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12/10/2014
1
ruralhealth.und.edu/research
2014 Update of the Rural-Urban Chartbook
Rural Health Research Gateway Webinar
December 9, 2014
Alana Knudson, PhD
Michael Meit, MA, MPH
2
Examination of Trends in Rural and Urban Health: Establishing a Baseline for Health Reform
• CDC published Health United States, 2001 With Urban
and Rural Health Chartbook
• No urban/rural data update since 2001
• Purpose of this study:• Update of rural health status ten years later to understand trends• Provide baseline of rural/urban differences in health status and
access to care prior to ACA implementation
12/10/2014
2
3
Methods• Replicated analyses conducted in 2001 using most recent data
available (2006-2011)• Used same data source, when possible:
• National Vital Statistics System• Area Resource File (HRSA) • U.S. Census Bureau• National Health Interview Survey (NCHS)• National Hospital Discharge Survey (NCHS)• National Survey on Drug Use and Health (SAMHSA)• Treatment Episode Data Set (SAMHSA)
• Applied same geographic definitions, although classifications may have changed since 2001:
• Metropolitan Counties: Large central, Large fringe, Small metro • Nonmetropolitan Counties: Micropolitan, Non-core
4
Counties by Region and Rurality (2013)
12/10/2014
3
5
Overview of Presentation
• Demographics
• Mortality
• Risk factors
• Access issues
• Resources
6
Population: AgePopulation 65 years of age and over by rurality
11.8% 11.8%13.0%
13.7%
15.3%
11.6%12.7%
13.7%
15.7%
17.5%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
19982011
12/10/2014
4
7
Population: Race and Ethnicity
• Non-Hispanic white persons represent over half of the population in fringe counties of large metro areas, small metro counties, and nonmetro counties, but only 45% in central counties.
• In the Midwest, white persons represented 81% of its population. The Northeast had a larger proportion of residents of Hispanic and Asian or Pacific Island origin compared with the Midwest.
• In the South, non-Hispanic black persons constituted a larger proportion of the population than in any other region.
• The West had a disproportionately high concentration of persons of Hispanic origin.
Metropolitan CountiesA Large centralB Large fringeC Small metro
Nonmetropolitan CountiesD MicropolitanE Non-core
8
Population: Poverty
15.6
8.0
13.2
14.6
16.1
18.1
11.0
16.7
17.918.9
0
2
4
6
8
10
12
14
16
18
20
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
19972011
Population in poverty by rurality
12/10/2014
5
9
Population: Poverty
0
5
10
15
20
25
All Regions Northeast Midwest South West
Perc
ent
Large central
Large fringe
Small metro
Micropolitan
Non-core
Population in poverty by region and rurality, 2011
10
Mortality: InfantsInfant mortality by rurality
7.5
6.1
7.5 7.7 7.7
6.8
5.7
6.7 6.8 7.0
0
1
2
3
4
5
6
7
8
9
Large central Large fringe Small metro Micropolitan Non-core
Dea
ths
per 1
,000
live
birt
hs
1996-19982008-2010
12/10/2014
6
11
Mortality: Children and Young AdultsDeath rates for all causes among persons 1–24 years of age by rurality
44.5
35.4
41.746.2
58.5
37.5 35.638.3
44.8
57.7
0
10
20
30
40
50
60
70
Large central Large fringe Small metro Micropolitan Non-core
Dea
ths
per 1
00,0
00 p
opul
atio
n
1996-19982008-2010
12
Mortality: Children and Young AdultsDeath rates for all causes among persons 1–24 years of age by region and rurality, 2008-2010
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
All Regions Northeast Midwest South West
Dea
ths
per 1
00,0
00 p
opul
atio
n
Large centralLarge fringeSmall metroMicropolitanNon-core
12/10/2014
7
13
Mortality: Working-Age AdultsDeath rates for all causes among persons 25-64 years of age by rurality
419.6
319.1
384.9399.8
421.5
329.8
282.5
346.5
390.1414.1
0
50
100
150
200
250
300
350
400
450
