BARNES-JEWISH HOSPITAL 2016 COMMUNITY HEALTH NEEDS ASSESSMENT & IMPLEMENTATION PLAN 1
TABLE OF CONTENTS Executive Summary... 3 Community Description... 4 Geography... 4 Population Trends... 5 Income... 7 Education... 10 Previous CHNA Measurement and Outcomes Results... 16 Conducting the 2016 CHNA... 18 Primary Data Collection... 18 Secondary Data Analyses... 21 Internal Work Group Prioritization Meetings... 74 Appendices... 82 Barnes-Jewish Hospital: Who We Are... 83 Community Focus Group... 84 Focus Group Report... 85 Internal Work Group... 94 Internal Work Group Worksheet 1... 95 Internal Work Group Worksheet 2... 96 Internal Work Group Worksheet 3... 97 Implementation Plan... 98 Community Health Needs to be Addressed... 98 Community Health Needs Identified that will not be addressed... 104 2
EXECUTIVE SUMMARY Barnes-Jewish Hospital, a member of BJC HealthCare, is a 1,315-bed, academic medical center located in the city of St. Louis,. Situated on Washington University Medical Campus, Barnes-Jewish Hospital provides inpatient, outpatient, emergency/trauma and ambulatory clinic services. Barnes-Jewish Hospital was created by the 1996 merger of Barnes Hospital and The Jewish Hospital of St. Louis. What began more than 100 years ago as two separate hospitals has evolved into a nationally recognized medical center delivering high quality health care services to patients across the St. Louis region. Barnes- Jewish Hospital has also established effective partnerships towards the goals of improving the health of the community. (See Appendix A for more information about Barnes-Jewish Hospital) Like all nonprofit hospitals, Barnes-Jewish Hospital is required by the Patient Protection and Affordable Care Act (PPACA) to conduct a community health needs assessment (CHNA) and create an implementation plan every three years. Barnes-Jewish Hospital completed its first CHNA and implementation plan on Dec. 31, 2013. The report was posted to the hospital s website to ensure easy access to the public. As part of the CHNA process, each hospital is required to define its community. Barnes-Jewish Hospital defined its community as St. Louis City. Once the community is defined, input must be solicited from those who represent the broad interests of the community served by the hospital, as well as those who have special knowledge and expertise in the area of public health. Barnes-Jewish Hospital conducted its 2016 assessment in two phases. The first phase consisted of a focus group discussion with key leaders and stakeholders representing the community. This group reviewed the primary data and community health need findings from 2013 and discussed changes that had occurred since 2013. Additionally, the focus group reviewed gaps in meeting needs, as well as identified potential community organizations for Barnes-Jewish Hospital to collaborate with in addressing needs. During phase two, findings from the focus group meeting were reviewed and analyzed by a hospital internal work group of clinical and non-clinical staff. Using multiple sources, including but not limited to Healthy Communities Institute and the Centers for Disease Control and Prevention (CDC), a secondary data analysis was conducted to further assess the identified needs. This data analysis identified some unique health disparities and trends evident in St. Louis City when compared against data for the state and country. At the conclusion of the comprehensive assessment process, Barnes-Jewish Hospital identified four health needs where focus is most needed to improve the health of the community it serves: 1) Access to Services; 2) Healthy Lifestyles: Obesity; 3) Mental and Behavioral Health: Substance Abuse; and 4) Public Safety: Violence. The analysis and conclusions were presented, reviewed and approved by the Barnes-Jewish Hospital board of directors. 3
COMMUNITY DESCRIPTION GEOGRAPHY Barnes-Jewish Hospital is the largest of the 15 BJC HealthCare hospitals that comprise the system. BJC HealthCare hospitals serve urban, suburban and rural community locations primarily in the greater St. Louis, southern Illinois and mid- regions. Barnes-Jewish Hospital and St. Louis Children s Hospital are the two BJC HealthCare hospitals located in St. Louis City. Barnes-Jewish Hospital is the largest hospital in. Seventy-five percent of the hospital s patients come from the hospital s primary service area, including eight counties in and eight counties in Illinois. The remaining 25 percent of patients come from the surrounding 250 miles of St. Louis. As the major safety net provider, Barnes-Jewish Hospital serves a larger community; however, for the purpose of the CHNA, Barnes-Jewish Hospital defined its community as St. Louis City. The shaded area in the map below represents St. Louis City. This area includes the following ZIP codes: 63101 63102 63103 63104 63106 63107 63108 63109 63110 63111 63112 63113 63115 63116 63118 63120 63139 63147 63164 63166 63196 63199 4
POPULATION TREND Population and demographic data is necessary to understand the health of the community and plan for future needs. In 2015, St. Louis City reported a total population estimate of 315,685 compared to the state population of 6,083,672. St. Louis City comprised five percent of s total population. Since the 2010 census, the population of the city declined 1.2 percent while the state population increased 1.6 percent. Table 1: Population Trend, St. Louis City vs. St. Louis City Total Population: 315,685 6,083,672 Percent Number Percent Number Female 51.70 163,209 50.9 3,096,590 Male 48.30 152,476 49.1 2,987,082 White 46.60 149,224 83.50 5,079,866 African American 47.27 147,109 1.8 717,873 Hispanic or Latino 3.93 12,406 4.0 243,347 Two or More Races 2.28 7,198 2.1 127,757 Asian 3.01 9,502 1.9 115,590 The table on the following page further details the city s demographics as compared to the state. 5
