You may access a downloadable version of this report here (pdf)
A PICTURE OF VERNON COUNTY
Vernon County is a rustic expanse of land situated in Wisconsin’s “driftless” region. The landscape is legendary for its verdant hills, meandering Kickapoo river, and craggy bluffs dotted with quaint barns and ranches. The total population as of the 2010 census is approximately 29,000. By objective standards, it is a relatively healthy county, ranking 5th out of 72 in the 2012 iteration of the County Health Rankings report. It has the best composite morbidity index in the entire state. In light of these flattering indices though, it is paradoxical that its performance on health factors (44th), clinical care (66th), and socioeconomic milieu (33rd) are so discrepantly behind.
The social makeup of Vernon County is an eclectic confluence of several different factions. Approximately 86% of the population lives in a “rural” habitat. Traditional farmers and sharecroppers have intermingled with progressive organic farmers. Agriculture represents 20% of the job market, and provides just over half of the gross annual revenue. In the boomer generation, there was a steady exodus of hipsters from the major metropolitan areas, providing a base of independent artists and small business owners. Retail industries supply an additional 25% of total jobs. The relative expansion of non-farm employment (+7.1% since 2000) is in contrast to the overall trend of shrinkage statewide. Finally, one conspicuous feature of this community is the abundance of various Mennonite sects, ranging from the purist Amish to the more liberal “new order”.
The unemployment rate has held stably at 7.6%. Approximately 16% of the population is uninsured. According to the 2010 census, Vernon County is considered to be quite impoverished, with 13.6% of the population at large – and around 26% of minors – live below the poverty line. Racially, the county is rather homogeneous, with 98.9% Whites, <0.1% African American, <1% Hispanic. A high school equivalent education was achieved in 92% of individuals and a Bachelor’s degree or beyond were obtained in 19%. Again, these data do not account for the Amish, who cease formal schooling at the 8th grade level. The violent crime rate is 61 per 100,000, far lower than the state average.
Healthcare in Vernon County is delivered at the primary and secondary levels. The flagship institution is Vernon Memorial Healthcare (VHA), which operates a critical access hospital in Viroqia, along with several outlying rural primary care clinics. The Amish population derives most of their care from house calls and a rural clinic in La Farge, WI. Gundersen Lutheran, a tertiary level community hospital headquartered in La Crosse, does have a large presence in Viroqua, and offers outreach specialty care. The University of Wisconsin does not have a standalone clinic in the area; however, a great majority of the upper level providers have received their training and medical education there.
SUBJECTIVE HEALTH CONCERNS
In my clinical experiences within this community, I found that there was actually very little consensus about the leading health issues. From the limited samples of laypersons’ perspectives, it seemed that the preeminent health concerns were: illicit substance abuse (methamphetamine in particular), poverty, mental health, and the high cost of healthcare. I participated in three unique patient encounters in which methamphetamine use was highly destructive influence, via collateral effects, to the patient and family. The local media have also sensationalized the phenomenon of methamphetamine in their coverage of strings of lab busts in the region.
The Compass Now dataset from 2012 includes a random household telephone survey, and the results are reproduced below. It is interesting that alcohol use ranked was ranked equivalently with illicit substance abuse and adult obesity.
Amongst medical providers and my student colleagues, leading health concerns were: alcohol abuse, poverty, and health illiteracy. I was involved in the clinical care of several patients with alcohol dependence and concomitant mental illness; one such patient eventually passed away in the nursing home from end-stage hepatic cirrhosis. Curiously, I did not see an emphasis of referral to alcohol rehabilitation or treatment programs despite a very clear need in our high-risk patients. This may be due to a prevailing unawareness about the dangers of alcohol consumption, and the fact that alcohol dependence and abuse are not widely accepted as clinical entities requiring intervention. In addition, poverty was cited rather consistently by healthcare workers (nurses, clinicians, dieticians, etc) as major concern. I frequently met patients who subsisted on Medicaid and other forms of social insurance, and who often could not afford brand-name medications. Other important subjective health concerns I encountered include:
- Teenage depression and suicide
- Poor oral and dental hygiene
- Endemic Lyme Disease and post-treatment Lyme syndrome
- Antibiotic overuse/misuse
- Lack of advanced healthcare planning and end-of-life care discussions
OBJECTIVE HEALTH DATA
For a detailed discussion of ten objective health problems and specific impact metrics, please consult the online supplemental information.
