Health Care and Quality of Life in the Chattanooga Region

Health Care and Quality of Life in the Chattanooga Region

According to the May 2006 SOCRR Survey, 86% of Hamilton County residents stated that “quality health care and hospitals” was very important to their quality of life in the Chattanooga Area – among fifteen factors, it ranked second overall.

Although the overwhelming majority of respondents in all groups rated quality health care and hospitals as very important, there were differences based on residence (inside or outside city limits) and demographic factors.

Gauging Health in the Chattanooga Region

Over the past several years, our nation’s concept of health has evolved from a focus primarily on avoidance or treatment of disease to the pursuit of wellness, involving a range of “non-medical quality of life factors.”¹

One hundred years ago, life expectancy in Chattanooga was only 47 years, and unpreventable, untreatable infectious diseases were the biggest cause of death. Today, life expectancy has jumped to 77.6 years² and chronic illnesses, including heart disease, cancer, stroke and chronic respiratory disease have replaced infectious diseases as the primary causes of death.

As antibiotics, vaccines and other medical advances have drastically reduced death from infection and communicable diseases, chronic illness associated with aging has become more prevalent. The development of many chronic illnesses, such as heart disease, cancer, and stroke may be attributed to lifestyle choices, such as tobacco use, obesity and lack of exercise. The Institute for the Future reports that lifestyle factors are responsible for about 50% of health status. The Institute further reports that biology and environment are responsible for 20% of health status, while access to health care is responsible for 10%.³

The health indicators selected for this report are framed in the context of their potential contribution to health status. For example, indicators addressing health behaviors include tobacco use, obesity, and binge drinking; environmental indicators include measures of air quality; and access to care measures include health insurance status, hospital use and substance abuse treatment capacity. In addition, the report presents mortality data for the leading causes of death in Hamilton County and morbidity (illness) data includes the incidence of reportable infectious diseases, such as sexually transmitted diseases and HIV/AIDS.

Hamilton County data come from a variety of sources, including survey data from the May 2006 SOCRR survey (countywide survey), the Hamilton County 2004 Behavioral Risk Factor Surveillance Survey (BRFSS), and the 2002 Hamilton County Youth Risk Behavior Survey (YRBS), Tennessee and Chattanooga/Hamilton County Departments of Health, the Chattanooga-Hamilton County Air Pollution Control Bureau, and the American Lung Association. Within Hamilton County several indicators are presented by region, defined by groups of zip codes. (See Demographics section for description of zip code groupings.)

Most Chattanooga Area Residents Say they are in Excellent or Very Good Health

Self-reported health status is one measure of overall health. In the 2006 countywide survey, a majority of survey respondents – 59% -- indicated that their health was very good or excellent. In 2005, BRFSS data indicate that a somewhat smaller proportion of adults nation-wide (54%) believe they have excellent or very good health.

There were no significant differences between the reported health status of Chattanooga residents and Hamilton County residents who live outside Chattanooga city limits.

There were, however, some differences – frequently within the margin of error -- based on race, gender, and age of the respondent.

Differences based on income and education level were more significant. Individuals in households with annual income of $50,000 or more were almost twenty percentage points more likely to rate their health as excellent or good. Similarly, just over half of all individuals with a high school education or less rated their health as excellent or good, compared to close to 70% of college graduates.

Mortality

As life expectancy has increased over the past hundred years, the leading causes of death have shifted from infectious diseases to chronic diseases associated with living longer: one hundred years ago, people generally did not live long enough to develop chronic diseases such as heart disease or cancer. In 2003, the leading causes of death in the both the nation and Hamilton County were cardiovascular disease, cancer, stroke, and chronic lower respiratory diseases.⁴ Together, these four diagnoses accounted for 63% of all deaths in Hamilton County as well as in the nation. The most recent estimates place the annual national cost of these four illnesses at $633.8 billion in direct medical costs and indirect costs from lost productivity resulting from illness and death.⁵

Hamilton County reports more deaths per 100,000 residents, on average, for each of these causes of death. In 2003, the most recent year for county and national comparable data, age-adjusted death rates⁶ in Hamilton County exceeded national rates by anywhere from 6% to 41%.

Between 1990 and 2003, trend data for Hamilton County death rates declined for several causes of death: influenza and pneumonia (down 52.3%), heart disease (down 26.6%), stroke (down 11.2%), accidents (down 5.5%), and cancer (down 3.8%). Over the same time period, there have been increases in deaths due to diabetes (up 64.3%), chronic lower respiratory disease (up 48.7%), arthrosclerosis (up 30.9%), and chronic liver disease (up 11.2%).

Differences by Race

There are some marked differences in the death rates of African Americans and Whites in Hamilton County. The table below details the 2001-2003 age adjusted death rates for the ten leading causes of death for the county overall and for both Whites and African Americans. Among the notable differences, death rates for:

• Diabetes among African Americans is over twice that among Whites.
• Stroke among African Americans is 60% higher than among Whites.
• Heart disease among African Americans is 36% higher than among Whites.
• Cancer among African Americans is 33% higher than among Whites.