Table 2: Demographics, St. Louis City vs. St. Louis City Geography Land area in square miles, 2010 61.91 68,741.52 Persons per square miles, 2010 5,157.50 87.1 Population Population, July 1, 2015 estimate 315,685 6,083,672 Population, April 1, 2010 estimate base 319,365 5,988,923 Population, percent change April 1, 2010 to July 1, 2015-1.2% 1.6% Population, 2010 317,294 5,988,927 Race / Ethnicity White alone, percent, 2015 47.1% 83.3% Black or African American alone, percent, 2015 46.9% 11.8% American Indian and Alaska Native alone, percent, 2015 0.3% 0.6% Asian alone, percent, 2015 3.3% 2.0% Native Hawaiian and Other Pacific Islander alone, percent 2015 0.0% 0.1% Two or more races, percent, 2015 2.4% 2.2% Hispanic or Latino, percent, 2015 3.9% 4.1% White alone, not Hispanic or Latino, percent, 2015 44.0% 79.8% Foreign born persons, percent, 2010-2014 6.8% 3.9% Age Persons under 5 years, percent, 2015 6.7% 6.2% Persons under 18 years, percent, 2015 20.1% 22.9% Persons 65 years and over, percent, 2015 11.6% 15.7% Language Language other than English spoken at home, percent of age 5 years+, 2015 9.6% 6.1% Gender Female persons, percent, 2015 51.6% 51.0% Male persons, percent, 2015 48.4% 49.0% Source: United States Census Bureau 6
INCOME St. Louis City s median household income for the five-year period ending 2014 was 27 percent lower than the state overall. Persons living below the poverty level in St. Louis City totaled 28.8 percent compared to 15.5 percent in the state. Home ownership was higher in St. Louis City (70.8 percent) than (67.9 percent). Table 3: Education, Income & Housing, St. Louis City vs. St. Louis City Education High school graduate or higher, percent of persons age 25+, 2010-2014 Bachelor s degree or higher, percent of persons age 25+, 2010-2014 83.2% 88.0% 30.4% 26.7% Income Per capita money income in the past 12 months (2011 dollars), 2010-2014 $23,244 $26,006 Median household income (2014 dollars), 2010-2014 $34,800 $47,764 Persons in poverty, percent, 2010-2014 28.8% 15.5% Housing Housing units, July 1, 2014 175,355 2,735,742 Home ownership rate, 2010-2014 70.8% 67.9% Housing units in multi-unit structures, percent, 2010-2014 22.7% 19.7% Median value of owner-occupied housing units, 2010-2014 118,600 136,700 Households, 2010-2014 139,594 2,361,232 Persons per household, 2010-2014 2.2 2.48 Source: United States Census Bureau 7
RACE / ETHNICITY Chart 1: St. Louis City Families Living Below Poverty Level by Race / Ethnicity, 2010-2014 AMERICAN INDIAN OR ALASKA NATIVE 5.6 ASIAN 14.4 AFRICAN AMERICAN 34.4 HISPANIC OR LATINO 23.1 OTHER 25.6 TWO OR MORE RACES 25 WHITE, NON-HISPANIC 8.6 OVERALL 22 0 5 10 15 20 25 30 35 40 PERCENT Source: Healthy Communities Institute The rate of families living below the poverty level in St. Louis City was 22.0 percent. The rate of African American families living below the poverty level in the city was higher than any other race at 34.4 percent. 8
AGE Chart 2: People Living Below Poverty Level by Age, 2010-2014 UNDER 6 YEAR 25.6 42 6-11 YEAR 21.5 46.9 12-17 YEAR 17.6 37.1 18-24 YEAR 27.4 39.2 25-44 YEAR 14.8 22.7 45-54 YEAR 10.9 22.5 65-74 YEAR 7.7 16.6 75 & OVER 10.6 18.4 OVERALL 15.6 27.8 0 5 10 15 20 25 30 35 40 45 50 PERCENT St. Louis City Source: Healthy Communities Institute The overall rate of people living in poverty in St. Louis City was 27.8 percent, 78 percent higher than in the state. The 6-11 age group had the highest rate of poverty in the city followed by the under 6 age group. 9
PERCENT EDUCATION Chart 3: People 25+ with a High School Degree or Higher by Age, 2010-2014 100 90 80 90.3 89.2 90.2 89.9 84.4 84.1 80.8 88 83.2 70 69.9 60 50 40 30 20 10 0 25-34 35-44 45-64 65 & OVER OVERALL AGE St. Louis City Source: Healthy Communities Institute In St. Louis City, 83.2 percent of the population 25 and older had a high school diploma compared to at 88 percent. The Healthy People 2020 national health target is to increase the proportion of students who graduate high school within four years of their first enrollment in 9th grade to 82.4 percent. Individuals who do not finish high school are more likely than people who finish high school to lack the basic skills required to function in an increasingly complicated job market and society. Adults with limited education levels are more likely to be unemployed, on government assistance, or involved in crime. (Healthy Communities Institute). 10
RACE / ETHNICITY Chart 4: People 25+ with a High School Degree or Higher by Race / Ethnicity, 2010-2014 AMERICAN INDIAN OR ALASKA NATIVE 85.2 84 ASIAN 77.3 86.2 AFRICAN AMERICAN 77.1 83.1 HISPANIC OR LATINO 70.1 68.5 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER OTHER TWO OR MORE RACES WHITE, NON-HISPANIC OVERALL 59.1 60.8 65.4 87.9 78.7 83.6 90 89.4 83.2 88 0 10 20 30 40 50 60 70 80 90 100 PERCENT St. Louis City Source: Healthy Communities Institute Whites had the highest rate of individuals with a high school degree or higher in St. Louis City, followed by American Indian or Alaska Native. Those who identify as Other had the lowest rate of individuals with a high school degree or higher followed by Native Hawaiian or Other Pacific Islander. In, Whites also had the highest rate of individuals with a high school degree or higher, followed by Native Hawaiian or Other Pacific Islander. Those who identify as Other had the lowest rate of individuals with a high school degree or higher followed by Hispanics. 11
PERCENT Chart 5: People 25+ with a High School Degree or Higher by Gender, 2010-2014 100 90 80 70 60 50 40 30 20 10 0 88.4 87.6 88 83.1 83.4 83.2 FEMALE MALE OVERALL GENDER St. Louis City Source: Healthy Communities Institute St. Louis City had a 5.5 percent lower rate of individuals with a high school degree or higher than. Rates among females and males in St. Louis City and the state were similar. 12
PERCENT Chart 6: People 25+ with a Bachelor s Degree or Higher by Age, 2010-2014 50 45 44.6 40 35 30 25 31.7 32.2 31.3 26.3 24.1 26.7 30.4 20 18.9 18.5 15 10 5 0 25-34 35-44 45-64 65 & OVER OVERALL AGE St. Louis City Source: Healthy Communities Institute In St. Louis City, 30.4 percent of the population 25 and older had a bachelor s degree when compared to at 26.7 percent. For many, having a bachelor's degree is the key to a better life. The college experience develops cognitive skills, and allows learning about a wide range of subjects, people, cultures, and communities. Having a degree also opens up career opportunities in a variety of fields, and is often the prerequisite to a higher-paying job. It is estimated that college graduates earn about $1 million more per lifetime than their non-graduate peers. (Healthy Communities Institute). 13