Large central Large fringe Small metro Micropolitan Non-core
Dea
ths
per 1
00,0
00 p
opul
atio
n
1996-19982008-2010
14
Mortality: Working-Age AdultsDeath rates for all causes among persons 25-64 years of age by region and rurality, 2008-2010
0
100
200
300
400
500
600
All regions Northeast Midwest South West
Dea
ths
per 1
00,0
00 p
opul
atio
n
Large centralLarge fringeSmall metroMicropolitanNon-core
12/10/2014
8
15
Mortality: SeniorsDeath rates for all causes among persons 65 years of age and over by rurality
5,063.8 5,111.4 5,227.15,428.4 5,407.4
4,221.8 4,307.44,486.3
4,775.8 4,829.7
0.0
1,000.0
2,000.0
3,000.0
4,000.0
5,000.0
6,000.0
Large central Large fringe Small metro Micropolitan Non-core
Dea
ths
per 1
00,0
00 p
opul
atio
n
1996-19982008-2010
16
Mortality: Heart DiseaseDeath rates for ischemic heart disease among persons 20 years of age and over by rurality
259.1245.9 239.6
256.0269.2
192.9174.9 173.8
197.2206.5
0.0
50.0
100.0
150.0
200.0
250.0
300.0
Large central Large fringe Small metro Micropolitan Non-core
Dea
ths
per 1
00,0
00 p
opul
atio
n
1996-19982008-2010
12/10/2014
9
17
Mortality: Chronic Obstructive Pulmonary Diseases
Death rates for chronic obstructive pulmonary diseases among persons 20 years of age and over by rurality
52.9 54.7
61.164.0
61.556.2
60.6
70.9
79.9 81.9
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
Large central Large fringe Small metro Micropolitan Non-core
Dea
ths
per 1
00,0
00 p
opul
atio
n
1996-19982008-2010
18
Mortality: Chronic Obstructive Pulmonary Diseases
Death rates for chronic obstructive pulmonary diseases among persons 20 years of age and over by sex and rurality
0.0
20.0
40.0
60.0
80.0
100.0
120.0
Large central Large fringe Small metro Micropolitan Non-core
Dea
ths
per 1
00,0
00 p
opul
atio
n
Males (1996-1998)Males (2008-2010)Females (1996-1998)Females (2008-2010)
12/10/2014
10
19
Mortality: Unintentional InjuriesDeath rates for unintentional injuries by rurality
31.229.1
36.5
44.6
54.1
32.1 33.1
40.8
58.9
52.7
0
10
20
30
40
50
60
70
Large central Large fringe Small metro Micropolitan Non-core
Dea
ths
per 1
00,0
00 p
opul
atio
n
1996-1998
2008-2010
20
Mortality: Unintentional InjuriesDeath rates for unintentional injuries by region and rurality, 2008-2010
0
10
20
30
40
50
60
70
80
All Regions Northeast Midwest South West
Dea
ths
per 1
00,0
00 p
opul
atio
n
Large central
Large fringe
Small metro
Micropolitan
Non-core
12/10/2014
11
21
Mortality: Motor Vehicle InjuriesDeath rates for motor vehicle traffic-related injuries by rurality
11.512.5
16.1
21.4
28.3
7.99.3
12.1
23.3
19.5
0
5
10
15
20
25
30
Large central Large fringe Small metro Micropolitan Non-core
Dea
ths
per 1
00,0
00 p
opul
atio
n
1996-1998
2008-2010
22
Mortality: Motor Vehicle InjuriesDeath rates for motor vehicle traffic-related injuries by region and rurality, 2008-2010
0
5
10
15
20
25
30
All Regions Northeast Midwest South West
Dea
ths
per 1
00,0
00 p
opul
atio
n
Large central
Large fringe
Small metro
Micropolitan
Non-core
12/10/2014
12
23
Mortality: HomicideHomicide rates by rurality
11.5
3.9
6.4
5.2 5.4
8.1
4.0
4.94.4 4.5
0
2
4
6
8
10
12
14
Large central Large fringe Small metro Micropolitan Non-core
Dea
ths
per 1
00,0
00 p
opul
atio
n
1996-19982008-2010
24
Mortality: HomicideHomicide rates by region and rurality, 2008-2010
0
2
4
6
8
10
12
14
All Regions Northeast Midwest South West
Dea
ths
per 1
00,0
00 p
opul
atio
n
Large centralLarge fringeSmall metroMicropolitanNon-core
12/10/2014
13
25
Mortality: SuicideSuicide rates among persons 15 years of age and over by rurality
13.2 12.6
15.216.5
18.0
12.813.7
16.1
18.2
20.0
0.0
5.0
10.0
15.0
20.0
25.0
Large central Large fringe Small metro Micropolitan Non-core
Dea
ths
per 1
00,0
00 p
opul
atio
n
1996-19982008-2010
26
Mortality: SuicideSuicide rates among persons 15 years of age and over by region and rurality, 2008-2010