In addition, assault, HIV/AIDS, and primary hypertension are among the top ten causes of death for African Americans but not for Whites.

Whites were 26% more likely to die from accidents and 7% more likely to die from Alzheimer’s disease than African Americans. Three of the ten leading causes of death for Whites – influenza and pneumonia, atherosclerosis and suicide were not among the top ten for African Americans.

Infant Mortality

Infant mortality is a traditional indicator of the health and well being of a community. The leading causes of infant mortality are congenital abnormalities, fatal conditions arising from preterm/low birthweight, sudden infant death syndrome and accidents.⁸

In 2003, the most recently available year for national data, 6.9 of every 1,000 babies born in the United States did not live until their first birthday, compared to 11.7 per 1,000 babies born in Hamilton County. From 2001 to 2004, infant mortality rates in Hamilton County averaged 9.6 per 1,000 births.

Infant mortality is significantly higher among African Americans than Whites. Between 2001 and 2004, the rate per 1,000 births among African Americans (20.1) was almost four times the rate among Whites (5.5). The CDC reports similar racial disparities nation-wide: infant mortality rates in 2002 were 14.4 per 1,000 births for African Americans and 5.8 per 1,000 births for Whites.⁹

Health Conditions and Risk Factors in the Chattanooga Region

Measuring Morbidity or Illness

Obtaining reliable data on the incidence of certain illnesses or conditions (morbidity) is challenging. Unlike mortality data, which comes from death certificates, information about specific illnesses and conditions is obtained from a variety of sources, including state departments of health, population based surveys and hospital data.

Health reporting is further complicated by privacy issues. While some data provided by the Tennessee Department of Health is available at the sub-county level, sub-group data with fewer than 5 cases are suppressed for privacy.

Hospital Admissions by Major Diagnostic Categories

One way to assess morbidity in a community is to look at hospital usage. The Tennessee Department of Health provides this data through the Tennessee Joint Annual Report (JAR). The JAR includes the reported conditions for hospital admissions or dismissals (each hospital reports either admissions or dismissals, and will be referred to as admissions) using a coding system developed by the Health Care Financing Administration (HCFA). Within the coding system, conditions were grouped into 25 broad diagnostic categories.

Using 2004 JAR data for Hamilton County hospitals (the most recently available data), the broad diagnostic categories were sorted in order of total admissions. Pregnancy and child birth -- including admissions of mothers and babies -- account for 18.5% of the total. After childbirth related admissions, circulatory system disorders accounted for the greatest share of admissions (16.1%), followed by diagnoses related to mental diseases and disorders (10.1%)¹⁰

Annual HIV and AIDS Diagnoses

HIV and AIDS diagnoses per 100,000 in Hamilton County have declined since their peak in 1995 – HIV by 62.7% and AIDS by 36.2%. In Hamilton County 13.9 cases of AIDS were diagnosed for every 100,000 residents, a rate that is somewhat below the national rate of 14.1.¹²

Cumulative Diagnoses of HIV/AIDS in Hamilton County

A total of 62 cases of HIV/AIDS were diagnosed in Hamilton County in 2004, bringing the county’s cumulative number of cases since 1984 to 1,194.

The majority of people diagnosed with HIV/AIDS are male, although females are closing the gap. While 78% of those diagnosed since 1984 have been men, only 66% of those diagnosed in 2004 were men.

African Americans comprise a disproportionate share of those diagnosed with HIV/AIDS. While comprising 20% of the county’s population, African Americans account for almost half of all Hamilton County HIV/AIDS diagnoses, both cumulatively (since 1984) and in 2004.

Sixty percent (60%) of 2004 diagnoses and 69% of cumulative diagnoses were among people between the ages of 25 and 44.

Sexually Transmitted Diseases

Sexually transmitted diseases are a concern because of their potential for long term health consequences. Tracking rates of sexually transmitted diseases also provides some indication of the extent of unprotected sex.

Chlamydia and gonorrhea produce few symptoms and often go undetected, which, in turn, allows infected people to unknowingly spread the disease. But, left untreated, STDs may lead to long-term health problems. Untreated Chlamydia and gonorrhea in women can lead to pelvic inflammatory disease, infertility and cervical cancer.

Infection rates for chlamydia and gonorrhea in Hamilton County are significantly higher than national rates. Hamilton County reported 276.8 new cases of gonorrhea per 100,000 residents in 2005, 2.4 times the national rate of 116.2 in 2003 (the most recent data available). The chlamydia infection rate in Hamilton County in 2005 was 500.5 per 100,000 residents, 1.6 times the national rate in 2005 of 304.3 per 100,000.