In terms of overall health, Vernon County is actually faring quite well (ranked 1st) in terms of aggregate morbidity, and roughly average (ranked 30th) in terms of aggregate mortality. As measured by years of potential life lost before age 75 (YPL), the burden of premature death was 5,597 per 105 person years, just slightly above the national benchmark and lower than the Wisconsin average YPL (6,124). Turning to measures of morbidity, we find that Vernon County actually had record-low levels of self-reported poor health (7%), poor physical and mental health days per month (2.1 days each; average 3.3 and 3.0 days respectively), and incidence of low birth weight neonates (4.9%; average 6.9%). The discrepancy of morbidity and mortality in this county can be explained by either: (1) a self reporting bias in the survey technique, or (2) a higher rate of premature death from acute events such as infectious diseases and injuries. In fact, according to the 2009 Compass Now dataset, Vernon County is an outlier in that the rates of death from Pneumonia or Influenza (34.4 per 105 person years) and Motor Vehicle Accidents (27.5 per 105 person years) were both significantly higher than four neighboring counties.
Earlier in this project, I reported on the following ten health problems in Vernon County:
- Poor Oral and Dental Hygiene
- Vaccine-Preventable Infectious Disease
- Motor Vehicle Accidents
- Alcohol Abuse and Dependence
- Obesity (adult and pediatric)
- Mental Illness
- Illicit Drug Use
- Limited Healthcare Access
The top three items (emphasized in the list above) are unique to Vernon County, in that the impact or prevalence of those conditions far exceeds state and national averages. In terms of oral and dental health, Vernon County lags woefully behind the rest of the state. The BRFSS data gathered by the CDC consistently reveals this county to have the highest rate of premature tooth extraction (53% of adults) due to decay, as well as the lowest prevalence of fluoridated water sources. In children, the prevalence of untreated tooth decay and caries is 26% statewide. The Amish population, in particular, is stricken by very poor dental health. Although concrete data about this population is lacking, the ubiquitous impression is that almost all Amish persons require a full denture set by the time of marriage. Unexpected connections are beginning to be elucidated between dental and periodontal disease and systemic health, specifically glycemic control, ischemic cardiac disease, and lower respiratory infections.
Vaccine-preventable illnesses of note include: seasonal influenza, pneumococcal community-acquired pneumonia, varicella zoster, and Pertussis. Due to the lower rates of childhood vaccination amongst the Amish in Vernon County, there are consistently annual epidemics of Pertussis, with some cases being fatal. There has been increasing attention among healthcare providers in this county to ensure polyvalent pneumonocccal vaccination in patients at risk of serious illness (see interview with JoAnn von Ruden, below). Finally, while not vaccinatable, Lyme disease is endemic to the region. High clinician awareness and a nearby reference laboratory enable routine testing, and so patients are detected in the acute phase of the disease.
In terms of Motor Vehicle Accidents (MVAs), Vernon County has been plagued by disproportionately high rates of both total accidents and resultant fatalities. Excluding suicide, MVAs are the leading cause of death due to injury in Vernon County. Between 2007 and 2009, the rate of fatal MVAs in Vernon County was 18 per 105, significantly higher than the statewide rate, and also higher than preceding years. They are the 4th leading cause of survivable hospitalization. It is unclear how many of these incidents are related to alcohol use. The Vernon County road system is considered to be quite treacherous due to the presence of unmonitored and undivided county roads.
HEALTH ASSESSMENT AND KEY PROBLEM IDENTIFICATION
For a subjective impact ranking of the top ten health problems in my community, please consult the online supplementary information.
Taken together, these data portray a community that is performing well in terms of self-reported morbidity, but is consistently near or below state average in terms of premature mortality and health determinants such as socioeconomic factors, clinical care quality and access, and unhealthy behaviors. The community is largely defined by its endemic poverty and fringe populations who operate outside of the medical system and do not seek care until they have reached advanced stages of disease.
