Community Health Needs Analysis & Assessment Prepared for The Center for Health Affairs 1226 Huron Road East Cleveland, Ohio 44115 by 1226 Huron Road, Suite 300 Cleveland, Ohio 44115 (216) 781-2944 Fax: (216) 781-2988 www.communitysolutions.com December 31, 2007 Page 1 of 407
TABLE OF CONTENTS Introduction... 3 Demographic and Socioeconomic Profile... 10 Access to Health Care... 51 Health Status and Conditions... 113 Health Care Utilization... 194 Maternal and Infant Health... 249 Mortality... 287 Health Risk and Prevention Factors... 329 Calls for Health-Related Services... 379 Data tables appear at the end of each chapter. ACKNOWLEDGEMENTS The following staff members of The Center for Community Solutions contributed to the completion of the project. Mark Salling, Ph.D., Williamson Fellow for Applied Research and Director of the Northern Ohio Data & Information Service (NODIS) at the Maxine Goodman Levin College of Urban Affairs, Cleveland State University Joseph G. Ahern, Policy and Planning Associate Terese J. Lenahan, Policy and Planning Associate Richard A. Marountas, Director, Special Projects George D. Weiner, Ph.D., former William and Elizabeth Treuhaft Chair for Health Planning and Research at Community Solutions; former Executive-in-Residence, Maxine Goodman Levin College of Urban Affairs, and former director, Center for Health Equity at Cleveland State University Roslyn L. Bucy Miller, Director, Development and Community Affairs In addition, technical data assistance was provided by the following staff at the Northern Ohio Data & Information Service (NODIS) in the Maxine Goodman Levin College of Urban Affairs at Cleveland State University: Sharon Bliss, Community Information Specialist/Information Coordinator Ellen Cyran, Senior Programmer/Analyst Norm Friedman, Norm Friedman Communications, provided editorial assistance. Page 2 of 407
Community Health Needs Analysis & Assessment December 31, 2007 INTRODUCTION Purpose The Center for Community Solutions 1 (CCS) has prepared this analysis of health conditions in the region that is served by the member hospitals of the Center for Health Affairs 2 (CHA). The report provides statistical information and a descriptive analysis and assessment of health conditions and issues in Northeast Ohio. It documents and illuminates the range of health issues, problems, resources, and needs of the community and is intended to assist CHA, its member hospitals, and others involved in regional health care issues to better identify significant health needs and to marshal relevant resources conducive to improving the quality of life in the community. Although the report has been prepared with funding support from the CHA, the data and analyses are intended for use by the region s broader public health community. Furthermore, it is hoped that the report as a snapshot of current and recent conditions will be used as a base-line set of information that will lead to policies, actions, and future assessments of progress. The assessment has three purposes: to describe the state of health of the region s population, including access to and utilization of resources; to promote identification of major factors contributing to poor health; and to facilitate the identification of actions needed to address these issues. An individual s health is mainly affected by the following: the physical environment in which one lives, such as the quality of the air and water; the social and economic environment, because income and racial and ethnicity disparities can affect access to care, quality of care, risk behaviors, and risk factors; behavior and lifestyle factors, such as smoking, drinking,drug use, and obesity; and family genetics and individual biology. This report does not address factors associated with family genetics, and, regrettably, only one environmental factor is included (ozone action alert days). But the report does include data and analyses on a wide assortment of important indicators of the health of the region s population, including those in the list of the Healthy People 2010 Leading Indicators published by the U.S. Department of Health and Human Services. 3 1 The Center for Community Solutions is a community-based planning and research agency serving Greater Cleveland and the state of Ohio. It is a private, non-profit [501 C (3)] organization. Community Solutions helps policymakers, community leaders, and service providers identify the health, social, and economic challenges facing Greater Cleveland and target resources for sound, costeffective solutions. See http://www.communitysolutions.com. 2 The Center for Health Affairs is an association for health care and hospitals that provides leadership in health care advocacy. See http://www.chanet.org. 3 Healthy People 2010 was developed by the Healthy People Consortium an alliance of more than 350 national membership organizations and 250 state health, mental health, substance abuse, and environmental agencies. See http://www.healthypeople.gov/. Page 3 of 407