RACE / ETHNICITY Chart 7: People 25+ with a Bachelor s Degree or Higher by Race / Ethnicity, 2010-2014 AMERICAN INDIAN OR ALASKA NATIVE 20.3 17.5 ASIAN 54.3 56.3 AFRICAN AMERICAN HISPANIC OR LATINO 12.9 16.8 18.2 28.4 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 11.6 16.7 OTHER TWO OR MORE RACES 12.5 24.5 25.2 22.4 WHITE, NON-HISPANIC OVERALL 27.7 30.4 26.7 45 0 10 20 30 40 50 60 PERCENT St. Louis City Source: Healthy Communities Institute Asians had the highest rate of individuals with a bachelor s degree or higher both in St. Louis City and. African Americans had the lowest rate in St. Louis City and Native Hawaiian or Other Pacific Islander had the lowest rate in. 14
PERCENT Chart 8: People 25+ with a Bachelor s Degree or Higher by Gender, 2010-2014 35 30 25 20 15 10 5 30.2 30.6 30.4 26.9 26.4 26.7 0 FEMALE MALE OVERALL GENDER St. Louis City Source: Healthy Communities Institute St. Louis City had 13.9 percent higher rate of individuals with a bachelor s degree than the state. The rates among females and males in St. Louis City and were similar. 15
PREVIOUS (2013) CHNA MEASUREMENT AND OUTCOMES RESULTS At the completion of the 2013 CHNA, Barnes-Jewish Hospital outlined goals for meeting eight broad categories of health needs in St. Louis City. Mission-core priorities were identified as aligning with the strategic priorities of the hospital in order to ensure dedicated resources. These included Health Literacy and Education and Chronic Conditions. The additional needs were included as supporting priorities: Access to Health Care; Behavioral Health; Financial Barriers; Safety from Violence; Lack of Service Coordination; and Training of Health Care Professionals. Rather than choosing one program on which to focus for each of the priorities in the implementation plan, Barnes-Jewish Hospital included all programs that were being conducted under each category. This was done with the hopes of highlighting all the work being done for the community, even though it was not necessary to do so. Due to the length of the listing of programs, the table below includes a selection of major programs under mission-core priorities that outlines the details results, goals and current status of these community health needs. Table 4A: 2013 CHNA Outcomes, Barnes-Jewish Hospital Health Literacy & Education Goals Provide health education and free screenings to 4,000 community members. Results of program impact evaluation will average a score of 4 on a scale of 1-5 Current Status 2014: 5,644 community members attended health education and screening events. The average impact score for these events was 4.25 out of 5. 2015: 7,870 community members attended health education and screening events. The average impact score for these events was 4.42 out of 5. Chronic Conditions Goals Provide free flu shots to a minimum of 30,000 individuals in the broader Barnes-Jewish Hospital community. Reserve a minimum of 15 percent of free flu shots to be provided in key underserved regions as identified by the CHNA. Current Status 2014: 24,415 free flu shots were administered to members of the community. Of the 22,954 participants who provided ZIP codes, 5,576 (24 percent) were from St. Louis City and another 2,968 (13 percent) were from underserved areas in north St. Louis County as defined by the Christian Hospital CHNA. 2015: The number of shots available to give to the community was reduced because it was determined that Barnes-Jewish Hospital would provide the best vaccine available. The hospital offered quadrivalent doses instead of trivalent doses at an approximate 50 percent cost increase. 19,236 free flu shots were administered to members of the community. Of the 18,904 participants who provided ZIP codes, 4,968 (26 percent) were from St. Louis City and another 2,286 (12 percent) were from underserved areas in north St. Louis County as defined by the Christian Hospital CHNA. 16
Table 4B: 2013 CHNA Outcomes, OASIS Chronic Disease & Diabetes Self-Management Goals Increase enrollment in self-management programs by 5% annually. After establishing a baseline, increase knowledge of blood pressure management terms and tools, and positive medication management behaviors by 5%. Current Status 2014: Participation in OASIS self-management programs was inflated due to participation in a research study. 2015: Participation decreased by 41% from 2014 due to the previously inflated participation rates. In 2015, efforts to recruit participants was more evenly distributed among health programs. Physical Activity and Functional Fitness Goals Increase physical activity participation and functional fitness in adults ages 60 and older by 10% annually. At least 50% of participants will see improvement in strength, flexibility, and balance and agility, as measured by the Senior Fitness Test (SFT). Current Status 2015: 1859 participants was 20% increase from 2014. 68% of participants improved aerobic endurance; 61% of participants improved agility and balance; 60% of participants improved lower body strength; 50% of participants improved upper body flexibility. Increased knowledge in blood pressure management increased by 19%. Increased knowledge in medication management increased by 24%. For the 2013 CHNA, Barnes-Jewish Hospital chose to address all needs identified by the stakeholders and confirmed by the secondary data. Regrettably, there was a lack of focus on particular areas. The team was not able to show outcomes in all areas selected. Therefore, the team decided to limit priorities and use resources wisely in order to show outcomes in 2016. Barnes-Jewish Hospital will continue with all the programs from the 2013 CHNA and focus the implementation plan on fewer priorities and demonstrate greater impact. 17
