Sunday, August 30, 2015

Males Living Longer Outside Rural


Institute for Health Metrics and Evaluation /Daily Yonder This map shows the change in longevity for men living in rural and exurban counties between 1999 and 2009. In the dark green counties, life expectancy increased by 2.1 years or more. In the brown counties, life expectancy was stagnant or decreased. Click on the map to see a larger version.

The life expectancy of the average American male increased 2.1 years from 1999 to 2009, to just over 76 years of age.

But that increase was matched in only 382 rural and exurban counties, or 15 percent of all rural and exurban counties in the nation.

The map above shows the change in male life expectancy in rural and exurban counties between 1999 and 2009. In the dark green counties, male longevity increased 2.1 years (the national average) or more during that period.

Click on the map to see a larger version.

In the light green counties, life expectancy increased, but at less than the national average.

In the brown counties, male longevity was either stagnant or decreased. There were 158 rural or exurban counties where men are living shorter lives now than they were a decade earlier.

(Exurban counties are counties in metropolitan areas, but where half the population lives in a rural setting. The Institute for Health Metrics and Evaluation at the University of Washington compiled this data.)

Those counties where men’s lives are growing shorter in rural America are clustered largely in Appalachia, the South and in southern Oklahoma. 

The map shows that men living in rural America are simply not keeping up with the health advances in the rest of the country. In more than 8 out of ten rural counties, advances in male longevity failed to match the increase in the nation as a whole.

The chart below shows the 50 rural or exurban counties that had the largest absolute decline in lifespan among men. You can see that the counties with the biggest declines are largely in coal producing counties in Appalachia. Twenty-nine of these 50 counties were in Kentucky, Tennessee, Virginia or West Virginia. Six were in Oklahoma and four were in Georgia.

Even before 1999, men in these counties lived shorter lives than the national average of 76.2 years. In the last decade, however, in these counties men’s already-short lives grew shorter.

The chart below shows the 50 (and ties) rural and exurban counties where male longevity increased the most between 1999 and 2009. 

Most of these counties already had a long-lived male population, but some of these counties with above average gains were in places where men lived fewer years than the national average. Men in Clarke County, Alabama, for example, gained 3.4 years in the last decade, although they still live, on average, only 72.9 years, more than three year less than the national average.

There are a number of counties near the Texas/Mexico border with large gains added to male life expectancy that fell below the national. Zavala County is on this list and the map above shows a cluster of counties in South Texas with higher than average gains in life expectancy.



Social Determinant Themes

Education, employment, opportunity, parents, and other factors shape stressors that can shape longevity or early death. Lowest concentration origins in areas such as income, population density, property value (school funding), education, and language shape lower outcomes for male and female. This is seen in higher education access and medical school admission at the lowest levels or about 3 per 100,000 in the county per class year.

As males and females move up toward lower middle income there is a divergence with females moving up toward normal probability of medical school admission and higher education participation while males remain behind. In rural this is not quite 2 to 1 female to male but is headed this way. In African American it is already 2 to 1 female. Females other than the lowest concentration in origins have about the normal probability of admission while males are behind. Males of highest income tend to catch up and then reach 2 to 10 times greater probability of admission than the national average with populations male and female of the most combinations of concentration (income, pop density, property value, professional parents) having the top probability of medical school admission. Males have been falling behind for over a century except in the highest income levels.

Health care designers fail to understand social determinants in areas such as pay for performance. Physicians caring for those lower concentration in many dimensions will be rated lower in quality measures because they care for underserved populations as demonstrated by Hong in JAMA. More money thrown at teaching hospitals and taken from Medicare patients will not help outcomes for the same reasons.

The Institutes of Medicine recommendations to decrease funding for rural locations fails to understand lower per person health spending and increased complexity of care (social determinants) as well as shortages of workforce because of national designs that leave rural populations behind.

About half of the population is left behind in areas such as health spending, the impact of health economics, jobs, local leadership, and other areas. Most Americans left behind must remind American leaders that they exist, that they are a majority, and that the designs for past decades and decades to come must not cause their children and their children's children to fall further behind. 

Robert C. Bowman, M.D.