In total, 1,564 cases of chlamydia were reported among Hamilton County residents in 2005. The rate of infection among females was over two and a half times the male rate (708.2 versus 272.0 per 100,000 residents). Among African Americans, the rate was almost six times the rate for Whites (1,290.3 versus 217.5 per 100,000 residents).

In total, 865 cases of Gonorrhea were reported among Hamilton County residents in 2005. The infection rate among males was slightly higher than among females (280 versus 252.3 per 100,000). The infection rate among African Americans was over 13 times the rate of Whites (932.7 versus 71.1 per 100,000).

Behavioral Risk Factors -- Adults

Overweight and Obesity

The CDC reports that the incidence of obesity among adults in the United States almost doubled from 1990 to 2002 – from 11.6% to 22.1%.¹³ Obesity is related to a number of poor health outcomes, including Type 2 diabetes, heart disease, hypertension, high cholesterol levels, stroke, cancer, osteoarthritis, some cancers and gallbladder disease.¹⁴

According to the 2004 Hamilton County BRFSS, six out of ten adults are either overweight (37%) or obese (22%), mirroring the national figures from the 2002 BRFSS.¹⁵

Obesity is present in all demographic groups: the incidence is higher, however, among some groups than others.

While men and women were equally likely to be obese, men were more likely to be overweight than women (43% versus 30%). Among African Americans, 36% of men and 39% of women were obese, compared to 20% of white men and 19% of white women. The prevalence of obesity increases with age up until age 64 (from 15% among those aged 18 to 24 to 26% among those aged 45 to 64), when it begins to decline.

Obesity was also associated with lower educational attainment and lower household income. Reported levels of obesity declined from 27% among individuals with no high school diploma to 16% among college graduates. Similarly, 32% of individuals with less than $15,000 household income were obese, compared to 19% among those with household incomes of $50,000 or more.

The only demographic group with less than half of respondents with a BMI of 25 or greater was the 18 to 24 year old group (39%).

Tobacco Use

Use of tobacco products is the number one cause of preventable disease and death in the United States and is said to be responsible for one in every five deaths in the United States each year. For Hamilton County, that translates into 643 tobacco related deaths in 2004.

In the 2006 countywide survey, 20% of respondents indicated that they are current smokers and another 6% say that they occasionally smoke. An additional 53% indicated that they never smoked, while another 21% said that they were former smokers. By comparison, 2005 BRFSS data indicate that 21% of adults nation-wide smoke everyday or on some days.

Twenty percent (20%) of respondents who live within the Chattanooga city limits indicated they were current smokers, versus 22% of Hamilton County residents outside of the city, a difference that is not statistically significant.

More than one-third of African American respondents indicated that they were current or occasional smokers, compared to less than one-quarter of all white respondents.

Respondents between the ages of 45 and 59 were the most likely to report being either a current or occasional smoker. Those 60 years old and older were less than half as likely to indicate that they were current smokers as those between the ages of 45 and 59.

Twenty-eight percent of men indicated that they were current or occasional smokers, compared to 24% of women.

Overall, non-smokers (never/former) reported to be in better health than smokers (current/occasional). Sixty-one percent of non-smokers reported they were in excellent or very good health, compared to 50% of current smokers. Moreover, 27% of smokers reported they were in fair or poor health, compared to 12% non-smokers.

Finally, smoking was more prevalent among the uninsured. Forty-one percent of respondents who lacked health insurance for at least some period during the last year smoke, compared to 23% of respondents with continuous coverage. Moreover, 57% of respondents with continuous coverage have never smoked, compared to 34% of uninsured respondents.

Alcohol Use

According to the 2004 Hamilton County BRFSS, 48% of Hamilton County adults consume alcoholic beverages at least once a month (current drinkers). Thirteen percent (13%) of Hamilton County adults are binge drinkers, defined as having five or more drinks on at least one occasion over the past month.

Overall, Hamilton County adults are less likely to drink than adults nationwide (56%); however, differences in percentages of binge drinkers are within the margins of error.¹⁶

Men are more than twice as likely to have engaged in binge drinking in the past month than women (19% versus 8%). Binge drinking is more prevalent among younger adults, decreasing from 24% among those ages 25 to 34 to 1% of those 65 or older. More Whites (13%) than African Americans (9%) indicated they had engaged in binge drinking, although the differences are within the margin of error.

Behavioral Risk Factors -- Youth

Weight Classification

In the 2002 Hamilton County Youth Risk Behavior Survey (YRBS), 60% of student respondents had a healthy weight for their height, while 13% were underweight, 15% were at risk for being overweight, and 12% were overweight.¹⁷

Higher percentages of boys and African American students were overweight. Conversely, higher percentages of girls and Whites were at a healthy weight.

The proportion of students at a healthy weight decreased as grade level increased (from 66% of ninth graders to 56% of twelfth graders), while the percentage of students who were underweight increased (from 8% of ninth graders to 18% of twelfth graders).