CONDUCTING THE 2016 CHNA PRIMARY DATA COLLECTION: FOCUS GROUP Barnes-Jewish Hospital conducted a focus group to solicit feedback from community stakeholders, public health experts and those with a special interest in the health needs of residents located in St. Louis City. Ten of 16 invited participants representing various St. Louis County organizations participated in the focus group (See Appendix B for Community Focus Group list). The focus group was held March 28, 2015, at the Chase Park Plaza Hotel with the following objectives identified: 1. Determine whether the needs identified in the 2013 CHNA remain the correct focus areas. 2. Explore whether any needs on the list should no longer be a priority. 3. Determine where gaps exist in the plan to address the prioritized needs. 4. Identify other potential organizations for collaboration. 5. Discuss how the community had changed since 2013 when Barnes-Jewish Hospital first identified these needs and whether there are new issues to consider. 6. Evaluate what issues the stakeholders anticipate becoming a greater concern in the future to consider now. 2016 FOCUS GROUP SUMMARY A general consensus was reached that needs identified in the previous assessment should remain as focus areas for the hospital. A few participants suggested that mental health and behavioral health should be rated higher in priority due to the effect these concerns have on contributing to violence in the community (See Appendix C for complete Focus Group Report). Needs that Should Be Removed There was discussion about why training of health professionals and service coordination was not present in the revised list of needs. The law now requires that any prioritized need must be measured so as to determine the impact of any implementation tactics. These items were removed because there was a lack of measures associated with them. Stakeholders from the Regional Health Commission indicated that they have some metrics for Barnes-Jewish Hospital to consider around these needs. Gaps in Implementation Strategies Financial access to coverage continues to be an issue for St. Louis City residents who are low-income. There was much discussion around the role that technology could play in improving access to services. Other comments around access to services included care coordination. Discussion also took place regarding increasing health provider awareness of trauma (post-traumatic stress disorder) and how recognition can ultimately impact the treatment of chronic conditions along with behavioral health issues. Special Populations The homeless population was identified as one that may require additional consideration, particularly following discharge, as no appropriate place currently exists. Additionally, several points were made in regard to those who are deaf and blind. Potential Partner Organizations Barnes-Jewish Hospital was positively recognized for its numerous collaborative efforts with a variety of organizations on various levels. The hospital was also noted for its excellent work on emergency preparedness and responsiveness as well as for collaborating with the St. Louis Integrated Health 18
Network on placing referring coordinators in the facility. There was one suggestion to examine the relationships the hospital has with homeless providers in the city to identify additional ways to address the needs of the homeless upon discharge. Needs of Increasing Importance Safety from Violence Although violence was identified in the 2013 CHNA, with the events that occurred in Ferguson in 2014 and 2015, many see violence as an issue that will continue to exist in St. Louis City. Access: Coverage The lack of Medicaid expansion will continue to affect access, as well as disparities in access related to low-income populations. Sexually Transmitted Disease (STD) There continues to be concern about STDs including gonorrhea as well as HIV/AIDs, especially within the African American community. Education is needed on these issues and information should be made available especially at community health fairs. Behavioral Health The spread of heroin and prescription drug abuse is a continued concern. Chronic Conditions Sickle cell anemia continues to be an issue among African Americans. RATING OF NEEDS Participants were given the list of the needs identified in the 2013 assessment and directed to re-rank them on a scale of 1 (low) to 5 (high), based on their perceived level of community concern and the ability of community organizations to address them collaboratively. The table on the following page shows the results of this ranking. Access to Coverage and Access to Services rated highest in terms of level of concern and ability to collaborate. Childbirth and Breastfeeding Education rated lowest on ability to collaborate and the level of concern. 19
Chart 9: Focus Group Ranking of Health Needs Access: Coverage Access: Services Obesity Diabetes Mental Health & Disorders Substance Abuse Cancer: Breast Smoking & Tobacco Education Health Literacy Heart Disease & Stroke: Heart Health Heart Disease & Stroke: Congestive Heart Failure Heart Disease & Stroke: Stroke Cancer: Colon & Rectal Cancer: Prostate Access: Transportation Injury & Violence: Crime Reproductive & Sexual Health Nutrition Cancer: GYN Respiratory Disease: Asthma Cancer: Head & Neck Cancer: Skin Immunizations and Infectious Disease Oral Health Injury & Violence: Fatal Injuries Cancer: Lung Respiratory Disease: COPD Childbirth & Breastfeeding Education 4 4 4 3.8 4 3.3 3.6 5 4.8 5 4.8 4.7 4.8 4.7 4.5 4.7 4.5 4.7 4.5 4.3 4.8 4.5 4.6 4.8 4.2 4.5 4.5 4.5 4.5 4.5 4.5 4.3 4.7 4.5 4.5 4.5 4.3 4.5 4.3 4.2 4.5 4.2 4.5 4.3 4.3 4.2 4.3 4.2 4.2 4.2 4.2 4.3 4.3 4.3 4.3 0 1 2 3 4 5 6 Level of Concern Ability to Collaborate 20
SECONDARY DATA ANALYSES Based on the primary data reviewed by focus group members (see graph on previous page), key areas were identified by the internal workgroup (see internal workgroup process beginning on page 66) for secondary data analysis. These areas represent the most prevailing issues identified by the focus group. DATA SOURCES Healthy Communities Institute (HCI), an online community dashboard of health indicators for St. Louis County as well as the ability to evaluate and track the information against state and national data and Healthy People 2020 goals. This online dashboard of health indicators for St. Louis County evaluates and tracks information against state and national data and Healthy People 2020 goals. Sources of data include the National Cancer Institute, Environmental Protection Agency, US Census Bureau, US Department of Education, and other national, state, and regional sources. Healthy People 2020 provides science-based, 10-year national objectives for improving the health of all Americans. For three decades, Healthy People has established benchmarks and monitored progress over time in order to encourage collaborations across communities and sectors, empower individuals toward making informed health decisions and measure the impact of prevention activities. Hospital Industries Data Institute (HIDI, 2014) is a data source