The county’s prevalence of obesity, cigarette smoking, and inappropriate alcohol use are comparable to the prevalence statewide. The observed impact of illicit drug use is actually less severe than believed by the general public, with notably low rates of hospitalization and arrests related to drug use. On the other hand, Vernon County has a uniquely high rate of dental disease, vaccine-preventable infectious disease, and motor vehicle accidents. It was difficult to accurately define the relative magnitudes of these health issues because of the lack of standardization between community health surveys. Many of the surveys were conducted via mailings to randomly selected households, creating a potential selection bias for patients who were better integrated within the community. An excellent discussion this bias included in the 2012 Compass Now consortium report. The authors noted that respondents were more likely to be home owners, have a higher educational attainment, and be older than the general population Also, many surveys relied on small sample sizes, resulting in large margins of error. Finally, some event rates were so low (e.g. MVA fatalities), that statistical comparison between the county and state level was underpowered.
I have decided to explore the problem of alcohol abuse and dependence because of its insidious nature and apparently poor recognition in the community. Data about the burden of alcoholism Vernon County are tragically absent. From the 2012 BRFSS data, 23% of adults reported “excessive drinking”, which includes either (1) episodic or binge drinking and (2) chronically heavy drinking, specific to gender. This was comparable to the state average. It is troubling that 25% of high-school youth in Vernon County reported binge drinking within the last 30 days, and that 10% reported driving while intoxicated on alcohol. From this limited data, I formed the impression that alcoholism is a very serious problem that is not being properly addressed in my community. A brief internet query revealed that the closest Alcoholics Anonymous (AA) meetings took place in La Crosse, WI – an impractical commute for many. Resources for alcoholism had very little internet presence. I was only able to locate one licensed therapist who offered services on a sliding scale fee structure. Despite hearing peripherally about the new mental health cooperative (Center Point Counseling Services), I was unable to locate more detailed information on the internet. With such barriers to access, it becomes incumbent upon primary health providers to disseminate this information to patients.
In order to elucidate the scope of alcohol dependence and abuse in Vernon County, I propose the following measures:
- Implement standard screening questionnaires (AUDIT-C, T-ACE) for all patients in both the ambulatory and inpatient clinical settings. Data may be collected over a period of three months.
- For any patient screening positive, administer a questionnaire assessing awareness and access to therapeutic resources.
- For any patient screening positive, determine if a formal diagnosis of Alcohol Abuse or Alcohol Dependence can be made.
- For any patient screening positive, investigate further for medical sequelae such as liver dysfunction, hematologic abnormalities, neuropathy, etc.
- For any patient screening positive, administer a questionnaire to extend the screen to MDD and other substance abuse.
This could be implemented as a cross-sectional study over a period of three months. The primary endpoints would be to determine (1) the true prevalence of alcoholism in the community, and (2) visibility and access to referral centers for treatment.
For an analysis of risk factors contributing to Alcohol Abuse and Dependence, please refer to the online supplementary materials.
Alcohol addiction is a vastly complex and multifactorial disease. It involves the interface between biological, social, and psychological factors. Biological risk factors include: genetic predisposition, male gender, age between 30 – 64 years old, and Caucasian or Native American race. Social risk factors include: social isolation, single status, social stressors (e.g. bereavement, divorce, indebtedness), poverty, close contact with alcohol abuser, early drinking, and history of military combat. Psychological risk factors include: co-morbid mental illness, vulnerable personality type, childhood conduct or hyperactivity disorders, and innate alcohol insensitivity. One might also consider a fourth layer of cultural or environmental factors that modulates these aforementioned risk factors. This exogenous layer might include: legal repercussions of alcohol misuse, social norms, alcohol accessibility, and literacy about the health effects of alcohol.
Community health interventions seek to address this exogenous or “upstream” risk layer. The principle here is to change the sociopolitical environment such that all of the downstream risks are attenuated. Interventions at this level are expensive and labor-intensive, but typically have the largest layoff. Interventions at the individual level are equally important, and there is a well-supported role of combined counseling and pharmacologic therapy for patients identified as having alcohol addiction. I have summarized some salient examples of interventions for alcohol abuse in the table below. Note that these interventions only pertain to alcoholism, and not to alcohol-related motor vehicle operation.