Tobacco Use

The majority of adult smokers start smoking by the age of 18. The CDC estimates that every day, 3,900 youth try their first cigarette. In the 2002 YRBS survey, about six out of ten Hamilton County high school students reported trying cigarette smoking. Twenty-six percent of students smoked at least one cigarette in the past month (current smokers) while 12% smoked on twenty of the past thirty days (frequent smokers).

National YRBS data for 2003 show that 58% of students surveyed have tried cigarette smoking, 22% were current smokers and 10% were frequent smokers.

Overall, 26% of Hamilton County high school students smoke, but there are differences based on sex, race, school performance and grade level. Specifically, smoking is more common among:

• Male students than female students (29% vs. 24%)
• White students than black students (29% vs. 16%)
• Poorer performing students (mostly C’s, D’s, or F’s) than better performing students (mostly A’s and B’s) (37% vs. 20%)
• 12th grade students, and decreases with grade level (12th – 33%; 11 – 30%; 10th – 22%; 9th – 23%).

Smoking and Other Risky Behaviors

Students who smoked cigarettes were significantly more likely than nonsmokers to engage in other risky behaviors. Some notable differences in risktaking among local high school student smokers and non-smokers are listed below.¹⁸ It is important to recognize, however, that non-smokers also engage in risky behaviors, albeit at lower levels.

Alcohol Use

Seventy-two percent (72%) of Hamilton County high school students surveyed have ever tried alcohol.²⁰ Thirty-nine percent (39%) had a drink within the past month and are considered current drinkers. Twenty-four percent (24%) had engaged in binge drinking, defined as having five or more drinks in a row.²¹

By comparison, 75% of students surveyed in the 2003 national YRBS reported ever consuming alcohol. Within the previous month, 45% had consumed alcohol and 28% had engaged in binge drinking.

Although alcohol use among Hamilton County high school students varied among different groups of students, at least one third of students in each demographic group studied were current drinkers. Males and females were equally likely to drink. Drinking in the past thirty days was more common among:

• White students than Black students (40% vs. 33%)
• 12th grade students, and decreases with grade level (12th – 47%; 11th– 40%; 10th – 38%; 9th – 32%)
• Students from parent/stepparent and single-parent families than students from two-parent families (46% and 43% vs. 34%)
• Poorer performing students (mostly C’s, D’s, or F’s) than better performing students (mostly A’s or B’s) (42% vs. 34%).

Binge Drinking

One in four students reported they had engaged in binge drinking. Black students were significantly less likely to engage in binge drinking than any other group. In all other demographic groups studied, at least one in five students engaged in this behavior. Reported binge drinking is higher among:

• White students than black students (26% vs. 13%)
• Male students than female students (27% vs. 20%)
• 12th grade students, and declines with grade in school (31% 12th grade; 27% 11th grade; 20% 10th grade; 19% 9th grade)
• Poorer performing students than better performing students (32% vs. 19%)
• Students from parent/stepparent and single-parent families than students from two-parent families (28% and 26% vs. 20%)

Marijuana Use

Overall, 40% of Hamilton County high school students surveyed had tried marijuana. Twenty-three percent (23%) had smoked marijuana within the past month and are considered current users.

Similar to Hamilton County data, national YRBS data for 2003 show that 40% of students surveyed had ever used marijuana, while 22% had used within the past month.

The percentage of students who had smoked marijuana within the past month did not vary significantly by grade level or race. Sex, living situation, and school performance were associated with marijuana use, with marijuana use more prevalent among:

Lifetime Use of Other Drugs

Within their lifetime, 13% of Hamilton County high school students reported having tried huffing, while 10% had tried ecstasy and 9% had tried cocaine. These numbers were similar to national figures.

Environmental Risk Factors

Air Quality

According to the American Lung Association (ALA), “over half of the US population lives in counties that have unhealthy levels of either ozone or particle pollution.”²² In its State of the Air 2005, the ALA reported that, compared to other regions, the Southeastern states made the greatest improvements in ozone and particle pollution – every Southeastern state reported fewer unhealthy ozone and particle pollution days in 2001-2003.

Air quality is especially important to people with chronic lung diseases such as asthma, chronic bronchitis, and emphysema. In 1969, the federal government declared that Chattanooga had the most polluted air of any city in the country. This lead to a vigorous campaign for cleaner air, and by the late 1980’s local air quality met or exceeded federal guidelines. In 2003, the Environmental Protection Agency instituted more stringent standards, however, and the region no longer met EPA standards. In order to meet its goal of attainment by 2007, the county implemented the following clean air initiatives:²³

• Auto emissions testing program
• Restrictions on burning from May 1 through September 30
• Stage 1 vapor recovery plan for gas stations
• Pollution Solution Action Days, an air quality alert day program