provides insight into the patterns and frequency of health care utilization in the hospital. Information for Community Assessment (MICA) is an online system that helps to prioritize diseases using publicly available data. The system also provides for the subjective input of experts to rank their perceived seriousness of each issue. Centers for Disease Control and Prevention (CDC)/State Cancer Profiles is a web site that provide data, maps, and graphs to help guide and prioritize cancer control activities at the state and local levels. It is a collaboration of the National Cancer Institute and the Centers for Disease Control and Prevention. https://statecancerprofiles.cancer.gov Department of Mental Health provides numerous comprehensive reports and statistics on mental health diseases, alcohol and drug abuse. http://dmh.mo.gov/ada/countylinks/saint_louis_county_link.html In addition to the resources listed above, while not directly cited in this report, Barnes-Jewish Hospital utilized information from the following organizations during internal work group discussions: The Commonwealth Fund County Health Rankings and Roadmaps Kaiser Family Foundation Robert Wood Johnson Foundation 21
HEALTH NEEDS In order to provide a comprehensive analysis of disparities and trends, the most up-to-date secondary data was included on the following needs determined by the internal work group (see internal workgroup process beginning on page 74): Access: Coverage Access: Services Access: Transportation Cancer Diabetes Healthy Lifestyles Heart Health Maternal & Child Health Mental & Behavioral Health: Mental Illness Mental & Behavioral Health: Substance Abuse Public Safety: Violence Reproductive & Sexual Health Respiratory Disease: Asthma We acknowledge that, like most cities, tremendous variation exists in demographic and health characteristics between neighborhoods in the City of St. Louis. Some areas have multiple, high-risk factors clustered together. However, most data is not available at a more granular level than by county. For this reason, the analysis was completed comparing St. Louis City, and the U.S. When necessary during implementation, more specific data will be used when available. Following the secondary data analysis, a summary is provided that outlines observations noted in the disparities and trends for each of the above needs. (See page 73). 22
AGE ACCESS: COVERAGE Individuals without medical insurance are more likely to lack a traditional source of medical care, such as a Primary Care Provider (PCP), and are more likely to skip routine medical care due to costs, therefore, increasing the risk for serious and debilitating health conditions. Those who access health services are often burdened with large medical bills and out-of-pocket expenses. Increasing access to both routine medical care and medical insurance are vital steps in improving the health of the community. (Healthy Communities Institute). Chart 10: Adults with Health Insurance by Age, 2014 18-24 81.7 80.8 25-34 75.6 77.5 35-44 76.1 82.4 45-54 81.7 86.5 55-64 89.2 91.1 OVERALL 80.3 83.9 0 10 20 30 40 50 60 70 80 90 100 PERCENT St. Louis City Source: Healthy Communities Institute The overall rate of adults in St. Louis City with health insurance in 2014 was 80.3 percent, 4.3 percent lower than. Of the total number of insured adults, the 55-64 age group had the most adults with health insurance in St. Louis City; the 18-24 age group and the 45-54 age group had the second highest percentage of insured adults in St. Louis City. The 25-34 age group had the lowest number of insured adults in St. Louis City. The Healthy People 2020 national health target is to increase the proportion of people with health insurance to 100 percent. 23
RACE / ETHNICITY Chart 11: Adults with Health Insurance by Race / Ethnicity, 2014 ASIAN 87 83.2 AFRICAN AMERICAN 71.6 75.3 HISPANIC OR LATINO 69.2 66.9 TWO OR MORE RACES 78 81 WHITE, NON-HISPANIC 89 86 OVERALL 80.3 83.9 0 10 20 30 40 50 60 70 80 90 100 PERCENT St. Louis City Source: Healthy Communities Institute The overall rate of adults with health insurance was higher in the state than in St. Louis City. When comparing the rate by race/ethnicity, the city had higher rates of adults with health insurance than the state except for African Americans and those with two or more races. 24
PERCENT PERCENT Chart 12: Adults with Health Insurance by Gender, 2014 100 80 85.1 82.6 83.9 83.3 77.2 80.3 60 40 20 0 FEMALE MALE OVERALL GENDER St. Louis City Source: Healthy Communities Institute The health insurance rate among females in St. Louis City was lower than, but higher than the rate of males in the city. Males in St. Louis City also had a lower health insurance rate than the state. Chart 13: Adults 18-64 with Health Insurance: Time Series 90 80 70 81.4 80.7 80.9 81.7 74 75.3 76.8 72.6 83.9 80.3 60 50 40 30 20 10 0 2010 2011 2012 2013 2014 St. Louis City Source: Healthy Communities Institute The graph above shows the rate of adults in St. Louis City with health insurance coverage from 2010 until 2014. A decline occurred in the city between 2010 and 2011 followed by an increase from 2012 to 2014. This increase could have resulted from the ACA, which mandates that all residents should be covered under some form of health insurance. The rate in was statistically the same from 2010 to 2013, with an increase noted in 2014. 25
The ability of an individual to access health services has a profound and direct effect on every aspect of health. Beginning in 2010, nearly 1 in 4 Americans lacked a primary care provider or health center to receive ongoing medical services. Table 5: Access to Health Care, St. Louis City vs. Health Indicators St. Louis City Adults with health insurance, percent of age 18-64, 2014 80.3 83.9 Children with health insurance, percent, 2014 93.5 92.8 Primary care providers rate / 100,000, 2013 84 71 Dentist rate / 100,000, 2014 46 54 Mental health providers rate / 100,000, 2015 271 167 Non-physician primary care provider rate / 100,000, 2015 143 66 Preventable hospital stays, discharges / 1,000 enrollees, 2013 57 59 Source: Healthy Communities Institute/County Health Ranking The rate of primary care providers and mental health providers was higher in the city than the rate of providers in the state. Further, the rate of non-physician primary care providers was more than double the rate in the city than in the state. However, the rate of dental providers was lower in the city than the rate of dentists in the state. 26