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
All Regions Northeast Midwest South West
Dea
ths
per 1
00,0
00 p
opul
atio
n
Large centralLarge fringeSmall metroMicropolitanNon-core
12/10/2014
14
27
Risk Factors: Adolescent Smoking Cigarette smoking in the past month among adolescents 12-17 years of age by rurality
11.0
15.9 16.115.2
18.9
5.2
7.88.7
9.7
11.3
0
2
4
6
8
10
12
14
16
18
20
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
1999
2010-2011
28
Risk Factors: Adolescent SmokingCigarette smoking in the past month among adolescents 12-17 years of age by region and rurality, 2010-2011
0
2
4
6
8
10
12
14
All regions Northeast Midwest South West
Perc
ent
Large central
Large fringe
Small metro
Micropolitan
Non-core
12/10/2014
15
29
Risk Factors: Adult Smoking
22.621.6
25.4
26.1
28.5
15.8
17.8
20.0
27.1
27.0
0
5
10
15
20
25
30
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
1997-1998
2010-2011
Cigarette smoking among persons 18 years of age and older by rurality
30
Risk Factors: Adult SmokingCigarette smoking among persons 18 years of age and older by region and rurality, 2010-2011
0
5
10
15
20
25
30
35
All Regions Northeast Midwest South West
Perc
ent Large central
Large fringe
Small metro
Nonmetropolitan counties
12/10/2014
16
31
Risk Factors: Alcohol ConsumptionConsumption of five or more alcoholic drinks in one day in the last year among persons 18-49 years of age by rurality
24.8
29.5
27.2
29.6
24.8
29.0
31.2 31.330.1 29.9
0
5
10
15
20
25
30
35
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
1997-1998
2010-2011
32
Risk Factors: Alcohol Consumption
0
5
10
15
20
25
30
35
40
45
All Regions Northeast Midwest South West
Perc
ent Large central
Large fringe
Small metro
Nonmetropolitan counties
Consumption of five or more alcoholic drinks in one day in the last year among persons 18-49 years of age by region and rurality, 2010-2011
12/10/2014
17
33
Risk Factors: ObesityObesity among persons 18 years of age and older by rurality
19.117.7
19.8 20.522.7
27.429.0
30.6
34.936.9
0
5
10
15
20
25
30
35
40
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
1997-1998
2010-2011
34
Risk Factors: ObesityObesity among persons 18 years of age and older by region and rurality, 2010-2011
0
5
10
15
20
25
30
35
40
All Regions Northeast Midwest South West
Perc
ent Large central
Large fringe
Small metro
Nonmetropolitan counties
12/10/2014
18
35
Risk Factors: Physical Inactivity
40.9
31.1
38.3 38.4
46.5
32.329.5
30.9
37.2
41.0
0
5
10
15
20
25
30
35
40
45
50
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
1997-1998
2010-2011
Physical inactivity among persons 18 years of age and older by rurality
36
Risk Factors: Physical InactivityPhysical inactivity among persons 18 years of age and older by region and rurality, 2010-2011
0
5
10
15
20
25
30
35
40
45
50
All Regions Northeast Midwest South West
Perc
ent Large central
Large fringe
Small metro
Nonmetropolitan counties
12/10/2014
19
37
Other Health Status: Adolescent BirthsBirth rates among adolescents15-19 years of age by rurality
59.6
36.1
53.6 54.657.9
39.7
26.6
39.5
45.449.1
0
10
20
30
40
50
60
70
Large central Large fringe Small metro Micropolitan Non-core
Birt
hs p
er 1
,000
fem
ale
adol
esce
nts
1996-1998
2008-2010
38
Other Health Status: Adolescent BirthsBirth rates among adolescents15-19 years of age by region and rurality, 2008-2010
0
10
20
30
40
50
60
70
All regions Northeast Midwest South West
Birt
hs p
er 1
,000
fem
ale
adol
esce
nts
Large central
Large fringe
Small metro
Micropolitan
Non-core
12/10/2014
20
39
Other Health Status: Activity LimitationLimitation of activity caused by chronic health conditions among persons 18 years of age and older by rurality
14.013.0
15.8
17.618.2
12.911.9
14.7
17.1
18.8
0
2
4
6
8
10
12
14
16
18
20
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
1997-1998
2010-2011
40