Measuring Air Quality

The Chattanooga-Hamilton County Air Pollution Control Bureau monitors concentrations of ozone and particulate matter in accordance with EPA standards. “The particulate standard requires the monitoring of PM2.5 and is set at a concentration of 15 micrograms per cubic meter (mg/m3), with a 24-hour standard set at 65 mg/m3. The standard for ozone is based on an 8-hour standard of 0.08 parts per million based on numerous health studies showing adverse effects for chronic exposure.”²⁴

The following graphs show pollution levels at local monitors from 1999-2005. Note that the UTC site and the Soddy Daisy site have met standards for particulate levels, and that the two monitoring sites that have not met the standard are in or close to the Georgia boarder (Rossville and East Ridge). All three ozone monitoring sites – Eastside Utility, Soddy Daisy, and Meigs County – met attainment levels with the 2003-2005 three-year averages. The Air Pollution Control Board expects the downward trend to continue and projects that both standards will be met by 2007.

Incidence of Adult Asthma

With 8% of adults reporting they have asthma, the prevalence of asthma among Hamilton County adults is equal to the nationwide rate.²⁵

In Hamilton County, women were more likely than men to indicate they had asthma (10% versus 6%). The incidence of asthma did not differ significantly by race or age.

Low Weight Live Births

Low birthweight babies (less than 2,500 grams, or 5 pounds, 8 ounces) face serious health problems as infants and many have lifelong disabilities. The percentage of low birthweight babies in Hamilton County increased 50.6% from 1990 to 2000, and has since leveled off.²⁶

The 2004 percentage of low birthweight in Hamilton County is not only higher than national and state percentages, it is the highest of the four largest counties in Tennessee.

In Hamilton County, the rate of low birthweight among African American babies is more than double that of Whites, and rates for both African Americans and Whites exceeded the national average in 2004.

Access to Health Care

TennCare and Medicare Enrollment

As of January 2006, 40,983 Hamilton County residents -- 13.2% of the population -- were enrolled in TennCare. In 2003, the most recently available year for county-level data, 51,069 Hamilton County residents -- 16.5% of the population -- Hamilton County residents were enrolled in Medicare. Medicare enrollees include 42,765 -- 13.8% of the population -- who were eligible based on age (65 and older) and 8,304 -- 2.7% of the population -- who were eligible due to disability.

Health Care Coverage

The following section includes data from the 2006 countywide survey and the 2004 BRFSS survey. The data refer to the respondents’ individual circumstances and refer only to adult county residents.

Based on 2006 countywide survey responses, 20% of Hamilton County adults were uninsured for at least some time during the last twelve months.

By comparison, the 2004 Hamilton County BRFSS found that 13% of all adults were uninsured at some time during the prior twelve months: the Medical Foundation and Chattanooga Hamilton County Regional Health Council projected that after all then contemplated cuts to TennCare were imposed, the percentage of uninsured would reach 18%.

While there was no significant difference in insurance coverage based on gender, there were significant differences based on race, income, age and education level. More than one-third of individual respondents in households with incomes less than $50,000 indicated that they were uninsured at some point during the last twelve months.

Individuals who reported that they were in fair or poor health were more than twice as likely to have been uninsured at some point during the year as those who reported that their health was excellent or very good.

Among countywide survey respondents with health insurance at the time of the survey, 45% had coverage through their employer, with another 13% covered through someone else’s employer and 22% covered by Medicare. These data refer only to the source of insurance coverage of the actual respondent and refer to sources of insurance for adults only.

Reasons for Lack of Coverage

Of the countywide survey respondents who lacked health insurance at some point during the preceding year, there was no single clear reason for their lack of coverage. When asked: “Which of the following reasons best describes why you have gone without health insurance,” no one factor explained more than one-quarter of the uninsured.

Finally, among those who have had continuous health insurance coverage over the last year, 23% are either current or occasional smokers. By comparison, just over 40% of respondents who lacked health insurance for at least some period during the last year are current or occasional smokers.

Attitudes About Employer Sponsored Health Insurance

Under legislation recently enacted in Massachusetts, all employers with ten or more employees in the state will be required to either provide health insurance to their employees or make an annual contribution for the provision of health insurance.

Chattanooga area residents were asked whether they would support a similar requirement. Specifically, respondents were asked whether they agreed or disagreed with the following statement: “All employers should be required to offer health insurance to their employees.” Two-thirds of respondents indicated that they strongly agreed, with another 8% indicating that they agreed – though not so strongly.

Hospitals in Hamilton County

Thirteen hospitals are located in Hamilton County, including seven general medical and surgical hospitals, three chemical dependency/psychiatric hospitals, two physical rehabilitation hospitals, and one acute long-term care hospital. In total, these hospitals provide 2,158 licensed hospital beds, or 6.97 beds per 1,000 Hamilton County residents.

Hamilton County serves as a regional health center. Out of some 75,000 admissions in 2004, only 54.9% included Hamilton County residents. Other patients lived in Georgia (16.3%), nearby Bradley, Rhea, Marion, or Sequatchie Counties (14.2%), other Tennessee Counties (8.0%), and states other than Tennessee or Georgia (7.0%).