There is a fair amount of literature to support the efficacy of Dram Shop Liability (DSL). In brief, DSL refers to the right ofa patron to file suit against an alcoholic establishment if said patron was overserved alcoholic and subsequently caused harm to a third party while under the influence. Such a suit would be hearable in court only if it could be demonstrated that the sale of alcohol was the proximate cause of such damages or harm. Prospective data are available from the state of Texas, in which suites filed after the initiation of DSL in 1994 led to a 6.6% decline in the rate of single-vehicle nighttime crashes. Rulings are based on state precedent. In a meta-analysis of eleven studies on DSL (Rammohan et al. 2011; Am J Prev Med), states with DSL were found to have a 6.4% (range 3.7 – 11.3%) reduction in the frequency of fatal alcohol-related accident compared to states without such laws. Since it impossible to performed controlled studies on the effect of DSL, these studies are universally subject to confounding bias. For example, states with DSL precedent may have other legal structures that would curtail the use of alcohol. In states with powerful and entrenched tavern lobbies – such as Wisconsin – passing DSL legislation would be met with significant resistance. Thus, I do not believe that reform at this level would be practical.
Furthermore, it would seem nonsensical to effect legislative reform without first optimizing the interaction between patients and medical providers. The practice of Alcohol Screen and Brief Intervention (ASBI) has been thoroughly researched and is well-supported by the literature. For example, a Cochrane review of 22 randomized control trials involving ASBI showed that that in-office screening and brief intervention resulted in lower alcohol consumption at one-year follow up (mean decrease -38 g/wk), but that this effect was limited to men only. There was a trend towards significantly decreased consumption in women than did not meet statistical significance. The number of brief intervention sessions did not affect sobriety (Kanel et al. 2009). Numerical screening for alcohol abuse (for instance, with the AUDIT-C) tool takes approximately 2 – 3 minutes to complete. The Brief Intervention may require a variable amount of time, typically between 5 – 15 minutes. This intervention essentially employs the techniques of motivational interviewing (such as reflective listening and negotiation) to enact internal change from within the patient.
I was surprised to find that despite the high prevalence of self-reported heavy alcohol use in Vernon County, most primary care providers did not routinely practice ASBI in their clinics. Potential barriers to implementation might include: physician discomfort, lack of competence, apathy or ignorance about the impact of alcohol, time restraints, and lack of appropriate referral resources for high-risk patients. Thus, a community-based intervention to increase physicians’ use of the ASBI technique might be rolled out on a platform such as the following:
- Mandate ASBI training for all mid-level and upper-level providers affiliated with VMH. This may be accomplished via an online or annual seminar format.
- Require annual renewal of competency in ASBI.
- Incentivize ASBI via monetary reimbursement for time spent and/or a competitive award scheme
- Once ASBI has been initiated, require assessment and documentation of alcohol use at follow-up visits
The field of Family Medicine is especially poised to detect and treat patients presenting with de novo alcohol abuse or dependence. Providers typically have the benefit of firm rapport with their patients, increasing the likelihood of success. They also have the unique ability to treat the entire family unit, since alcoholism is never a solitary disease. Enaction of this platform may rake 3 – 6 months, and could be achieved at a minimum cost.
HEALTH SYSTEMS IMMERSION INTERVIEWS
Dana Ibergan is a clinical dietician working at Vernon Memorial Hospital (VMH) in Viroqua, WI. She is a recent graduate of the dietetics program at UW-Madison. We met with her over lunch hour. Her work entails a wide multiplicity of activities including: inpatient consultations for patients with complex nutritional needs (e.g. malabsorption, cachexia), diet counseling for newly diagnosed diabetes and pre-diabetes, food allergies and intolerances, weight loss support strategies, and pre and post-operative counseling for bariatric surgery. Almost all of her referrals are generated from the inpatient setting with continuity in her clinic after acute hospitalization. Outside medical providers and self-referrals are rare. In her perspective, diabetes has become the central focus of her practice, and she is dismayed to see many patients struggling to obtain access to healthy foods and affordable nutritional care. The closest free nutrition clinic is a thirty minute drive away at the St. Clair Health Mission in La Crosse, WI. Waiting lists often exceed six months. Due to the economic limitations of her patients, she recommends locally sourced – but not necessarily organic – foods. She prefers frozen vegetables as an acceptable alternative to the expensive organic produce at the local food cooperative. Dysphagia is another major clinical problem that she negotiates on a daily basis. Disorders or oropharyngeal transport stemming from dental disease, neurologic impairment, or anatomical lesions often prohibit intake of adequate calories. She works in conjunction with speech and language pathologists (SLP) to address the needs of these patients. Educational outreach to the community at large appeared to be somewhat limited.