ACCESS: TRANSPORTATION Owning a car has a direct correlation with the ability to travel. Individuals with no car in the household make fewer than half the number of trips compared to those with a car and have limited access to essential local services such as supermarkets, post offices, doctors' offices and hospitals. Most households with above-average income own a car while only half of low-income households have a car. (Healthy Communities Institute). Table 6: Access: Transportation, St. Louis City vs., 2010-2014 Health Indicators St. Louis City Households without a vehicle, percent 21.9 7.4 Workers commuting by public transportation, percent 9.7 1.5 Mean travel time to work, age 16+ in minutes 23.8 23.1 Source: Healthy Communities Institute St. Louis City had three times the number of households without a vehicle when compared to the state. 27
CASES / 100,000 CASES / 100,000 POPULATION CANCER Cancer is a leading cause of death in the United States, with more than 100 different types of the disease. According to the National Cancer Institute, lung, colon and rectal, breast, pancreatic and prostate cancer lead in the greatest number of annual deaths. Chart 14: Death and Incidence Rates due to Cancer 600 500 400 485.1 454.8 453.8 300 200 220.6 184.1 171.2 100 0 ST. LOUIS CITY MISSOURI U.S. Incidence Rate Death Rate Source: CDC State Cancer Profile Overall, death and incidence rates of cancer in St. Louis City were higher than the respective rates in and in the U.S. Chart 15: Age-Adjusted Incidence Rate Compared to Age-Adjusted Death Rate Due to All Cancer: Time Series 500 400 438.9 435.4 439.8 488.3 490.2 485.1 300 200 221.5 217.4 210.7 231.4 224 220.6 100 0 2003-2007 2004-2008 2005-2009 2006-2010 2007-2011 2008-2012 Incidences Deaths Source: Healthy Communities Institute 28
3.7 2.6 2.3 12.8 11.1 10.9 DEATHS / 100,000 27.2 23.4 19.9 16.8 15.5 21.9 21.4 22.6 28.4 47.2 57 67.1 DEATHS / 100,000 100.6 93.5 106.6 182.2 170.9 203.7 202 184.1 171.2 218.9 220.6 244.7 Between the period ending 2007 and the period ending 2012, the incidence rate from cancer increased 10.5 percent in the city. The highest incidence rate occurred the period ending 2011. The death rate remained relatively flat except for the period ending 2010 when the rate increased to 231.4. Chart 16: Age-Adjusted Death Rate Due to Cancer by Race, 2008-2012 300 250 200 150 100 50 0 WHITE AFRICAN AMERICAN ASIAN PACIFIC ISLANDER OVERALL St. Louis City US Source: CDC State Cancer Profile The overall cancer age-adjusted death rate in St. Louis City was higher than the rate in and in the U.S. Of the overall rate, African Americans had the highest rate of cancer in the city, state and in the country. Chart 17: Age-Adjusted Death Rate by Cancer Type, 2008-2012 80 70 60 50 40 30 20 10 0 BREAST CANCER LUNG CANCER PROSTATE CANCER PANCREATIC CANCER COLORECTAL CANCER CERVICAL CANCER St. Louis City US Source: CDC State Cancer Profile 29
The age-adjusted death rates of breast, lung and bronchus, prostate, pancreatic, colon and cervical cancer in the city were higher than the rates in the state and the country. The highest death rate of cancer in the city was reported in lung and bronchus cancer and prostate cancer. In, the highest death rate occurred in lung and bronchus cancer and breast cancer. According to Healthy Communities Institute: Breast Cancer Breast cancer is a leading cause of cancer death among women in the United States. According to the American Cancer Society, about 1 in 8 women will develop breast cancer and about 1 in 36 women will die from breast cancer. Breast cancer is associated with increased age, hereditary factors, obesity and alcohol use. Since 1990, breast cancer death rates have declined progressively due to advancements in treatment and detection. The Healthy People 2020 national health target is to reduce the breast cancer death rate to 20.7 deaths per 100,000 females. Lung Cancer According to the American Lung Association, more people die from lung cancer annually than any other type of cancer, exceeding the total deaths caused by breast cancer, colorectal cancer, and prostate cancer combined. The greatest risk factor for lung cancer is duration and quantity of smoking. While the mortality rate due to lung cancer among men has reached a plateau, the mortality rate due to lung cancer among women continues to increase. African Americans have the highest risk of developing lung cancer. The Healthy People 2020 national health target is to reduce the lung cancer death rate to 45.5 deaths per 100,000 population. Prostate Cancer Prostate cancer is a leading cause of cancer death among men in the United States. According to the American Cancer Society, about 1 in 7 men will be diagnosed with prostate cancer. And about 1 in 36 will die from prostate cancer. The two greatest risk factors for prostate cancer are age and race, with men over the age of 65 and men of African descent possessing the highest incidence rates of prostate cancer in the U.S. The Healthy People 2020 national health target is to reduce the prostate cancer death rate to 21.8 deaths per 100,000 males. Colorectal Cancer Colorectal cancer cancer of the colon or rectum is a leading cause of cancer-related deaths in the United States. The Centers for Disease Control and Prevention estimates that if all adults aged 50 or older had regular screening tests for colon cancer, as many as 60 percent of the deaths from colorectal cancer could be prevented. While 90 percent of colorectal cancer cases occur in adults aged 50 or older, it is essential for individuals with risk factors (those with a family history of colorectal cancer, inflammatory bowel disease, or heavy alcohol use) to seek regular screening earlier. The Healthy People 2020 national health target is to reduce the colorectal cancer death rate to 14.5 deaths per 100,000 population. 30
