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PubMed1998

Use of Medicare claims data to measure county-level variations in the incidence of colorectal carcinoma.

BACKGROUND: Population-based cancer registries that can be used to compare cancer incidence and mortality across regions of the U.S. are currently lacking. The authors conducted this study to validate Medicare claims as a measure of county-level colorectal carcinoma incidence among older Americans. Variations found among counties are described in this article. METHODS: A total of 183,174 hospitalized patients age 65 years in 1991-1993 with newly diagnosed colorectal carcinoma who resided in one of 480 large counties were identified in Medicare files. The county-level truncated age, race, and gender adjusted incidence rates for the population age 65 years, the proportion of patients with a code indicating distant metastases, and the 2-year case-fatality rates were determined. Corresponding rates from the SEER database were compared. RESULTS: The median truncated adjusted 3-year incidence rate was 870 per 100,000 (Quartile 1-Quartile 3, 779-955), with almost twofold differences among counties even after the exclusion of outliers. The median proportion of patients with codes indicating distant metastases was 23.4% (range, 10.2-46.9%; Quartile 1-Quartile 3, 20.8-25.8), and the average 2-year case-fatality rate was 39.2% (range, 26.5-51.4%; Quartile 1-Quartile 3, 37.0-41.6). Medicare files tended to underestimate the truncated incidence rate according to SEER, but among counties the two sets of rates were closely correlated (r = 0.94, P < 0.0001). CONCLUSIONS: Medicare files are a potential alternative source of national data for the study of colorectal carcinoma incidence among the elderly at the county level. The data also suggest significant variations among counties in colorectal carcinoma incidence, stage, and mortality that could be used in public health initiatives.

Age Factors↗
PubMed1985

Female reproductive organs and breast cancer mortality in New Jersey counties and the relationship with certain environmental variables.

Age-adjusted female reproductive organs and breast cancer mortality rates (all sites combined) were higher in 19 of 21 New Jersey counties than the U.S. national rates. Compared with national trends, New Jersey cervical cancer and corpus uteri rates have declined less than the national rate among all races. Ovarian and breast cancer rates have not changed over the years, a pattern similar to that of the nation. New Jersey cancer mortality rates during the period 1968-1977 that highly significantly (P less than 0.0005) exceeded national rates were cancers of the cervix in 2 counties among whites and in one county among nonwhites; of the corpus uteri and uterus not specified in 3 counties among whites; of the ovaries in 3 counties among whites; and of the breast in 10 counties among whites. The overall New Jersey cancer mortality significantly (P less than 0.0005) exceeded national rates for ovarian cancer among whites and nonwhites and for breast cancer among whites. Statistically significant and positive correlations were found between breast cancer mortality and chemical toxic waste disposal sites, annual per capita income, urbanization index, and population density among whites in 21 New Jersey counties. Ovarian cancer mortality was also significantly and positively correlated with annual per capita income, and negatively with birth defects. Cervical cancer mortality showed a significant negative correlation with annual per capita income and a significant positive correlation with birth defects and low birth weight among nonwhites in 21 New Jersey counties.

Age Factors↗
PubMed2004

County characteristics and racial and ethnic disparities in the use of preventive services.

BACKGROUND: Studies examining predictors of preventive service utilization generally focus on individual characteristics and ignore the role of contextual variables. To help address this gap in the literature, the present study investigates whether county-level characteristics, such as racial and ethnic composition, are associated with the use of preventive services. METHODS: Data from the Medical Expenditure Panel Survey and the Area Resource Files (1996-1998) are used to identify the individual- and county-level predictors of five types of preventive services (n = 49,063). RESULTS: County racial or ethnic composition is associated with the utilization of certain preventive services, net of individual-level characteristics. Specifically, individuals in high percent Hispanic counties are more likely to report cholesterol screenings, while those in counties with more blacks are more likely to have regular mammograms. Moreover, county racial or ethnic composition modifies the relationship between individual race or ethnicity and preventive use. In particular, Hispanic individuals who reside in high percent black counties report higher levels of utilization for most preventive services compared to Hispanics living in other counties. CONCLUSIONS: Physical and social environments are key determinants of health behaviors and outcomes. Future studies should take into account the racial or ethnic composition of an area and how this interacts with individual race or ethnicity when investigating predictors of preventive care use.

