule based on proportion of total hospital admissions or hospitalizations from the small area.
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From page 166... ...
Neighborhoods (used 28,381 Block Groups only in 1980) ZIP Codes 39,850 Tabulated Parts ZIP Code Tabulation 40,000 Blocks Zones (ZCTAs)
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From page 167... ...
Using that crosswalk, the census reports data at the ZIP code level on "Summary Tape File-3" (STF-3~. The ZIP codes included on that file are modified in that they are the ZIP codes that have some boundary characteristics.
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From page 168... ...
2 and ZIP code clusters. 2 LMAs are formally described using county-level data and are based on a clustering algorithm that makes use of county-to-county commuting flows that are part of the census data collection process.
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From page 169... ...
The geographic unit of analysis is often key to the ability of a measure to be sensitive to the underlying construct or local characteristic that is being measured. In a review of studies of geographic access to health care in rural areas, Connor and colleagues described studies that used "town/community/ZIP code areas," counties, "market share defined areas," and "other areas," which were usually aggregates of ZIP codes or clusters of counties (Conner et al., 1994~.
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From page 170... ...
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.
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From page 171... ...
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)
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From page 172... ...
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.
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From page 173... ...
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.
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From page 174... ...
Medical Care Research arid Review 56 (41:395-414. Cherkin, D., and D
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From page 175... ...
1998. An exploration of social capital, giving, and volunteering at the United States county level.
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1997. How to build strong home towns.
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From page 177... ...
2002. Researcher tries to accurately measure socioeconomic differences and health disparities.
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From page 178... ...
2001. Community Capacity for Improving Population Health: Feasibility and Design Study.
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From page 179... ...
2001. Community Capacity to Improve Population Health: Defining Community.
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From page 180... ...
1997. Social capital and the generation of human capital.
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