County Health Rankings: Why do we all want to be above average? Julie Willems Van Dijk RN PhD University of Wisconsin Population Health Institute Gianfranco Pezzino Senior Fellow, Kansas Health Institute

Today… The County Health Rankings Population Health Model County Health Rankings—WHY? What is MATCH? Using the Rankings Are Rankings a QI Tool? Real Life Experience Discussion

Who?

Rankings are everywhere

Our Logic Model

Programs and Policies

Health Factors Programs and Policies

Health Factors Programs and Policies Health Outcomes

Programs and Policies

Health Factors

Programs and Policies Health Factors Health Outcomes

Physical environment Social and economic factors Health behaviors Clinical care Health Factors Programs and Policies Health Outcomes

Health Factors Programs and Policies Health Outcomes Physical environment (10%) Social & economic factors (40%) Health behaviors (30%) Clinical care (20%)

Health Factors Programs and Policies Health Outcomes Physical environment (10%) Social & economic factors (40%) Health behaviors (30%) Clinical care (20%) Mortality (length of life): 50% Morbidity (quality of life): 50%

Community safety Education Family & social support Employment Built environment Environmental quality Income Unsafe sex Alcohol use Diet & exercise Tobacco use Access to care Quality of care Physical environment (10%) Social & economic factors (40%) Health behaviors (30%) Clinical care (20%) Health Factors Programs and Policies Health Outcomes Mortality (length of life): 50% Morbidity (quality of life): 50% County Health Rankings model © 2010 UWPHI

Why County Health Rankings? Where we live matters to our health & there are great disparities between communities; And, health depends on many different factors. It’s more than medical care; Therefore, health is everybody’s business; So, we all need to work together to find solutions. Yet, there is relatively little attention in the public or among policy makers to the above points

Getting Attention…..

Why rank? Easy to understand one’s rank Draws attention to all the factors that affect community health Draws more people into discussions about how to improve health:

MATCH Mobilize Action Toward Community Health

Mobilize through County Health Rankings Physical environment Social and economic factors Health behaviors Clinical care Health Factors Programs and Policies Health Outcomes

Action depends on stage of readiness in the county

Toward Community Health by setting goals and monitoring progress over time Setting goals and objectives for overall health Keeping track of progress

MobilizingActionToward Community Health through County Health Rankings Setting goals and objectives for overall health Keeping track of progress

Juneau County Experience

Mobilizing… After the release of this article in the Juneau County Star Times, a meeting was held in the Juneau County courtroom. People from across the community came to learn about the Rankings and then began to discuss ways to improve Juneau County’s health.

A broad coalition of partners requested and won a grant from a statewide foundation, worked on a community health needs assessment, and looked for evidence on what works …Action…

…Toward Community Health Juneau County now has a plan to address: parenting, health literacy, and health care access

Ways to Use the Rankings Raising awareness about the multiple determinants of health via media interviews and follow-up conversations Initiating community health assessment and planning efforts where none previously existed Celebrating successes and reinvigorating existing community health improvement efforts

Ways to Use the Rankings (cont.) Informing policy makers and community leaders about the multiple determinants of health and community health improvement planning Citing the County Health Rankings as justification in securing grant funding to conduct community health improvement efforts and/or to address the determinants of health As a tool or as input for QI???

Limitations of County Health Rankings as a QI Tool Although QI is system-based, in practice it generally focuses on programs, agencies or organizations—Rankings focus on whole communities Multiple years of data for individual measures limits ability to compare trends Just like report cards, the components we rank may change from year to year Relative nature of Rankings means true improvement may not result in improvement in rank

How Rankings Can be Used in QI To draw attention for the need for improvement To focus organizational QI efforts To raise awareness in a community that QI is needed To shift our focus from small QI (program level) to big QI (organizational level) to BIG QI (community level)

Acknowledgements Robert Wood Johnson Foundation Our communications partners (Burness et al) Patrick Remington, David Kindig and Bridget Booske Other UWPHI colleagues, past and present (Peppard, Rohan, Vila, Athens, et al) University of Wisconsin School of Medicine and Public Health Wisconsin Division of Public Health

County Health Rankings: An Example in Action Gianfranco Pezzino, M.D., M.P.H. Senior Fellow Kansas Health Institute