Adult↗
PubMedDate not supplied

Air pollution and fatal lung disease in three Utah counties.

A unique situation found in two Utah counties has made it possible to estimate the fraction of respiratory cancer and nonmalignant respiratory disease (NMRD) deaths, which are attributable to community air pollution (CAP) in one county. The two counties were very similar in many ways, including low smoking rates, until a steel mill constructed during WW II caused substantial CAP in one of them. Subsequent differences in mortality rates from both respiratory cancer and NMRD are striking. A third county, similar to many counties outside Utah, was included in the analysis for comparison. In one county, 30-40% of the respiratory cancer and NMRD deaths were attributable to CAP. In this county, NMRD deaths (but not respiratory cancer deaths) were slightly more frequent than in Salt Lake County where smoking rates were twice as high.

Age Factors↗
PubMed1983

Gastrointestinal cancer mortality in New Jersey counties, and the relationship with environmental variables.

The State of New Jersey (NJ) USA has been thought to have an unusually high cancer mortality rate; this assumption has been based on 1950-1969 mortality data for its 21 counties. This paper presents an analysis of gastrointestinal (GI) cancer mortality rates in New Jersey counties during 1968-1977, a comparison with the 1950-1969 rates, and associations between current GI cancer mortality rates and selected environmental variables. Age-adjusted mortality rates for GI cancers were calculated for the 21 NJ counties during the period 1968-1977, and were compared with the period 1950-1969, with the Surveillance, Epidemiology and End Results (SEER) survey and with cancer mortality in the US, 1973-1977. The county rates were also correlated with: the distribution of chemical toxic waste disposal sites; annual per capita income; the rates of low birth weight, birth defects, and infant mortality; chemical industry distribution; percentage of the population employed in chemical industries; the density of population; and the urbanization index for each of the counties. Some of the major findings are: Age-adjusted GI cancer mortality rates (all sites combined) were higher than national rates in 20 of 21 NJ counties. In comparison with national trends, NJ stomach cancer rates have declined less, oesophageal cancer rates have declined more, and pancreatic cancer mortality rates have followed similar patterns. Cancer mortality rates in NJ during the period 1968-1977 significantly (p less than 0.0001) exceeded national rates for cancer of the oesophagus (white male, non-white male), stomach (men and women), colon (white male, white female, non-white female), and rectum (whites only). In 18 of the 21 NJ counties, the observed number of cancer deaths for at least one GI cancer site was significantly greater than expected at the 0.0001 level for at least one population subgroup. Among white men, a significant (p less than 0.0001) excess of observed over expected cancer deaths was observed for three or more GI cancer sites in seven counties. The environmental variables that were most frequently associated with GI cancer mortality rates (except pancreatic cancer) were degree of urbanization, population density, and chemical toxic waste disposal sites. Some of the implications of the study findings are discussed and recommendations made for future investigations.

Adult↗
PubMed1997

Predictions and maps of county mean indoor radon concentrations in the mid-Atlantic states.

Measured surface radium content, geologic province information, information on the fraction of homes with basements and with living-area basements, and measurements from the EPA/State Residential Radon Surveys, were used in a Bayesian mixed effects regression to predict the distributions of short-term winter and annual living-area average radon concentrations by county in the mid-Atlantic states. The information provided by those explanatory variables is roughly equivalent to collecting an extra 12 observations per county, effectively doubling the amount of information in a typical county. Predicted county geometric means are subject to standard errors of 15% to 30% for typical counties, with the uncertainty in a given county depending on the number of radon measurements in the county and the amount of information about the geologic province that contains the county. After controlling for soil radium concentration and the effect of measuring in a basement vs. the first floor, typical geologic provinces are found to be associated with elevation or depression of indoor radon concentrations by 30% on average, with some provinces having effects of considerably larger magnitude.

Air Pollutants, Radioactive↗
PubMed2004

Public attitudes toward smoking bans in a tobacco-producing county.

