Dr. Nir Menachemi, chair of the health policy and
management department at Indiana University’s
Richard M. Fairbanks School of Public Health.
There is one clue that speaks volumes about your health prospects but has nothing to do with your medical records.
“We know now that one of the greatest predictors of health outcomes for almost any patient, undergoing any procedure, or with almost any disease, is one value on a patient’s chart,” says Dr. Nir Menachemi, chair of the health policy and management department at Indiana University’s Richard M. Fairbanks School of Public Health. “And that value isn’t medical. It’s their ZIP code. You can tell with extreme accuracy how someone is going to fare, after a procedure, by their ZIP code.”
Where a person lives is critical because health is shaped by factors outside the scope of traditional medical interventions and advice.
“In this country, we tend to medicalize health-care issues,” Menachemi says. “If someone is having a health issue, we automatically assume the medical system can fix it. A lot of organizations are now beginning to realize that many health issues are not necessarily problems that can be addressed through medical care alone. They’re bigger issues in the communities where people live.”
Menachemi is participating in a study, funded by the Robert Wood Johnson Foundation, that aims to help medical professionals and institutions make better use of that data. The project, which draws on the resources of The Polis Center, the Regenestrief Institute, and the Richard M.
Fairbanks School of Health, is testing a tool that predicts what kind of care might best serve a patient. To do so, it uses an algorithm that incorporates medical records as well as neighborhood-level data from the SAVI Community Information System supplied by Polis.
“We’re taking data about the neighborhood where patients live and seeing if we can predict who’s at risk for needing some of these social services,” Menachemi says. Services include nutritionists, financial and legal advisers, and mental health professionals. “The medical way of thinking about a problem is, if the patient isn’t doing well after a couple of visits, figure out the next medical intervention. Whereas, if you deploy a nutritionist to take them grocery shopping, and better educate the family on how to stretch the buck to incorporate healthy eating into the family’s lifestyle, maybe you’ll actually put a dent in the ability of the family to manage diabetes, for example.”The tool has been in the pilot stages and will soon be implemented in the 10 health clinics maintained by Eskenazi Health.
“This is absolutely at the cutting edge,” Menachemi says of the collaboration. “It’s almost like this perfect marriage of forces— all of us on the same team, trying to figure out how to lead the nation in improving quality and reducing costs in health care.”
About 45 percent of the U.S. population smoked in the mid-1960s. In the last half century, the rate has fallen by two-thirds, to about 15 percent.
But the success is uneven, and the story is complicated. Smoking rates vary widely from state to state, city to city, and even neighborhood to neighborhood. In Indiana, 20.6 percent of the population smokes—the 12th highest rate in the nation. In Marion County, the rate is just as high: 21.8 percent of the population smokes. In the five states with the lowest smoking rates, the numbers range from nine to 14 percent.
Just as smoking rates vary widely across geographies, access to tobacco is radically uneven from place to place.
That’s the key finding of a new report from The Polis Center, Unequal Access, which details the density of tobacco
retailing in the Indianapolis area.
“While unequal access typically refers to less access to a desirable resource by marginalized populations,” the report notes, “greater access by and to marginalized populations is the troublesome inequity” in the case of tobacco products and tobacco marketing.
The disparities in tobacco access matter because greater density of tobacco retailers has been associated with higher rates of smoking. High density of retailers also means there is a concentration of tobacco marketing among populations that are already vulnerable to high rates of tobacco use. Unequal Access helps policymakers and public health professionals connect these dots—between poor health outcomes, high smoking rates, access to tobacco products, and
“We’ve known for a long time that smoking is bad—that it causes cancer and a lot of other health problems,” says Karen Frederickson Comer, a coauthor of the report and the director of collaborative research and health geoinformatics at The Polis Center. “And yet, despite all this knowledge, our population continues to smoke at higher rates than the rest of the nation. So the question is, what more can we do to target the problem?”
The price of access
Indiana has about 8,500 licensed tobacco retailers. About 2,000 of them are located in the Indianapolis metro area, where, “as in other U.S. cities, tobacco retail outlets are concentrated where smoking rates are predicted to be the highest.”
The report found that in “high access” areas, the poverty rate is more than three times higher than in “low access” areas. The differences are similarly stark across
a range of metrics. In the areas of high access, the number of people without a high school degree is almost three times higher than in low access areas; the rate
of maternal smoking is nearly double; and the number of people without access to a car is over four times higher. High access areas also have the greatest populations of people of color and the highest rates of people with self-reported mental health issues. Nationwide, people with psychiatric or addictive disorders consume about 40 percent of the cigarettes purchased.
“Smoking rates are higher among people of limited means, and there’s a very high rate of smoking among people with a mental health diagnosis,” says Virginia
Caine, director of the Marion County Health Department. “Many people with mental health issues want to quit, but for some of them it’s a coping mechanism, or strategy, that helps them reduce their stress.”