The Healthy People 2010 Leading Indicators are: * Physical Activity * Overweight and Obesity * Tobacco Use * Substance Abuse * Responsible Sexual Behavior * Mental Health * Injury and Violence * Environmental Quality * Immunization * Access to Health Care The indicators in this report are organized into chapters as described below (and shown in Table I-1). Demographic/Socio-Economic Profile. Knowing basic demographic and socio-economic information about the population is vital to knowing what specific services the region and its communities need and helping public health agencies and service providers more efficiently and effectively plan for and deliver services. Access to Health Care. Access to health care is both an economic and geographic issue. The indicators presented here are vital to understanding the availability of health care services to the region s population. Health Status and Conditions What are the significant health conditions of the region s population? These indicators help provide a basic knowledge of the overall health of the population and allow public health agencies and service providers to better understand the range of services needed. Health Care Utilization. Understanding how health care resources are utilized, combined with an understanding of access to those resources, can foster better planning and delivery of health care to the region. Maternal and Infant Health. Adequately addressing the needs of mothers and their infants will contribute to better health outcomes for the population now and in succeeding years because poor maternal and infant health are frequently associated with poorer health (as well as socio-economic) outcomes that continue into later life. Mothers and their infants are also among the more vulnerable in regard to health conditions. Mortality. Clearly, mortality rates by cause of death are indicators of some of the most serious health conditions and issues faced by the population. Health Risk/Prevention Factors. The health of the region s population is highly dependent on behaviors and factors that increase the risk for disease and other health problems. Calls for Health-Related Services. An important and insightful measure of the health of the region s population is provided by the calls to the local 211 agency. Data Sources The report includes data and descriptive analysis that, wherever possible, compare the region to the nation and/or state. Data sources include the following: Page 4 of 407
1. Census data provide a variety of demographic (e.g., age, sex, race, ethnicity, and household and family composition), socio-economic (e.g., poverty), and health (e.g., disabilities) factors. 2. Birth and death records provide many indicators on maternal and infant health (e.g., teen birth rate, pre-natal care, low birth weight, and tobacco usage), causes of mortality (e.g., cancer, heart disease, stroke, suicide), and years of life lost. 3. Data on patient admissions from the Ohio Hospital Association (OHA) provide specific information about diagnosed health conditions. The OHA data provide patient demographics, diagnoses, admission source, payer, outcome, etc. 4. The Ohio Family Health Survey (OFHS) of 2003-2004 and the Cuyahoga Family Health Survey (CFHS) of 2001 provide information about access to care and perceived health conditions of the population. OFHS and CFHS data include estimates of health insurance coverage, health status, and health care access and use, including usual source of health care, problems obtaining health care, hospital emergency room use, medical visits, dental care, and quality of care. The data permit county-level analysis for the whole region (and comparison with the state) and city-level analysis for Cleveland, Akron, and Lorain/Elyria. 5. The 211 First Call for Help (211-FCFH) provides data on calls for various types of service and thereby indicates relative need in the community. The data are limited to Cuyahoga County and some adjacent communities. 6. Mental health data from county mental health boards are also presented. How the Indicators Can be Used This report does not provide recommendations; it provides comprehensive information to be used to help set priorities for action and to ensure that scarce resources are allocated most effectively and efficiently. The analysis can help address some of the following questions: How many people are affected by a particular problem? What is the information telling you about equity? What is the impact on people s lives quality of life and years of potential life? Are there appropriate and effective interventions? Are the services adequate? Is there duplication in terms of treatment, prevention, or services for a particular age or disease? Does the health need coincide with national priorities is the local problem being addressed as part of a national strategy? Page 5 of 407
Table I-1: Chapters and Indicators Chapter Demographic/ Socio-economic Profile Access to Health Care Health Status and Conditions continued on next page Indicator Total population Age distribution Female-Headed Families w Children Number of Older Persons (65+) Number of Very Old (85+) Educational Attainment Ages 25+ Median Household Income Persons below Poverty Persons near poverty Adults without Health Insurance Children without Health Insurance Medicaid enrollment (incl SCHIP) Medicare enrollment Adults without Medical Home Children without Medical Home ER use - Adults and Children Unmet Health Care Needs - Adults and Children Health professional shortage areas Nursing Home Residential Home beds Health Status - Adults and Children Adults and Children with Chronic Conditions Persons with Disabilities by Age Adults and Children Requiring Assistance Adults with High Blood Pressure Adults with Heart or Circulatory Disease Adults with Diabetes Children with Asthma Persons with HIV/AIDS Syphilis Gonorrhea Chlamydia Child Maltreatment Percent of clients in community mental health system who are seriously mentally disabled or emotionally disturbed Patient Discharges by Major Diagnostic Category Page 6 of 407