DEATHS / 100,000 14.6 12.1 12.3 11.8 8.4 7.7 CASES / 100,000 50.5 44.5 41.9 63.7 76.2 89.7 113.6 124.5 124.7 123 132.3 131.7 Chart 18: Age-Adjusted Incidence Rate Comparison Due to Cancer, 2008-2012 160 140 120 100 80 60 40 20 0 BREAST CANCER LUNG & BRONCHUS CANCER PROSTATE CANCER PANCREATIC CANCER COLORECTAL CANCER CERVICAL CANCER St. Louis City US Source: CDC State Cancer Profile The breast cancer incidence rate in the city was similar to the rate in the state and in the country. The prostate cancer incidence rate in the city and the rate in the country were similar while the rate was lower in the state. The rate of lung and bronchus cancer, pancreatic cancer, colon and rectum cancer and cervical cancer was higher in the city than and the country. Chart 19: Age-Adjusted Death Rate Due to Cancer Type by Race / Ethnicity 80 70 60 71.1 66.1 50 40 30 20 34.2 21.8 26.7 18.3 40.3 19.9 10 0 BREAST CANCER COLORECTAL CANCER LUNG CANCER PROSTATE CANCER African American White Source: Healthy Communities Institute 31
DEATHS / 100,000 The age-adjusted death rate due to breast, colorectal, lung and prostate cancers among African Americans in St. Louis City was higher than the rate among Whites in the city. The rate of breast cancer among African Americans was one-and one-half times higher than the rate of Whites. The death rate of prostate cancer among African Americans was twice the rate of Whites. Chart 20: All Cancer Incidence Rate by Race / Ethnicity 600 500 506.5 493.2 468.5 485.14 451.4 454.8 400 300 268.3 299.1 200 100 0 AFRICAN AMERICAN HISPANIC WHITE OVERALL St. Louis City Source: Healthy Communities Institute The incidence rate of all cancer was 6.7 percent higher in the city than in the state. The incidence of cancer among African Americans in St. Louis City was 2.7 percent higher when compared to the state. The incidence of cancer among Whites in St. Louis City was 3.8 percent higher when compared to the state. As noted in the previous graph regarding breast cancer, African American women lead the way in both incidence and mortality. Some of the social determinants of health that play into cancer are similar to many of the other issues in terms of influences on health behaviors that are risk factors for cancer, such as nutrition or tobacco use, as well as barriers to access. In this case, barriers to access may result in delays not just in screening and early detection, but throughout the entire process of cancer care. 32
CASES / 100,000 156 145.4 187.3 184.1 171.2 222.7 207.9 220.6 274.4 CASES / 100,000 435.1 421.5 412.3 502.9 485.1 454.8 453.8 561.2 512.6 Chart 21: Age-Adjusted Incidence Rates Due to Cancer by Gender, 2008-2012 700 600 500 400 300 200 100 0 FEMALE MALE BOTH St. Louis City US Source: CDC State Cancer Profile The overall rate of cancer incidence among both genders in the city was higher than the rate in the state and in the country. Chart 22: Age-Adjusted Death Rates Due to Cancer by Gender, 2008-2012 350 300 250 200 150 100 50 0 FEMALE MALE BOTH St. Louis City US Source: CDC State Cancer Profile Even though the death rate due to cancer by both genders was higher in the city than in the state and in the country, the death rate due to cancer among females was lower in the city than the rate in the state and in the country. Males had a 76 percent higher death rate in the city when compared to the state and an 89 percent higher death rate when compared to the country. 33
DEATHS / 100,000 268.3 299.1 354.6 468.5 451.4 454.1 506.5 493.2 465.8 485.1 454.8 453.8 Chart 23: Age-Adjusted Death Rates Due to Cancer by Gender, 2008-2012 600 500 400 300 200 100 0 WHITE AFRICAN AMERICAN HISPANIC ALL RACES St. Louis City US Source: CDC State Cancer Profile The age-adjusted incidence rate due to cancer was higher in the city among Whites and African Americans, but lower among Hispanics. 34
PERCENT DIABETES Diabetes is a leading cause of death in the United States. According to the Centers for Disease Prevention and Control, more than 25 million people have diabetes, including both individuals already diagnosed and those who have gone undiagnosed. This disease can have harmful effects on most of the organ systems in the human body. It is a frequent cause of end-stage renal disease, non-traumatic lower-extremity amputation, and a leading cause of blindness among working-age adults. Persons with diabetes are also at increased risk for coronary heart disease, neuropathy and stroke. Diabetes disproportionately affects minority populations and the elderly, and its incidence is likely to increase as minority populations grow and the U.S. population becomes older. (Healthy Communities Institute). Chart 24: Age-Adjusted Death Rates Due to Diabetes by Gender, 2010-2014 45 40 38 35 31.8 30 25 20 26.8 17.2 24 20.2 15 10 5 0 FEMALE MALE BOTH St. Louis City Source: Healthy Communities Institute The age-adjusted death rate of adults due to diabetes in the city was 57.4 percent higher than the state. The rate of females in the county was 55.8 percent higher than the rate of females in the state. The rate of males in the state was 37.0 percent higher than the rate of males in the county. 35
DEATHS / 100,000 POPULATION PERCENT Chart 25: Adults with Diabetes, 2013 20 18 16 14 12 10 8 6 4 2 0 14.4 12.6 13.5 10.8 10.9 10.8 FEMALE MALE BOTH St. Louis City Source: Healthy Communities Institute The rate of adults with diabetes was 25 percent higher in the city when compared to the state. The rate of females in the city was 33.3 percent higher than the state. The rate of males was 15.5 percent higher than the state. Chart 26: Age-Adjusted Death Rate Due to Diabetes by Race / Ethnicity 50 45 40 41.9 38.4 35 31.8 30 25 20 22.7 18.5 20.2 15 10 5 0 AFRICAN AMERICAN WHITE OVERALL St. Louis City Source: Healthy Communities Institute The age-adjusted death rate due to diabetes was 57.4 percent higher in the city than the state. African Americans in the city had a 9.1 percent higher death rate when compared to the state. Whites in St. Louis City had a 22.7 percent higher death rate than the state. 36
DEATHS / 100,000 POPULATION PERCENT Chart 27: Adults with Diabetes: Time Series 20 18 16 14 12 10 8 6 4 2 0 12.3 12.4 13.5 10.6 10.7 10.8 2011 2012 2013 St. Louis City Source: Healthy Communities Institute From 2011 to 2013, the rate of adults with diabetes increased 9.8 percent. The rate in remained relatively flat. Chart 28: Age-Adjusted Death Rate Due to Diabetes, 2010-2014 35 30 32 31.3 32.7 31.8 25 20 20.8 20.2 20.3 20.2 15 10 5 0 2007-2011 2008-2012 2009-2013 2010-2014 St. Louis City Source: Healthy Communities Institute The age-adjusted death rate due to diabetes for St. Louis City and remained relatively flat during the period ending 2011 to the period ending 2014. 37