OBJECTIVES: Allen County, KY, is a rural county with a population of approximately 18,000. The county has a tobacco crop and is in a state in which tobacco interests are influential. The tobacco control program at the public health department developed a goal to reduce environmental tobacco smoke by restricting smoking in public places. To progress toward that goal, a public opinion poll was conducted to determine citizens' views regarding smoking restrictions in the county courthouse. METHODS: A telephone survey was conducted using the Allen County telephone directory as a sampling frame. The survey instrument included questions on support for smoking restrictions in the courthouse, restaurants, and workplaces as well as support for increasing Kentucky's cigarette tax. Interviews with 374 individuals--53.6% of the initial sample--were completed. RESULTS: Banning all smoking in the Allen County Courthouse was supported by 163 (43.4%) of the respondents. Designated smoking areas were supported by 168 (44.7%) of the respondents. Twenty-four (6.4%) of the respondents opposed any smoking restrictions at the courthouse. Women were more likely to support a ban on all smoking at the courthouse (45.4% compared with 40%). Males were more likely to support designated smoking areas (46.2% of males versus 43.8% of females). There was a small association between opposition to smoking restrictions at the courthouse and smoking by the respondent. An increase in Kentucky's cigarette tax was supported by 132 (35.1%) of the respondents and opposed by 184 (48.9%). There was no association between ownership of a tobacco-farming allotment and opinion regarding any of the tobacco control measures. CONCLUSIONS: Most Allen County residents support some form of restriction on smoking in public places (including the county courthouse and restaurants) and in workplaces. Only approximately one-third, however, supported an increase in the cigarette tax, perhaps reflecting a general antitax feeling. Ownership of tobacco allotments does not appear to be an important factor in determining attitudes on smoking control issues.

Agriculture↗
PubMed2006

Cancer mortality among populations residing in counties near the Hanford site, 1950-2000.

A descriptive epidemiologic study of cancer mortality among residents of counties near the Hanford nuclear facility site in Richland, Washington, was conducted. Between 1944 and 1957, radioactive 131I was released into the environment from the Hanford site. Cancer mortality from 1950 through 2000 was evaluated in four counties with the highest estimated exposure to 131I and compared with the cancer mortality experience in five demographically similar counties in Washington State with minimal 131I exposure. Overall, cancer rates in the study counties were slightly below those in the comparison counties [relative risk (RR) 0.95; 95% confidence interval (CI) 0.93-0.97], due mainly to a low risk for lung cancer (RR 0.89; 95% CI 0.85-0.93). Thyroid cancer (n=33; RR 0.84; 95% CI 0.56-1.26), female breast cancer (n=1,233; RR 0.99; 95% CI 0.92-1.06), leukemia other than chronic lymphocytic leukemia (n=492; RR 0.95; 95% CI 0.85-1.06), and childhood leukemia (n=71; RR=1.06; 95% CI 0.78-1.43) were not significantly increased in the exposed counties. Furthermore, there was no evidence that the cancer death rates over time differed between study and comparison counties. Patterns over time of thyroid cancer in particular were similar for exposure and comparison counties. Although based on a geographic correlation design, these data suggest that living near the Hanford site has not increased cancer rates.

Adult↗
PubMed2004

Variation in access to health care for different racial/ethnic groups by the racial/ethnic composition of an individual's county of residence.

BACKGROUND: Although the majority of studies examining racial/ethnic disparities in health care have focused on the characteristics of the individual, more recently there has been growing attention to the notion that an individual's health practices could be influenced by the characteristics of the place where they reside. OBJECTIVE: The objective of this study was to examine whether access to care for individuals of different racial/ethnic groups varies by the prevalence of blacks and the prevalence of Latinos in their county of residence. STUDY DESIGN: We conducted a cross-sectional cohort. PARTICIPANTS: Individuals from the 1996 Medical Expenditure Panel Survey, a nationally representative sample of U.S. households, who described their race/ethnicity as white, black, or Latino, and who resided in 1 of 677 counties (n = 14740) were studied. MEASURES: Counties were assigned to 6 groups based on the prevalence of blacks and Latinos who resided there (<6% referred to as "low prevalence," 6-39% referred to as "midprevalence," >or=40% referred to as "high prevalence" separately for both blacks and Latinos). Outcomes included whether during the past year any family members: 1). experienced difficulty obtaining any type of health care, delayed obtaining care, or did not receive health care they thought they needed (referred to as "difficulty obtaining care"); or (2). did not receive a doctor's care or a prescription medication because the family needed money to buy food, clothing, or pay for housing (referred to as "financial barriers"). RESULTS: After controlling for other individual and area-level covariates, blacks reported lower rates of both outcome variables when they lived in a county with a high prevalence of blacks compared with blacks who lived in a county with a low prevalence of blacks (difficulty obtaining care: 4.3% vs. 18.8%, P <0.005; financial barriers: 1.6% vs. 10.5%, P <0.005). There was a similar association for Latinos by the prevalence of Latinos in the county for difficulty obtaining care (high: 5.0% vs. low: 13.4%, P <0.05), but not the financial barriers outcome (high: 2.2% vs. low: 2.4%, P = 0.90). Whites who lived in an area with a high prevalence of Latinos were more likely to report both outcomes compared with whites who lived in a county with a low prevalence of Latinos (difficulty obtaining care: 17.7% vs. 9.4%, P <0.05; financial barriers: 8.5% vs. 3.2%, P <0.005) . CONCLUSIONS: Blacks and Latinos may perceive fewer barriers to care when they live in a county with a high prevalence of people of similar race/ethnicity. Conversely, whites may perceive more difficulty receiving care when they live in an area with a high prevalence of Latinos. Diminishing disparities in access to health care may require interventions that extend beyond the individual.

