How healthy is your county?

IIn the late winter of 2010, the Robert Wood Johnson Foundation (RWJF) announced a new national project called “County Health Rankings.” This is the first set of reports to rank the overall health of every county in all 50 states in the U.S. The RWJF, in concert with the University of Wisconsin’s Population Health Institute, put this amazing project together. The report is ostensibly designed to aid public health and community leaders, policymakers, consumers, and others to see how healthy their county is, to compare it with others within their state, and to find ways to improve the heath of their community.1 This study differs from previous projects; it is the first time that researchers have examined multiple factors that affect health in every county in the nation. Each county is rated on key factors that affect health, such as smoking, obesity, alcohol use, access to primar y care providers, the population’s overall education level, unemployment rates, and the number of children living in poverty. You can probably sense where this report is going; we all recognize that the actual delivery of health care services is only one small part of the overall mix of critical variables that determine the health of a county. For example, the report reveals twofold and three-fold higher rates of premature death in some counties, often from preventable conditions, and that 80% of the counties with populations in poorest health were rural.2 In addition, high smoking rates lead to cancer, heart disease, bronchitis, and emphysema in some counties when compared with others. With this tool, we can observe what makes people in every county unhealthy. The answers should be no surprise to readers of P&T. Conversely, people who live in the healthier-ranked counties tend to have higher education levels, are more likely to be employed; and have access to more health care providers, healthful foods, parks, and recreational facilities. The report does not specify which pharmaceutical agents garner the best clinical outcomes. We know that this information is important for individual patients, but it does little to contribute to the overall health status of a population. The rankings also show sharp health disparities even in contiguous counties. For example, someone living in Chester County, Pennsylvania—the county ranking highest in the state for overall health—has a better chance of staying well than a resident of nearby Delaware County—which ranks 22nd of 67 counties; Delaware County, unfortunately, has higher rates of smoking, adult obesity, and violent crime, as well as more children living in poverty.3 I was particularly interested in the report’s quality-of-care measures that were used to assess outcomes of care. In delving into the report, I found three measures that make sense to me:4