September 19, 2019

Death in America, charted

Daily Briefing

    In 2017, death rates for the five states with the highest rates of mortality were 49% higher than the five states with the lowest rates, according to a new CDC report. The discrepancy proves just how much impact location-based and race-based inequities yield at a population level.

    10 tools for prioritizing community health interventions

    Report details

    For the report, researchers looked at mortality data from the National Vital Statistics System and adjusted them for a standard age distribution. They then honed in on the states with the five highest and five lowest death rates, and broke down the rates by race and ethnicity. They also compared the leading causes of death in the states analyzed.

    The five states with the highest death rates were:

    • Alabama;
    • Kentucky;
    • Mississippi;
    • Oklahoma; and
    • West Virginia.

    The five states with the lowest death rates were:

    • California;
    • Connecticut;
    • Hawaii;
    • Minnesota; and
    • New York.

    Researchers found that the average death rate in the states where they were highest was 926.8 per 100,000—that is 49% higher than the rates in the five states where they were lowest, which averaged 624 per 100,000. The average rate in the higher states was also 27% greater than the national rate of 731.9 per 100,000.

    Specifically, the researchers found that the death rates for those age 24-34 and 35-44 in the states with the highest death rates were more than double those of the states with the lowest death rates.

    When broken down by race, researchers found that the rates among the Hispanic population were actually reversed. That is, death rates among Hispanics were 27% higher in the five states with the lowest death rates than the five states with the highest.

    The researchers found that all of the 10 states shared the same five leading causes of death. They were:

    • Heart disease;
    • Cancer;
    • Chronic lower respiratory diseases;
    • Unintentional injuries; and
    • Stroke.

    However, rates of deaths from these causes varied widely between the two sets of states. Among the five states with the highest rates, death rates from chronic lower respiratory diseases and unintentional injuries were almost double those of the five states with the lowest rates. Meanwhile, death rates from heart disease in the five highest-rate states were 46% higher than the five lowest states, and rates of death from stroke deaths in the five highest-rate states were 39% higher than the five lowest states.

    There were some interesting aberrations, however. Some of the lowest-rate states had higher death rates of specific diseases than the highest-rate states, Jiaquan Xu, a researcher for the National Center for Health Statistics and author of the new report, told CNN.

    "Alzheimer's disease for California, one of the five lowest-rate states, was higher than the rates for Kentucky and West Virginia, two of the five [highest]-rate states," he said.

    "California had a higher death rate from diabetes than Alabama. Hawaii had the highest death rate from influenza and pneumonia in the nation," he added. "The findings in this report are important information for the health community to learn about inequalities in mortality between the two groups of the states and help them in their important work using such information." They also emphasize why it's so important to tailor interventions to a community's specific needs rather than take a one-size-fits-all approach.

    Why this report shows the importance of the social determinants of health

    Georges Benjamin, executive director of the American Public Health Association, told CNN that he wasn't surprised by the extent of the state-based discrepancies.

    "We know very clearly that things such as educational attainment, access and utilization of things like tobacco, physical inactivity, nutrition, the location of if they have access to things like grocery stores, all those things matter at the county level and at the local level," he said. "When you roll those up at the state level, they also matter."

    These social determinants of health play a major role in the health of the community—and they can also have a significant effect on hospitals. For example, research shows that inadequate access to housing can reduce life expectancy for patients by 26 to up to 36 years, and translates to an annual average ED cost of $44,000 for the highest-use ED patients.

    Similarly, food insecurity can lead to increased rates of chronic diseases, dental issues, behavioral health problems, and hospitalizations, leading to $179 billion in annual direct and indirect health-related costs nationwide.

    Economic insecurity can also have a significant impact, resulting in a 24 to 67% increased risk of readmission among dual-eligible patients and a 2.13 times increased risk of mortality among Medicaid beneficiaries compared with privately insured patients.

    What can providers do to try to minimize these discrepancies?

    As Benjamin emphasized to CNN, there are a range of things states can do to improve the social determinants of health and improve their death rates. "It's not inevitable," he told CNN, "We know that states that have looked at these kinds of rankings and get into the data and understand why they rank or do so poorly can make changes."

    And hospitals can—and should—also be an important player in the effort. So how do providers address the social determinants of health? Advisory Board research has found that the most efficient way is not to reinvent the wheel by trying to start new programs, but by partnering with organizations that already have a footprint in the community. By distributing resource investment across multiple community partners, providers can invest in the services that have already proven successful.

    It's important when choosing a community organization partner that you focus on finding an organization that's already trusted in the community and maintains existing positive relationships with your target population.

    One hospital has followed this model successfully to address housing insecurity is the University of Vermont Medical Center (UVMMC), a tertiary care center in Burlington, Vermont.

    UVMMC partnered with Champlain Housing Trust, a nonprofit that creates and preserves affordable housing, and paid them to develop and maintain units for patients in their buildings. They also funded additional case management services for these patients in partnership with the Community Health Centers of Burlington.

    For those provided short-term housing, inpatient admissions at UVMMC dropped from 95 to 30 days, and ED utilization decreased sharply from 161 to 94 visits. The partnerships also decreased annual health care costs for permanently housed patients from $750,000 to $250,000.

    Hospitals can also impact the social determinants of health by carefully screening for those factors and offering proactive support to patients who might benefit from it. In a recent cross-sectional study of providers in JAMA, only 24% of hospitals and 16% of physician practices reported screening patients for five major social determinants of health (food insecurity, housing instability, utility needs, transformation needs, and interpersonal violence).

    But doing so can yield substantial clinical and financial benefits. For instance, ProMedica, a 13-hospital system based in Ohio, began a program for system-wide food insecurity screenings. In inpatient settings, RNs perform a two-question food insecurity screening for admitted patients. If patients screen as at-risk for insecurity, a licensed clinical social worker or a discharge planner will follow up with the patient to connect them to any psychosocial services they may need. They will also discharge these patients with one day's worth of calories as well as information on follow-up support and an appointment with a primary care provider.

    In outpatient settings, primary care staff screen all patients for food insecurity and refer appropriate patients to the system's food clinic. The clinic offers healthy, condition-specific food once a month to patients for six months.

    Preliminary data from a small group of Medicaid beneficiaries showed ProMedica's program led to a 53% reduction in readmission rates, and a 15% decrease in health care costs compared with those not using the program. ProMedica also saw a 3% reduction in ED usage and a 4% increase in primary care usage.

    Want to learn more about addressing the social determinants of health in your community in a sustainable way? Check out our Population Health Resource Library for a full catalogue of implementation resources.

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