Pastor Steven Fossum is a clergyman who is based at the Bethel Home, a non-profit and non-denominational Christian ministry with centers for skilled nursing, assisted living, and advanced dementia care. We met with him at his office in Viroqua over a cup of coffee at breakfast. He spun a very vivid story of his life in ministry, which began in the inner city of Philadelphia. At this point in his life, he feels that his calling is to synthesize the experiences and collective wisdom of his many years as a spiritual leader. His main objective is to understand his patients at a deep and holistic level. He ministers to a huge range of patients, from the completely secular to very fundamental Christians. He has seen, repeatedly, the anxiolytic and transformative effect of prayer for many patients at the verge of death. He prefers not to be evangelical with patients, but rather to elicit their fears and hopes as a confidante.
Kyle Bakkum is the Chief Operating Officer (COO) of VMH. The contents of this interview were related to me by my student partner, Brittany Strawn. His main responsibility is to superintend the clinical services provided by four rural clinics affiliated with VMH. These clinics include a site in La Farge, WI that is heavily frequented by the Amish, and the Kickapoo Valley Medical Clinic in Soldiers Grove, WI, staffed by two midlevel providers. His main interest is to reduce the cost of care for patients, since reimbursement in these clinics occurs primarily through the state (Medicaid) and federal governments. This is accomplished by implementing systems that minimize the redundancy of information. For example, he has invested in a VMH-wide electronic medical record (EMR), so that patient labs and other clinical data may be shared across the network. He has also invested in a PACS frame that allows radiologic studies to be transmitted between the outlying clinics and major quaternary care centers such as the UW and Mayo Clinic. He does concede that the acquisition cost of these technologies is not trivial, but will be offset by future savings gained by avoiding redundancy.
Susan Sullivan and JoAnn von Ruden are officers with the Quality Improvement (QI) office at VMH. Both of them collaborate to improve the quality and safety of healthcare delivery within the inpatient setting at the hospital. To do this, they employ the PDSA improvement cycle and respond to feedback from various hospital departments and patient units. Benchmarks are set by external standards, such as CheckPoint (run by the Wisconsin Hospital Association) and HCAHPS, a federal survey of patient satisfaction. Recent successes of these programs include increased pneumococcal vaccination rates for patients being admitted pneumonia from 10% in 2004 to virtually 100% in 2008. Other successful interventions include universal color-coded wrist bands for patients (DNR, high fall risk), and improvement in antibiotic stewardship in the perioperative setting (for example, preoperative antibiotic prophylaxis increased from 69% to 95% between 2005 and 2011). Specific challenges faced by the QI department include (1) medication reconciliation at transitions of care and (2) increasing hand-washing compliance. Hand hygiene compliance appears to have plateaued at roughly 84% between 2010 and 2011. This has led to more a more aggressive campaign involving patient safety rounds and a video directed at medical and surgical staff.
- COMPASS NOW 2012 Random Household Survey. “A Health Profile of the Great Rivers Region”.
- Injury Research Center at MCW et al. “The Burden of Injury in Wisconsin” ed. 2011.
- Rammohan et al. Effects of dram shop liability and enhanced overservice law enforcement initiatives on excessive alcohol consumption and related harms: Two community guide systematic reviews. Am J Prev Med. 2011 Sep; 41(3):334-43.
- Kaner et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007 Apr 18; (2):CD004148.
- Public Health Institute at the University of Wisconsin et al. “County Health Rankings” ed. 2012