Other Health Status: Activity LimitationLimitation of activity caused by chronic health conditions among persons 18 years of age and older by region and rurality, 2010-2011
0
5
10
15
20
25
All Regions Northeast Midwest South West
Large central
Large fringe
Small metro
Nonmetropolitan counties
12/10/2014
21
41
Health Care Access and Use: UninsuredNo health insurance coverage among persons less than 65 years of age by poverty status and rurality
34.6
29.631.1
32.834.0
10.0
6.67.9
8.910.6
33.432.9
31.3
30.0
35.2
11.39.0
10.611.6
14.1
0
5
10
15
20
25
30
35
40
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
Family Income < 200% Poverty (1997-1998)
Family Income ≥ 200% Poverty (1997-1998)Family Income < 200% Poverty (2010-2011)
Family Income ≥ 200% Poverty (2010-2011)
42
Health Care Access and Use: UninsuredNo health insurance coverage among persons less than 65 years of age by region and rurality, 2010-2011
0
5
10
15
20
25
30
All Regions Northeast Midwest South West
Perc
ent Large central
Large fringe
Small metro
Nonmetropolitan counties
12/10/2014
22
43
Health Care Access and Use: MedicaidMedicaid coverage among persons less than 65 years of age by poverty status and rurality
29.8
19.3
22.420.4 21.1
2.0 1.3 1.9 1.8 2.2
33.2
25.6
30.6
33.8
31.0
4.02.7 3.6
4.6 4.5
0
5
10
15
20
25
30
35
40
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
Family Income < 200% Poverty (1997-1998)
Family Income ≥ 200% Poverty (1997-1998)Family Income < 200% Poverty (2010-2011)
Family Income ≥ 200% Poverty (2010-2011)
44
Health Care Access and Use: MedicaidMedicaid coverage among persons less than 65 years of age by region and rurality, 2010-2011
0
5
10
15
20
25
30
All Regions Northeast Midwest South West
Perc
ent Large central
Large fringe
Small metro
Nonmetropolitan counties
12/10/2014
23
45
Health Care Access and Use: Private InsurancePrivate insurance coverage among persons less than 65 years of age by poverty status and rurality
31.5
46.341.1 42.2 41.0
86.590.5
87.1 87.4 85.8
23.6
30.227.7 26.0
22.9
80.684.6
80.3 78.8 76.8
0
10
20
30
40
50
60
70
80
90
100
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
Family Income < 200% Poverty (1997-1998)
Family Income ≥ 200% Poverty (1997-1998)Family Income < 200% Poverty (2010-2011)
Family Income ≥ 200% Poverty (2010-2011)
46
Health Care Access and Use: Employer-Sponsored Health Insurance
Employer-sponsored insurance coverage among persons less than 65 years of age by poverty status and rurality
27.9
41.437.4 37.6 36.3
80.984.9
82.1 81.778.1
19.1
25.4 23.4 23.018.8
74.0
79.775.2
72.968.6
0
10
20
30
40
50
60
70
80
90
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
Family Income < 200% Poverty (1997-1998)
Family Income ≥ 200% Poverty (1997-1998)Family Income < 200% Poverty (2010-2011)
Family Income ≥ 200% Poverty (2010-2011)
12/10/2014
24
47
Health Care Access and Use: Employer-Sponsored Health Insurance
Employer-sponsored insurance coverage among persons less than 65 years of age by region and rurality, 2010-2011
0
10
20
30
40
50
60
70
80
All Regions Northeast Midwest South West
Perc
ent Large central
Large fringe
Small metro
Nonmetropolitan counties
48
Health Care Access and Use: Physician SupplyPatient care physicians per 100,000 population by rurality
308.5
223.5 227.7
147.2
80.0
380.5
268.4 260.8
143.9
77.3
0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
400.0
Large central Large fringe Small metro Micropolitan Non-core
Patie
nt c
are
phys
icia
ns p
er 1
00,0
00 p
opul
atio
n
19982010
12/10/2014
25
49
Health Care Access and Use: Physician SupplyPrimary care physicians per 100,000 population by rurality, 2010
27.024.5
34.2
29.631.6
25.1
20.1
15.6
8.8
3.7
49.6
37.1
30.5
17.9
8.9
16.0
12.4 11.4
7.5
3.00.0
10.0
20.0
30.0
40.0
50.0
60.0
Large central Large fringe Small metro Micropolitan Non-core
Patie
nt c
are
phys
icia