Emergency Department / Inpatient Usage

Hamilton County hospitals reported a total of 211,713 visits to their emergency departments (EDs) in 2004, which translates to a rate of 683.5 visits per 1,000 residents. Inpatient admissions totaled 75,011, or 242.2 per 1,000 residents.

Payer Source for Hospital Visits

Sources of payment varied as to whether the care was provided in the ED or as an admitted patient. Most notably, Medicare patients made up the highest proportion of inpatient visits, 43%, double their proportion of ED visits. In the ED, most patients had either private coverage (33%), TennCare (29%), or Medicare (21%). While responsible for only 12% of ED visits, the proportion of self-pay patients was 4.5 times greater than for inpatient visits. This suggests that self-pay patients may be more likely to use the ED for non-emergent care rather than emergent care.

Charity Care

In 2004, Hamilton County hospitals provided a total of $33.9 million in charity care, which comprised 1.4% of all gross patient charges.²⁷

Substance Abuse Treatment Capacity

Drug and Alcohol Abuse

According to the most recent BRFSS and YRBS data available for Hamilton County, alcohol and drug use in Hamilton County is slightly lower than the national average.

At the state level, however, data from the 2003-2004 National Survey on Drug Use and Health (NSDUH) indicate that an estimated 6.5% of Tennesseans age 12 and older used any drug within the past month, including marijuana (5.0%) or other illicit drug (3.5%). In addition, within the past year 2.1% of Tennesseans are estimated to have used cocaine and 4.6% are estimated to have used non-medical pain relievers.²⁸

NSDUH data report lower incidences of drug and alcohol abuse in Tennessee than in most other states. Based on 2003-2003 NSDUH data, the Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that, within the past year, 6.3% of Tennesseans have alcohol dependence or abuse problems and 2.8% have illicit drug dependence or abuse problems. Tennessee ranked 47th for alcohol abuse – the percentage of alcohol abuse by state ranged from 5.6% (North Carolina and Alabama, tie) to 11.3% (Wisconsin). Tennessee ranked 40th for illicit drug abuse – the percentage of a drug abuse problems by ranged from 2.5% (South Dakota) to 3.7% (New Mexico).

Tennessee Substance Abuse Treatment Admissions

The SAMHSA Treatment Episode Data Set (TEDS) provides state-specific data for substance abuse treatment admissions. In 2004, Tennessee reported 7,533 substance abuse treatment admissions. At a rate of 128 treatment admissions per 100,000 residents, Tennessee ranked last of the 49 states reporting. Colorado had the highest substance abuse treatment admission rate – at 1,489 admissions per 100,000, almost twelve times greater than Tennessee.²⁹

Among Tennessee treatment admissions, the primary substance of abuse is alcohol, followed by smoked cocaine, marijuana, opiates, and amphetamine/methamphetamine.

Local Substance Abuse Treatment Facilities

A total of eleven substance abuse treatment facilities are located within a 20 mile radius of Chattanooga, including two in North Georgia. With the exception of methadone, none of the programs are substance-specific. Five facilities accept Medicaid, (although the one Georgia facility does not accept TennCare), three provide services on a sliding fee scale and two offer other forms of payment assistance. Most facilities offer multiple services. The chart below details the numbers of facilities within a 20 mile radius of Chattanooga offering various treatment services.

Benchmark Jurisdictions

Comparable health data addressing mortality, communicable diseases, air quality, low birthweight, hospital usage and substance abuse treatment facilities were obtained for the thirteen other benchmark jurisdictions. Most data are provided at the county-level. Information about substance abuse treatment programs are reported for a 20 mile radius of each city, and drug and alcohol abuse data are available at the state level only.

Mortality Rates

In order to provide comparable data for all 14 benchmark jurisdictions, mortality data are reported using crude death rates and are not age-adjusted. Therefore, differences in observed rates have not been adjusted for differences in age composition.

In 2004, Hamilton County had the highest reported mortality rates of all 14 benchmark counties, including death from all causes, as well as for the five leading causes of death.

Hamilton County had 1,038.6 deaths per 100,000 residents in 2004 – 33.7% higher than the 14-county average of 776.5. Hamilton County 2004 deaths per 100,000 by cause were:

• Heart disease -- 266.4 – 42.6% higher than the benchmark average
• Cancer – 232.8 – 29.8% higher than the benchmark average
• Stroke – 80.1 – 55.8% higher than the benchmark average
• Chronic lower respiratory disease (CLRD) 73.3 -- 69.7% higher than the benchmark average, and
• Alzheimer’s Disease – 51.1 – 74.6% higher than the benchmark average

Leading Causes of Death as a Percentage of All Deaths

The five leading causes of death in Hamilton County accounted for 68% of all deaths in 2004, with two causes, heart disease and cancer, accounting for almost half all deaths. In the other 13 jurisdictions, these causes accounted for 58% to 66% of all deaths.