Why ranking Allows comparisons Easy to understand:  Summarizes and translates PH info non- technical audience Stimulates discussion, debate about health disparities, differences  Learn from each other how to achieve best possible level of population health

This is not Rocket Science… A.K.A. there is more than one way to skin a cat As demonstrated by the differences between MATCH and the Kansas report

KS and MATCH Report Comparison KS used three Major Rankings:  Health Outcomes  Health Determinants  Overall Health Index Some indicators are different Some weights are different As a result, ranking will probably be (slightly?) different

Kansas Health Model and Indicators

Community safety Education Family & social support Employment Built environment Environmental quality Income Unsafe sex Alcohol use Diet & exercise Tobacco use Access to care Quality of care Physical environment (10%) Social & economic factors (40%) Health behaviors (30%) Clinical care (20%) Health Factors Programs and Policies Health Outcomes Mortality (length of life): 50% Morbidity (quality of life): 50% County Health Rankings model © 2010 UWPHI MATCH Logic Model and Indicators (4 measures of morbidity)

Weights (original slides from ) Based on best evidence, but somewhat arbitrary

Kansas Health Model and Indicators

Community safety Education Family & social support Employment Built environment Environmental quality Income Unsafe sex Alcohol use Diet & exercise Tobacco use Access to care Quality of care Physical environment (10%) Social & economic factors (40%) Health behaviors (30%) Clinical care (20%) Health Factors Programs and Policies Health Outcomes Mortality (length of life): 50% Morbidity (quality of life): 50% County Health Rankings model © 2010 UWPHI MATCH Logic Model and Indicators

Limitations of County Health Rankings First, you need to “believe” in the logic model  if not, it is easy to find design “flaws” and dismiss report Second, you need to understand what these numbers DO and do NOT mean  if not, you will abuse and misuse the data Some limitations are unavoidable given the study design

Some of the Limitations Small counts for some counties Appropriate indicators  Environmental indicators particularly limited Within-county variability (disparities) is NOT measured Single measures less meaningful than overall trends and indexes

Small Counts Acceptable sample size depends on source of data KDHE: no vital events with < 6 counts are reported (confidentiality concerns) CDC: no BRFSS reporting if N < 50 Multiple years collapsed (up to 6) When count is insufficient:  Values are not shown in any of the tables  Values are included in the calculation of the ranking

Number of “Reportable” Indicators in KS 31 Indicators26 counties 20 to 30 Indicators69 counties < 20 Indicators10 counties Smallest number of Indicators = 152 counties

How to account for what is NOT measured Our model (KS) explains about half of the variability among counties Some areas difficult to measure  Environment and health effects (lag time)  “Social capital”, intangible assets “Not everything that counts is counted…”

Other Things that Rankings can NOT do Show progress towards objective  Information is only relative to other units in the ranking Show distance between the best and worst performers  “When everybody is close to the average”, ranking position is less informative

Rankings and Quality Improvement Indirect linkage? Top performers can help disseminate best practices (used in Q.I.) Q.I. implies that indicators are measured and ideal status (i.e., goals, standards, etc.) is identified  Implicit comparisons  Rankings are all based on comparisons

A report was published on June 1, 2009

Media coverage* 15 printed newspapers 7 online news services 5 broadcast outlets * (as of June 12, 2009)

How Can we Use it? 1. Raise awareness of link between health outcomes and determinants  Policy makers, media, public, advocacy groups, ……  “Health Impact statements” 2. Community action and mobilization  Community Health assessments  Community Health Improvement Plans

“This has been the reality for the past 100 years. We are doing a better job at capturing it with quantifiable data.” Administrator, Community Health Center of South East Kansas

“We ourselves have to hear these statistics. The more we hear it, the more we are reminded about that, the more change will happen.” Administrator, Community Health Center of South East Kansas

Wyandotte County

The Reaction of the “Last one” Meeting with mayor, city officers, county state delegations, KHI Developed two-prong strategy:  Inform county and state policy makers  Initiate a community engagement process focused on teens in neighborhood and school settings Engagement of community health partners slow Funding is an issue for a non-categorical project

Conclusions Be ready!  The “no surprise” rule applies  Study results for your jurisdiction before release  Be prepared to answer the most uncomfortable questions  Stress what a ranking can and cannot do

Conclusions, Ctd. Be proactive  Be a driver, not a passenger Involve stakeholders before the release

Kansas Health Institute Healthier Kansans through informed decisions

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