ns p
er 1
00,0
00 p
opul
atio
n
General and family practitioners
General pediatricians
General internists
Obstetricians and gynecologists
50
Health Care Access and Use: Dentist SupplyDentists per 100,000 population by rurality
61.7 60.6
49.8
41.3
29.0
83.2
71.5
56.5
40.2
30.4
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
Large central Large fringe Small metro Micropolitan Non-core
Den
tists
per
100
,000
pop
ulat
ion
19982007
12/10/2014
26
51
Health Care Access and Use: Dental VisitsDental visit within the past year among persons 18-64 years of age by rurality
65.6
71.4
63.760.5
56.860.9
66.3
61.056.8
52.2
0
10
20
30
40
50
60
70
80
Large central Large fringe Small metro Micropolitan Non-core
Perc
ent
1997-1998
2010-2011
52
Health Care Access and Use: Inpatient Hospital Use
Hospital discharge rates among persons 18-64 years of age by rurality
67.565.0
70.8
92.6
71.367.6
75.9 73.9
0
10
20
30
40
50
60
70
80
90
100
Large central Large fringe Small metro Nonmetropolitan
Dis
char
ges
per 1
,000
pop
ulat
ion
1998
2010-2011
12/10/2014
27
53
Health Care Access and Use: Substance Abuse Treatment
Substance abuse treatment admission rates for alcohol by rurality
190.5
241.7
307.9
387.1
244.7247.8 245.2
292.7
326.8
250.3
0
50
100
150
200
250
300
350
400
450
Large central Large fringe Small metro Micropolitan Non-core
Adm
issi
ons
per 1
00,0
00 p
opul
atio
n
Alcohol (1998)
Alcohol (2010)
54
Health Care Access and Use: Substance Abuse Treatment
Substance abuse treatment admission rates for opiates by rurality
148.7
101.0
67.6
23.9
10.6
176.0 172.5
142.8
127.3
90.4
0
20
40
60
80
100
120
140
160
180
200
Large central Large fringe Small metro Micropolitan Non-core
Adm
issi
ons
per 1
00,0
00 p
opul
atio
n
Opiates (1998)
Opiates (2010)
12/10/2014
28
55
Health Care Access and Use: Substance Abuse Treatment
Substance abuse treatment admission rates for marijuana by rurality
67.5 67.4
90.8
106.9
67.8
128.9
99.9
137.2
162.8
112.0
0
20
40
60
80
100
120
140
160
180
Large central Large fringe Small metro Micropolitan Non-core
Adm
issi
ons
per 1
00,0
00 p
opul
atio
n
Marijuana (1998)
Marijuana (2010)
56
Health Care Access and Use: Substance Abuse Treatment
Substance abuse treatment admission rates for stimulants by rurality
26.4
17.6
27.0
45.7
21.8
48.7
21.5
50.1
57.9
45.8
0
10
20
30
40
50
60
70
Large central Large fringe Small metro Micropolitan Non-core
Adm
issi
ons
per 1
00,0
00 p
opul
atio
n
Stimulants (1998)
Stimulants (2010)
12/10/2014
29
57
Health Care Access and Use: Substance Abuse Treatment
Substance abuse treatment admission rates by primary substance and rurality, 2010
0
50
100
150
200
250
300
350
Alcohol Opiates Cocaine Marijuana Stimulants
Large central
Large fringe
Small metro
Micropolitan
Non-core
58
Other Mental Health Measures: Serious Psychological Distress
Past 30-day serious psychological distress (SPD) among persons 18 years of age and older by region and rurality, 2010-2011
0
1
2
3
4
5
6
7
8
All Regions Northeast Midwest South West
Perc
ent
Large central
Large fringe
Small metro
Micropolitan
Non-core
12/10/2014
30
59
Resources
• Rural Health Research Gatewayhttp://www.ruralhealthresearch.org/
• Rural Assistance CenterTools for Success
http://www.raconline.org/success
Community Health Gateway
http://www.raconline.org/communityhealth
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Alana Knudson, PhD, Deputy DirectorNORC Walsh Center for Rural Health Analysis4350 East West Highway, Suite 700Bethesda, Maryland 20814301.634.9326 • walshcenter.norc.org • knudson-alana@norc.org
Gary Hart, PhD, DirectorCenter for Rural HealthUniversity of North DakotaSchool of Medicine & Health Sciences, Room 4909501 North Columbia Road, Stop #9037Grand Forks, ND 58202-9037701.777.3848 • ruralhealth.und.edu • gary.hart@med.und.edu
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