Four of the five leading causes of death – heart disease, cancer, stroke and chronic lower respiratory disease – are generally among the leading causes of death nation-wide as well as in the benchmark jurisdictions. The fifth leading cause is usually accidents, which was ranked sixth in Hamilton County in 2004 (132 deaths or 42.6 per 100,000 residents), after Alzheimer’s disease.

Infant Mortality

With 7.3 infant deaths per 1,000 births in 2004, the Hamilton County infant mortality rate was 5.8% above the 14-county average of 6.9. Rates of infant mortality ranged from 3.8 per 1,000 births in Lehigh County Pennsylvania (Allentown) to 10.7 per 1,000 births for Cumberland County North Carolina (Fayetteville).

Communicable Diseases

Compared to the 14-county averages for 2004, Hamilton County reported higher incidences of chlamydia and gonorrhea diagnoses and lower incidence of new HIV diagnoses.

In Hamilton County, 238 new cases of gonorrhea per 100,000 residents were diagnosed in 2004, 43.9% higher than the fourteen county average of 165.4. Ada County (Boise) and Lane County (Eugene) had the lowest reported rates, with 11.4 and 11.8 per 100,000, respectively, while Cumberland County North Carolina, with 343.7 cases per 100,000 residents, had the highest rate.

With a rate of 564 new cases per 100,000 residents in 2004, Hamilton County’s chlamydia rate was 26% higher than the 14-county average of 447.4. At 865.6 per 100,000 residents, Cumberland County North Carolina had the highest chlamydia rate, while Ada County Idaho, with 232.2 cases per 100,000, had the lowest reported rate.

Methods of reporting HIV and AIDS infections are less consistent across the areas studied. The most commonly reported data, available for ten of fourteen benchmark counties, were the numbers of HIV infections diagnosed in 2004, which were converted into rates per 100,000 residents. Hamilton County reported 8.7 HIV diagnoses per 100,000 residents in 2004. The average rate of 11.2 per 100,000 is skewed by two high rates in North Carolina – 29.3 in Forsyth County and 23.1 in Cumberland County. With 4.9 diagnoses per 100,000 in 2004, Winnebago County Illinois had the lowest rate of ten counties.

Air Quality

The American Lung Association’s Report State of the Air 2005 named Lane County Oregon the 7th most polluted county for short-term particle pollution (24-Hour PM 2.5). Of the 14 benchmark counties, Lehigh County was the only county to receive a failing grade for both particle and ozone pollution levels. No benchmark counties were cited among the 25 worst for ozone.

The report also included limited data at the MSA level: the Allentown-Bethlehem-Easton PA-NJ MSA was named 22nd most polluted MSA for short term particle pollution.

With an average of three orange³⁰

State of the Air 2005 gave failing ozone grades to eight of fourteen counties, including Hamilton: these cities averaged 24.1 orange ozone days per year during the reporting period (Hamilton averaged 26 orange ozone days). The other four cities had a total eight orange ozone days combined.

Low Birthweight

Hamilton County hospitals reported above average numbers of hospital beds and greater utilization of emergency departments and inpatient visits per 1,000 residents.

With 6.3 hospital beds for every 1,000 residents, Hamilton County has 31.2% more hospital beds per 1,000 residents than the 14-county average of 4.8. Of the 14 counties, Richland County South Carolina (Columbia), has the greatest number of beds per 1,000 residents -- 9.6, while Ada County Idaho has the fewest -- 3.0 beds per 1,000 residents.

The 2002 Hamilton County inpatient utilization rate of 157.9 visits per 1,000 residents was 27.1% higher than the 14-county average of 253.6.

Inpatient utilization is related to hospital bed capacity. Richland County, with the greatest number of beds per 1,000 of the 14 counties, also had the greatest number of inpatient visits per 1,000 – 207.9. Lane County Oregon, with the fewest beds on average, had the lowest inpatient utilization rates – 30.1 visits per 1,000 residents.

With 312 emergency department visits per 1,000 residents in 2002, Hamilton County emergency department utilization rates were 23.0% higher than the 14-county average of 253.6 and second only to Madison County Alabama, which had 462.1 visits per 1,000 residents. The two peer counties in Michigan, Washoe and Washtenaw, had the lowest ED usage rates – 71.8 and 74.2 per 1,000 residents, respectively.

Substance Abuse Treatment Capacity

The number of substance abuse treatment programs within a 20-mile radius of the 14 cities ranges from three programs in Huntsville to 32 programs in Ann Arbor. Eleven substance abuse programs are located within 20-mile radius of Chattanooga. Among the 14 jurisdictions, the four cities with the most substance abuse treatment programs are located in states with the highest rates of illicit drug abuse. Only one (Salem) was also among the top four states for alcohol abuse.

