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P T. 2010 August; 35(8): 427.
PMCID: PMC2935645

How Healthy Is Your County?

David B. Nash, MD, MBA

In the late winter of 2010, the Robert Wood Johnson Foundation (RWJF) announced a new national project called “County Health Rankings.” This is the first set of reports to rank the overall health of every county in all 50 states in the U.S. The RWJF, in concert with the University of Wisconsin’s Population Health Institute, put this amazing project together. The report is ostensibly designed to aid public health and community leaders, policymakers, consumers, and others to see how healthy their county is, to compare it with others within their state, and to find ways to improve the heath of their community.1

This study differs from previous projects; it is the first time that researchers have examined multiple factors that affect health in every county in the nation. Each county is rated on key factors that affect health, such as smoking, obesity, alcohol use, access to primary care providers, the population’s overall education level, unemployment rates, and the number of children living in poverty. You can probably sense where this report is going; we all recognize that the actual delivery of health care services is only one small part of the overall mix of critical variables that determine the health of a county.

For example, the report reveals twofold and three-fold higher rates of premature death in some counties, often from preventable conditions, and that 80% of the counties with populations in poorest health were rural.2 In addition, high smoking rates lead to cancer, heart disease, bronchitis, and emphysema in some counties when compared with others. With this tool, we can observe what makes people in every county unhealthy. The answers should be no surprise to readers of P&T.

Conversely, people who live in the healthier-ranked counties tend to have higher education levels, are more likely to be employed; and have access to more health care providers, healthful foods, parks, and recreational facilities. The report does not specify which pharmaceutical agents garner the best clinical outcomes. We know that this information is important for individual patients, but it does little to contribute to the overall health status of a population.

The rankings also show sharp health disparities even in contiguous counties. For example, someone living in Chester County, Pennsylvania—the county ranking highest in the state for overall health—has a better chance of staying well than a resident of nearby Delaware County—which ranks 22nd of 67 counties; Delaware County, unfortunately, has higher rates of smoking, adult obesity, and violent crime, as well as more children living in poverty.3

I was particularly interested in the report’s quality-of-care measures that were used to assess outcomes of care. In delving into the report, I found three measures that make sense to me:4

  1. The number of preventable hospitalizations is an indicator that is often used to assess the effectiveness and accessibility of primary health care; it is also an indirect indication of the availability of primary health care service. The evidence shows that a higher density of primary care providers is associated with a lower probability of hospitalization for “ambulatory care–sensitive” conditions.
  2. Diabetic screening is a sensible measure because improvements in quality of care can be seen through the implementation of disease-management programs that target multiple components of chronic diseases. Measuring glycosylated hemoglobin (HbA1c) levels for long-term monitoring of diabetes is widely accepted as one component of a comprehensive disease-management program.
  3. Hospice services, most agree, can provide end-of-life care that is superior to care given in an institution.

In summary, these measures are good indicators of the health of a population.

In view of this amazing report, I recommend that all P&T committee members go to the County Health Rankings Web site and evaluate their county’s ranking.3 It is a disturbing reminder that our national leaders are focused on insurance reform rather than on the more complex social and cultural issues we will need to tackle as a society to truly improve the health of our counties.

Along with many of our senior leaders in health policy, I believe that the first job of academic medicine is to improve the health of our population.5 Perhaps our P&T committees could hold a meeting to evaluate the findings in this path-changing report and begin to think about what truly influences the health of the residents of the county in which they live. This situation is certainly a clarion call for social action, for a broader understanding of health care, and for better leadership in obtaining the resources we need to improve the health of our citizens.

As always, I’m interested in your views. My e-mail address is ude.nosreffej@hsan.divad. Please also read my blog at


1. Robert Wood Johnson Foundation/University of Wisconsin How healthy is your county? New county health rankings give first county-by-county snapshot of health in each state. February 17, 2010. Available at: Accessed June 30, 2010.
2. Trapp D. Health status varies by county: Where patients live matters American Medical News March12010. Available at: Accessed June 30, 2010.
3. County Health Rankings Available at: Accessed March 16, 2010.
4. County Health Rankings Quality of care. Available at: Accessed June 30, 2010.
5. Ramsey PG, Miller ED. A single mission for academic medicine: Improving health. JAMA. 2009;301:1475–1476. [PubMed]

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