County Health Rankings:Why do we all want to be above

average?

Julie Willems Van Dijk RN PhDUniversity of Wisconsin Population Health

Institute

Gianfranco PezzinoSenior 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?

Who?

Rankings are everywhere

Our Logic Model

Population-based data collected

Media attention

County Health Rankings Local health

officers use report

Broad community engagement

Evidence-based health programs and policies implemented

Improved health outcomes

Population-based data collected

Media attention

County Health Rankings Local health

officers use report

Broad community engagement

Evidence-based health programs and policies implemented

Improved health outcomes

Our Logic Model

Programs and Policies

Health FactorsPrograms and

Policies

Health FactorsPrograms and

PoliciesHealth Outcomes

Programs and Policies

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 OutcomesMortality (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

Actiondepends on stage of readinessin the county

TowardCommunity Healthby setting goals and monitoring progress over time

Setting goals and objectives for overall health

Keeping track of progress

throughCounty 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

County Health Rankings:An Example in Action

Gianfranco Pezzino, M.D., M.P.H.

Senior Fellow

Kansas Health Institute

Why rankingWhy 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…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 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 IndicatorsKansas 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 OutcomesMortality (length of life): 50%

Morbidity (quality of life): 50%

County Health Rankings model © 2010 UWPHI

MATCH Logic Model and IndicatorsMATCH Logic Model and Indicators

(4 measures of morbidity)

Weights (original slides from 6-2009)Weights (original slides from 6-2009)

Based on best evidence, but

somewhat arbitrary

Kansas Health Model and IndicatorsKansas 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 OutcomesMortality (length of life): 50%

Morbidity (quality of life): 50%

County Health Rankings model © 2010 UWPHI

MATCH Logic Model and IndicatorsMATCH Logic Model and Indicators

Limitations of County Health Rankings

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 LimitationsSome 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 CountsSmall 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

Number of “Reportable” Indicators in KS

31 Indicators 26 counties

20 to 30 Indicators 69 counties

< 20 Indicators 10 counties

Smallest number of Indicators = 15 2 counties

How to account for what is NOT measured

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

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

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*Media coverage*

15 printed newspapers 7 online news services 5 broadcast outlets

* (as of June 12, 2009)

How Can we Use it?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 CountyWyandotte County

The Reaction of the “Last one”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

ConclusionsConclusions

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. Conclusions, Ctd.

Be proactive Be a driver, not

a passenger

Involve stakeholders before the release

Kansas Health InstituteKansas Health Institute

Healthier Kansans through informed decisions

DISCUSSION

Learn more at www.countyhealthrankings.org

Questions? Contact us atmatch-info@match.wisc.edu