Table I-1 continued Chapter Indicator Health Care Utilization Medical Visits - Adults Medical Visits - Children Multiple ER Visits - Adults Multiple ER Visits - Children Hospitalizations - Adults Hospitalizations - Children Dental Visits - Adults Dental Visits - Children Satisfaction with Health Care - Adults Satisfaction with Health Care - Children Insurance Utilization Admissions by Source/Type Utilization by Age Group Maternal and Infant Health Births to Unmarried Women Births to Teens 10-14, 15-17 Fertility Rates Maternal Smoking Late or No Prenatal Care Inadequate Prenatal Care Premature Births Low Birth Weight Infant Mortality Mortality Deaths from Suicide by Age Deaths from Accidents by Age Deaths from All Causes Deaths from Heart Disease Deaths from Coronary Heart Disease Deaths from Cancer Deaths from Lung Cancer Deaths from Stroke Deaths from COPD Years of Potential Life Lost Deaths from Motor Vehicle crashes Deaths from Homicides Health Risk / Prevention Factors Adult Smoking Adult Exercise Adult Overweight & Obesity Adolescent Overweight Teen Tobacco Use Teen Alcohol Use Teen Drug Use Teen Sexual Behavior Adolescent Exercise Children with Elevated Blood Lead Levels Adult binge drinking Adults 65+ with flu, pneumonia vaccines Childhood immunizations Ozone action days Calls for Health-Related Services Calls for health-related services Delineation of the Study Area We use data from the Ohio Hospital Association on service shares of members of the Center for Health Affairs (CHA) to delineate the Northeast Ohio Community Health Assessment study area. Hospital patient distribution and patient shares give us information about service areas and types of patients seen at area hospitals. The Ohio Hospital Association patient databases include the patient ZIP code of residence for all discharges from Ohio hospitals. For this analysis, we defined primary and secondary counties for our study based on CHA member hospitals total patient share (see Map I-1). These areas, which include urban, suburban, and rural counties, account for 29 percent of Ohio s population. In 2005, CHA member hospital discharges (hereafter described as CHA patients ) constituted 23 percent of 1.57 million discharges in Ohio. Page 7 of 407
Ninety percent of CHA s 357,230 patients came from the six primary counties and another 7 percent came from seven adjacent secondary counties (the patient distribution). CHA hospitals received 95 percent of all Ohio hospital patient discharges from these primary counties and 14 percent of those from the secondary counties (patient shares). CHA received a wide range of patient shares from the primary counties, from 97 percent in Cuyahoga County to 76 percent in Medina County. In the secondary counties, the CHA patient share ranged from 27 percent in Erie County to 9 percent in Trumbull County. By dividing the primary and secondary counties into urban, suburban, and rural county types, we ascertain that CHA received 90 percent of the suburban patient shares, 78 percent of the urban patient shares, and 26 percent of the rural patient shares. CHA received 1 percent of the patient share in the remaining 75 Ohio counties and, in all of Ohio, 23 percent. For patients living in Pennsylvania, nearly half of their 3,827 discharges from Ohio hospitals were from CHA hospitals. A Note on Confidence in Survey Data Used in This Report (specifically, the Ohio Family Health Survey) Because the data are derived from a sample and not from the whole population, each estimate has an associated margin of error, which yields a confidence interval. These intervals indicate the range within which we are 90 percent certain the true value of the characteristic lies. When comparing the ward to the city and the county, or comparing the city or county estimates for different years, the differences are said to be statistically significant only if the confidence intervals do not overlap. Statistical significance, or the lack thereof, is greatly dependent on sample size and the level of certainty desired. Where the sample size is relatively small, the confidence intervals are wider than when the sample size is larger. In addition, confidence intervals with a high level of certainty, as we use here at 90 percent, are wider than intervals with a lower level of certainty. With a small sample size and a high level of certainty, statistical significance is difficult to achieve. We indicate in the discussion which differences are statistically significant. In the charts, we show confidence intervals by an I-beam at the end of each data bar so it is easy to see whether the intervals do or do not overlap. However, while many differences discussed below are not statistically significant due to small sample sizes and/or 90-percent certainty, we believe, nevertheless, that in many cases they may still be meaningful in indicating the relative size of a given characteristic for different geographic areas and different years. Such apparent non-significant differences are noted, but we advise readers to come to their own conclusions about their validity. Page 8 of 407
Map I-1 Study Area Page 9 of 407