Adult↗
PubMed1999

What we say and what we do: county-level public spending for health care.

The purpose of this study is to examine county-level public spending for health care services in Kansas and to explain variation in spending levels with a model composed of population density, population age and per capita income. Data are abstracted from budget documents for all 105 counties in Kansas for the years 1994, 1995 and 1996. Health care expenditures are defined as county tax revenues spent for ambulance, hospitals, ambulatory care, home health services, nursing homes, and mental health and substance abuse services. Results show that Kansas counties spent between 12.1 percent and 13.6 percent of their budgets to fund local health care services between 1994 and 1996, spending more than $133 million in 1996 alone. In 10 counties, one-quarter to one-third of the budget went for health services. Low population density and relatively high per capita income explained nearly one-third of the variation in how much counties spent and an even greater proportion when analysis was limited to the most rural counties. Findings from this study suggest there may be a significant local commitment in the United States to publicly supported health care services, more support than typically recognized and perhaps more than is estimated in national health care spending data. Future research on the economic effects of the health sector on local communities should take account of local spending for health care, especially at the county level.

Budgets↗
PubMed2002

Disparities in mammography screening in rural areas: analysis of county differences in North Carolina.

The extent to which targeted mammography programs have impacted women in rural areas is not well defined. We investigated mammography screening rates among 843 women age 50 and over from a population-based sample in four predominantly rural eastern North Carolina counties. We examined age, race, education level, county of residence, health insurance, and the self-reported completion of mammography in the past year using contingency tables and logistic regression. African American females aged 65 years or older had the lowest reported mammography rates (42%), while white females aged 50 to 64 had the highest rates (58%). Uninsured women and those with less education were less likely to have received a mammogram. Logistic regression demonstrated that age, education, and health insurance were significant predictors of mammography completion. A county-level analysis revealed that three counties had similar rates and one county had substantially lower rates. A higher-than-expected rate of screening-mammography completion among African American women was noted in one predominantly rural county served by a breast cancer screening program. Logistic regression analysis confirmed that county was a significant predictor for mammography completion. In separate regressions run by race, county remained a significant predictor for African American women but not for white women. Differences in mammography screening appear to persist in some predominantly rural areas and are related to age, race, education, and health insurance. Programs that target hard-to-reach women with efforts tailored specifically to their needs may be effective in reducing persistent racial differences.

Black or African American↗
PubMed2005

Environmental perceptions related to physical activity in high- and low-risk counties.

To identify whether perceptions about the physical activity environment were related to the prevalence of sedentary lifestyle, residents from high-risk (n = 153) or low-risk (n = 100) counties were interviewed. County risk status was determined by the prevalence of cardiovascular mortality, overweight, and sedentary lifestyle. Key public officials in the same counties were also interviewed. Residents in the low-risk county were more likely to report having sidewalks in their community and that these sidewalks were safe and well lit than residents living in the high-risk counties. Low-risk county residents also reported more indoor recreation facilities being available than the residents in the high-risk counties. Residents supported allocating tax dollars toward improving sidewalks, lighting, and so on. Thus a more conducive environment for physical activity was found in the low-risk county. Improving physical environments and individual perceptions could help increase physical activity behavior.