PERCENT PERCENT Chart 29: Medicare Population with Diabetes: Time Series 35 30 25 20 15 10 5 29.4 29.8 30.1 30.1 29.9 25.9 26.1 26.1 26.1 25.9 0 2010 2011 2012 2013 2014 St. Louis City Source: Healthy Communities Institute For the period ending 2010 to the period ending 2014, diabetes in the Medicare population in St. Louis City and remained largely unchanged. Chart 30: Medicare Population with Diabetes by Age, 2014 35 30 25 28.4 24.9 30.7 29.9 27.1 25.9 20 15 10 5 0 UNDER 65 65 & OVER OVERALL St. Louis City Source: Healthy Communities Institute St. Louis City had a 15.4 percent higher rate of adults with diabetes than the state. The Under 65 Medicare population had a 14.1 percent higher rate than state. The 65 and Over Medicare population had a 13.3 percent higher rate than the state. 38
PERCENT HEALTHY LIFESTYLES Obesity increases the risk of many diseases and health conditions including heart disease, type 2 diabetes, cancer, hypertension, stroke, liver and gallbladder disease, respiratory problems and osteoarthritis. Losing weight and maintaining a healthy weight help to prevent and control these diseases. Being obese also carries significant economic costs due to increased healthcare spending and lost earnings. (Healthy Communities Institute). Chart 31: Adult Fruit and Vegetable Consumption by Race / Ethnicity, 2011 15 10 12.4 12 12.3 12.2 12.5 11.1 5 0 AFRICAN AMERICAN WHITE, NON-HISPANIC OVERALL St. Louis City Source: Healthy Communities Institute African Americans had a higher fruit and vegetable consumption rate in the city than the state and a 9 percent higher rate compared to White, non-hispanic. Numerous studies have shown a clear link between the amount and variety of fruits and vegetables consumed and rates of chronic diseases, especially cancer. According to the World Cancer Research Fund International, about 35 percent of all cancers can be prevented through increased fruit and vegetable consumption. (Healthy Communities Institute). Chart 32: Adults Who are Obese by Race / Ethnicity, 2011 45 40 35 30 25 20 15 10 5 0 37.7 41.1 27.4 31.1 29 30 AFRICAN AMERICAN WHITE OVERALL St. Louis City Source: Healthy Communities Institute 39
PERCENT African Americans in the city had an 8.3 percent lower rate of obesity when compared to the state. Whites also had a 5.5 percent lower rate of obesity when compared to the state. Chart 33: Adults Who are Obese vs. HealthyPeople 2020, 2011 35 30 25 20 15 10 5 31.1 31 30.5 0 ST. LOUIS CITY MISSOURI HP2020 TARGET Source: Healthy Communities Institute The Healthy People 2020 national health target is to reduce the proportion of adults age 20 and older who are obese to 30.5 percent. In the graph above, St. Louis City and the state slightly exceeded the target. 40
PERCENT HEART HEALTH Heart disease is a term that encompasses a variety of different diseases affecting the heart and is the leading cause of death in the United States accounting for 25.4 percent of total deaths. Chart 34: Age-Adjusted Death Rate Due to Heart Disease by Race / Ethnicity, 2010-2014 300 250 200 150 100 50 267.6 229.9 220.4 241 191.6 195 0 AFRICAN AMERICAN WHITE, NON-HISPANIC OVERALL St. Louis City Source: Healthy Communities Institute The age-adjusted death rate due to heart disease in St. Louis City was 23.5 percent higher than the rate in the state. African Americans in the city had a 16.4 percent higher death rate from heart disease in the city when compared to the rate in the state. Chart 35: High Cholesterol Prevalence in Adults 35+ by Race / Ethnicity, 2011 50 40 30 20 10 43.3 39.7 40.8 41.2 42.9 38.1 0 AFRICAN AMERICAN WHITE, NON-HISPANIC OVERALL St. Louis City Source: Healthy Communities Institute The overall high cholesterol prevalence was 4 percent lower in the city when compared to the state. African Americans in the city had a 4 percent higher rate when compared to the state. White, Non- Hispanics in the city had a 5.8 percent lower rate than the state. 41
DEATHS / 100,000 POPULATION Chart 36: Age-Adjusted Death Rate Due to Stroke by Race / Ethnicity, 2010-2014 60 50 40 49.7 52.4 44.7 46.8 40.7 41.9 30 20 10 0 AFRICAN AMERICAN WHITE, NON-HISPANIC OVERALL St. Louis City Source: Healthy Communities Institute The age-adjusted death rate due to stroke in the city was 11.7 percent higher when compared to the state. African Americans in the city had a 5.1 percent lower age-adjusted death rate due to stroke when compared to the state. Whites in the city had a 9.8 percent higher age-adjusted death rate due to stroke than the state. Table 7: Heart Health & Stroke, St. Louis City vs. ; Age-Adjusted Rate Health Topics St. Louis City Heart Disease Deaths / 100,000, 2003-2013 279.10 216.8 Hospitalizations / 10,000, 2009-2013 154.9 123.1 ER visits / 1,000, 2009-2013 16.20 14.7 Ischemic Heart Disease Deaths / 100,000, 2003-2013 185.1 144.7 Hospitalizations / 10,000, 2009-2013 35.1 39.3 ER visits / 1,000, 2009-2013 0.3 0.6 Stroke / Other Cerebrovascular Disease Deaths / 100,000, 2003-2013 53.8 47.8 Hospitalizations / 10,000, 2009-2013 38.4 38.3 ER visits / 1,000, 2009-2013 0.4 0.8 Source: Department of Health and Senior Services 42
For heart disease, ischemic heart disease and stroke, the death rate for the city was higher than in the state. The city was lower than the state in hospitalizations and ER Visits for ischemic heart disease and in ER Visits for stroke. Table 8: Heart Health & Stroke by Race/Ethnicity, St. Louis City vs. Health Topics St. Louis City Heart Disease White African American White African American Deaths / 100,000, 2003-2013 263.5 298.8 212.7 264.6 Hospitalizations / 10,000, 2009-2013 109.7 203.5 115.4 180.8 ER visits / 1,000, 2009-2013 8.6 24 13.1 24.7 Ischemic Heart Disease Deaths / 100,000, 2003-2013 189.2 182.4 143.1 168.6 Hospitalizations / 10,000, 2009-2013 31.1 39.0 37.9 36.9 ER visits / 1,000, 2009-2013 0.2 0.4 0.6 0.4 Stroke / Other Cerebrovascular Disease Deaths / 100,000, 2003-2013 48.3 59.2 46.4 60.9 Hospitalizations / 10,000, 2009-2013 29.0 47.9 26.7 44.7 ER visits / 1,000, 2009-2013 0.2 0.5 0.8 0.7 Source: Department of Health and Senior Services Like in the state, African Americans had a higher death rate compared to Whites for heart disease (+13.4 percent) and stroke (+22.6 percent). For ischemic heart disease in the city, African Americans had a 3.6 percent lower death rate compared to Whites. 43