There are good reasons to quantify tobacco retailing in relationship to high smoking rates in Indiana and the Indianapolis metro area. The stakes are high on multiple levels, beginning with economics.
Each year, healthcare expenses related to smoking cost Indiana an estimated $3 billion. The state and federal tax bill for treating smoking-related diseases, per
household, is about $900. And, the annual cost for lost productivity due to smoking is another estimated $3 billion.
Smoking also imposes profound human costs across all age ranges. Nearly 20 percent of deaths in the state are attributable to it, according to Caine, while
in Utah, which has the lowest percent of smoking-related deaths, the figure is less than 10 percent.
A long way come, a long way to go
The “common sense” about smoking, which blames it on a weakness of individual will, underplays the addictive power of tobacco and the power of marketing that targets vulnerable populations. Tobacco is “aggressively and skillfully marketed by the tobacco companies,” Caine says, and smoking is “often perceived as a bad habit that’s easily broken. Too often, it’s not seen as a public health issue” that can be dramatically influenced—for good or bad—by public policy.
Caine notes that Indiana has had some notable recent success in this arena. Over the past five years, the smoking rate has dropped by several points, from the mid-20s to the low-20s, and there are some small but important signs of progress. For example, the Indianapolis Motor Speedway recently announced that it would ban smoking in grandstand seats beginning in late 2017.
“We’ve come a long way,” Caine says. “I don’t think, even 10 to 15 years ago, people realized the extent of the harm done by smoking.”
For all the progress, though, much more could be done. Indiana should invest about $74 million per year in tobacco control, according to the Centers for Disease
Control’s recommendation. Yet the state’s tobacco control programs receive only $7 million annually in state and federal funding. Tobacco companies, meantime,
spend nearly $285 million on marketing their products in the state each year.
And, crucially, policy makers’ most powerful tool to reduce smoking is blunted in Indiana, relative to other states. Studies consistently demonstrate that “cigarettes are no different than any other consumer product,” in that they’re price sensitive: “As the price of cigarettes goes up, the sale of cigarettes goes down.”
Indiana’s tax per pack is $0.995, which is lower than all but 13 states. The average tax in all states is $1.69 per pack. “A broad coalition of business, health care, not-for-profit and academic groups have joined forces to advocate for legislation to raise the tax by $1.50,” the report notes. The move would have both human and economic benefits, “saving countless Hoosier lives and avoiding millions in healthcare and lost productivity costs.”
Stricter smoke-free air laws would also make a difference, along with raising the legal age for purchasing tobacco. State lawmakers could also address the problem by reducing the number of tobacco retailers and imposing tighter restriction on point-of-sale marketing—actions that cities and towns can’t take on their own, by state law. The key is to stay focused, and to keep working on a problem that poses serious health challenges and imposes steep costs on the whole state—but affects different communities in very different ways. “We have to continue to be vigilant,” Caine says. “We have to have discussions, and we have to push our policy makers to understand that we still have a crisis of public health related to tobacco use.”
A team whose players complement each other well is sometimes described as “more than the sum of its parts.” Patrick T.S. Lai was drawn to Central Indiana because such synergies are emerging in the realm of health care.
Lai, a doctoral candidate in the School of Informatics and Computing at IUPUI, says that the region has two resources that
are valuable in themselves: a network of comprehensive electronic health records, called the Indiana Network for Patient Care,
and The Polis Center’s SAVI database, which offers comprehensive community data.
By combining data from these resources for his dissertation work, Lai is trying to understand which neighborhoods have the
highest rates of two sexually transmitted diseases (STDs), chlamydia and gonorrhea. But, he’s also aiming to understand why
those neighborhoods have higher rates.
Getting at the “why” requires the kind of rich neighborhood profiles that SAVI offers, which when used with health record data
“is a great opportunity to understand the underlying factors of disease.”
Certain social factors influence and predict the rate of STDs in a given neighborhood. These “social determinants” include median income, education level,
population density, and the unemployment rate, among others.
It’s well know that such factors play a role in disease transmission, but the exact relationship isn’t clear. Lai aims “to identify which social determinants contribute most” to STD rates in a neighborhood.
His work is important, he says, because “knowing some of the biggest contributors could guide us in thinking about how we can effectively combat and reduce the
spread of disease.”
Another example of how SAVI is fostering healthcare synergies is the community public health course offered by Barbara Blackford, an assistant professor in
the School of Nursing at Marian College.
Blackford assigns groups of nursing students to conduct a “windshield survey” of certain census tracts. Each group drives around its assigned area, making notes of the community’s assets and liabilities. Then, they use SAVI to flesh out their observations with hard data about the prevailing socioeconomic and physical conditions, and each group gives a presentation about what they’ve learned.
Before Blackford’s students began using SAVI five years ago, they drew on a variety of scattered sources to supplement their windshield surveys.
“SAVI makes it so much easier,” she says. “It’s been a fantastic tool to help my students consider social and environmental determinants of health.”