Behavioral Risk Factor Surveillance System↗
PubMed1994

Cesarean section in twin pregnancies in two Danish counties with different cesarean section rates.

OBJECTIVE: Based on a comparison of the clinical indications for cesarean section (CS) in two Danish counties and a review of the literature regarding this issue the aim of this study was to discuss possible explanations for variations in CS rates in twin pregnancies. The comparison of indications for CS in twin pregnancies was made between two Danish counties, one with a high and one with a low overall CS rate in twin deliveries, taking into account the distribution of parity, mother's age, gestational age at birth, and birth weight. DESIGN: A population based, historic follow-up study based on antecedent data. SETTING: Two Danish counties, with a CS rate in twin pregnancies of 57% and 28%, respectively. SUBJECTS: All women with twin pregnancies who delivered in 1989 in the two counties. MAIN OUTCOME MEASURES: Comparison of the CS rates in the two counties according to indications and fetal presentation. SECONDARY MEASURES: Perinatal and maternal outcome. RESULTS: The difference in CS rates between the two counties could not be explained by different distributions of background characteristics. Different attitudes were found towards CS in cases with previous CS, with twin A in breech presentation and in cases with vertex-breech deliveries. These differences could explain less than two thirds of the overall 29% (CI: 12-46%) difference in risk of CS between the two counties, indicating more subtle reasons for the discrepancy. No difference between the two counties in perinatal morbidity and mortality was seen. CONCLUSION: In order to understand and discuss regional variations in the use of CSs in twin deliveries the subjects must be addressed in different ways: the unequivocal indications related to fetal presentations and previous CS can be subjected to randomised controlled trials or large scaled follow-up studies regarding maternal and perinatal morbidity and mortality. Other more subtle determinants of the physicians' and the pregnant women's attitude towards CS, however, seem quantitatively important, and these can only be evaluated in observational studies and through discussions.

Adult↗
PubMed2000

Income inequality and all-cause mortality in the 100 counties of North Carolina.

BACKGROUND: This study evaluated the relationship between income inequality and all-cause mortality in the 100 counties of North Carolina. METHODS: Mortality data for 1985 to 1994 came from the National Center for Health Statistics and household income data from the 1990 Census. Associations between county-level income inequality and age-adjusted, all-cause mortality rates were evaluated in stratified and regression analyses. RESULTS: Stratified analyses suggest that all-cause mortality was directly related to income inequality in all 100 counties and in non-metropolitan statistical area (MSA) counties. This relationship was statistically significant, controlling for per capita income in regression analyses for all age groups except > or =65 years among all 100 counties and for all ages combined and for ages 35 to 64 among non-MSA counties. CONCLUSIONS: A relationship between income inequality and all-cause mortality previously identified nationally among states and MSAs was also found among all counties and non-MSA counties of North Carolina in 1985 to 1994.

Adolescent↗
PubMed2001

Lung cancer mortality report card: measuring progress in Wisconsin's counties, 1979-1998.

PURPOSE: To compare and contrast trends in lung cancer mortality in Wisconsin's 72 counties, as a measure of long-term progress in tobacco control. METHODS: Lung cancer mortality data were abstracted from the Centers for Disease Control and Prevention's WONDER database from 1979 to 1998. Percent change in lung cancer mortality rates were analyzed at the county and national levels from 1979-1983 to 1994-1998. RESULTS: In Wisconsin, lung cancer mortality rates increased 23%, compared to a 19% increase in the United States. There was more variation in lung cancer mortality trends between Wisconsin counties than between states, with increases in 67 of Wisconsin's 72 counties. Lung cancer mortality rates increased for men in 44 counties and for women in 68 counties. Only 4 counties in Wisconsin had fewer lung cancer deaths in 1994-1998 compared with 1979-1983. CONCLUSIONS: Progress in reducing lung cancer mortality in Wisconsin--a long-term measure of progress in tobacco control--has lagged behind the rest of the United States. Nevertheless, some Wisconsin counties have experienced more progress in reducing the health burden from lung cancer, suggesting that differences exist between communities in the effectiveness of their tobacco control efforts.

Adult↗
PubMed2001

The effects of income inequality and income level on mortality vary by population size in Texas counties.

OBJECTIVES: This study uses the counties of Texas to empirically test the predictions of Wilkinson's theory on the role of income and inequality in explaining health differentials in populations. Wilkinson predicts (1) that health is affected more by income inequality than average income in areas with large population, and (2) that health is affected more by average income than income inequality in areas with small population. We investigate how large the population of a unit must be for income inequality within the unit to affect mortality. METHODS: Measures of income inequality were computed from the 1990 U.S. census data and mortality was computed from Vital Statistics data. Poisson regressions estimated the age-adjusted relative risk of the top quintile relative to the bottom quintile for equality and for income among selections of Texas counties based on population size. County ethnic composition, educational level, and health care access were controlled for. RESULTS: Among counties with populations greater than 150,000, the risk of death was lower in counties with more equal income distribution than in counties with less equal income distribution. Among counties with population less than 150,000, median income affected relative risk in counties with less than 30 percent Hispanics, but not in those with more than 30 percent Hispanics. CONCLUSIONS: This study provides some support for the predictions of Wilkinson's theory.

Censuses↗
PubMed2006

[Impact of rural land market on farm household's behavior of soil & water conservation and its regional difference: A case study of Xingguo, Shangrao, and Yujiang County in Jiangxi province ecologically vulnerable districts].

The paper analyzed the farm households' decision-making progress of soil & water conservation and its two-stage conceptual model. It also discussed the impacts of rural land market on the farm households' behavior of soil & water conservation. Given that, the article established models for the relations between the land market and soil & water conservation, and the models' parameters were estimated with Heckman's two-stage approach by using the farm household questionnaires in Xingguo, Shangrao and Yujiang counties of Jiangxi province. The paper analyzed the impact o f rural land market on farm household's behavior of soil & water conservation and its regional difference with the result of model estimation. The results show that the perception of soil & water loss and the tax & fee on the farm land have significant influence upon the soil and water conservation from the view of the population; however, because of different social and economic condition, and soil & water loss, there are differences of the influence among the three sample counties. These differences go as follows in detail: In Xingguo County, the rent-in land area and its cost have remarkable effect on the farm households' soil & water conservation behavior; In Yujiang County, the rent-in land area, rent-in cost and rent-out land area remarkably influence the farm households' behavior of soil and water conservation, with the influence of the rent-in land area being greater than Xingguo County; In Shangrao County, only rent-out land area has significant influence on the behaviors of soil & water conservation; In all samples, Xingguo County and Yujiang County samples, the rent-out income has no significant influence on the farm household's decision-making behavior soil and water conservation. Finally, the paper put forward some suggestions on how to bring the soil & water loss under control and use land resource in sustainable ways.

Agriculture↗
PubMed2006

[Study on the quality of death-case-reporting-system in county and above levels' medical institutions in 2004].

OBJECTIVE: To study the quality of reporting network system on death cases among county and above levels' medical institutions. METHODS: Data on variables related to county reporting rate, unit reporting rate, timeliness of reporting, eligibility rate of reporting, auditing rate, timeliness of auditing, eligibility rate of auditing, percentage of reporting deaths of medical institutes to deaths among total population, percentage of reporting deaths of county and above levels' medical institutes to deaths among estimated deaths at these institutes were collected and distribution of common coding errors was applied to the assessment of reporting deaths. RESULTS: The total reporting rates were: 82.58% at the county level, 42.79% at the units with auditing rate as 96.96%. The eligibility rate of reporting was 69.10% with eligibility rate of auditing as 73.58%. The percentage of reporting deaths from medical institutes to deaths among total population was 8.91%, and the percentage of reporting deaths of county and above levels' medical institutes to deaths among estimated deaths of these institutes was 30.76%. The percentage of obvious coding errors among deaths reported by county and above levels' medical institutes was as high as 22.87%. CONCLUSION: Network reporting system of death cases among county and above levels' medical institutes had remarkably increased the timeliness of data reporting system. Network reporting of data on death was the best opportunity to expand the coverage and to improve the quality of data reporting. Based on network reporting of death cases among county and above levels' medical institutes as well as deaths accrued at the communities should also be reported via this network in the eligible areas. The quality of coding on death causes among medical institutes were commonly poor, indicating that the training on ascertainment and coding of underlying death causes were quite essential.

China↗