County Regional Differences

In order to provide sub-county level geographic data, health statistics were organized into the nine Hamilton County regions used for countywide survey level data. This section includes sub-county level data from local surveys as well as health statistics from the Tennessee Department of Health, and TennCare enrollment data from the Tennessee Department of Human Services. Health data from state and federal sources include all reported incidences for each indicator and are not subject to confidence intervals.

Most survey data come from the 2006 countywide survey. Obesity and binge drinking data are from the 2004 Hamilton County BRFSS. Readers should be cautious when evaluating within county regional differences for survey data due to relatively large margins of error within regions.

Summary of Findings

Residents throughout the county value high quality health care – 95% or more respondents in each region rated “quality healthcare and hospitals” as very important or important to their quality of life in the Chattanooga area. The majority of respondents in all but one neighborhood (Downtown/South Chattanooga) indicated they were in excellent or very good health– the percentages reporting excellent or very good health ranged from 45% (Downtown/South Chattanooga) to 68% (Hixson). There were striking regional differences, however, for many other health indicators.

Most notably, the Downtown/South Chattanooga, East Ridge/Brainerd and East Chattanooga/ Highway 58 regions generally had the worst health outcomes overall, scoring above the county average for most health measures. These three regions reported the highest incidences for obesity, low birthweight, and crude (non-age-adjusted) death rates per 100,000 residents, HIV/AIDS, chlamydia, and gonorrhea.

Communicable disease data suggest high levels of risky sexual behavior among residents of the Downtown/South Chattanooga, East Ridge/Brainerd and East Chattanooga/ Highway 58 regions. Combined, these three regions account for 61% of cumulative HIV/AIDS diagnoses since 1984, as well as 68% of chlamydia and 80% of gonorrhea cases in 2005. Downtown/South Chattanooga had the highest percentages of all three diagnoses – 31% for HIV/AIDS, 36.3% for chlamydia and 42.7% for gonorrhea.

Out of the nine regions, however, Downtown/South Chattanooga generally had the worst health outcomes. Compared to the county-wide average, most recent data reveals the Downtown/South Chattanooga region had:

• A 3.4 times higher rate of 2005 gonorrhea diagnoses (939.1 versus 276.8 per 100,000 residents)
• A 2.9 times higher rate of 2005 chlamydia diagnoses (1,445.5 versus 500.5 per 100,000 residents)
• A 2.8 times higher rate of HIV/AIDS diagnoses (1,091.8 versus 385.5 per 100,000 residents)
• A 60% higher percentage of low birthweight babies in 2004 (18.3% versus 11.4%)
• A 26% higher rate of deaths per 100,000 residents in 2004 (1295.4 versus 1027.7 per 100,000 residents)
• 31% of all infant deaths in 2004 (10 out of 32 total county-wide).

In addition, Downtown/South Chattanooga had the greatest proportion of uninsured respondents (33%), as well as the greatest proportion of residents on TennCare (27.6%)

Other Findings

A third or more countywide survey respondents in three regions – East Hamilton, Downtown/South Chattanooga, and East Chattanooga -- were current smokers: smoking prevalence in the other regions ranged from 19% to 25%.

About one in four respondents in North Hamilton and East Chattanooga were uninsured. About one in four residents in the East Chattanooga region were enrolled in TennCare.

Low birthweight occurs county-wide. In 2004, eight of nine regions (excluding East Hamilton) had higher rates of low birthweight than the national rate (8.4%), and seven regions exceeded the state average (9.4%).

Health Risk Index

A Health Risk Index for each region was compiled from a list of twelve indicators. The index indicates the number of times a region was ranked as among the top three worst performing county regions for the health indicators, with a possible Health Risk Index ranging from 0 to 12.

The Downtown/South Chattanooga Region’s Health Risk Index is 12, indicating the region was among the three worst performing regions for all twelve indicators. East Ridge/Brainerd and East Chattanooga, both with a Health Risk Index of 9, tied for second place. No other region had a Health Risk Index greater than 3, and one region, East Hamilton, had an index of 0. A map illustrating the Health Risk Index by region follows.

Endnotes

1. What Creates Health? The Healthcare Forum, San Francisco, CA, 1994,p.1.

2. National Center for Health Statistics

3. Health and Health Care 2010: The Forecast, The Challenge, Second Addition, 2003.

4. Chronic lower respiratory diseases include chronic bronchitis, emphysema, asthma, and less common diseases such as cystic fibrosis.

5. Sources: American Heart Association (heart disease and stroke $403.0 billion), American Cancer Society ($209.9 billion), and American Lung Association (CLRD $20.9 billion).

6. According to the CDC’s National Center for Health Statistics, “Age adjustment is used to compare risks of two or more populations at one point in time or one population at two or more points in time. Age-adjusted rates are computed by the direct method by applying age-specific rates in a population of interest to a standardized age distribution, in order to eliminate differences in observed rates that result from age differences in population composition. Age-adjusted rates should be viewed as relative indexes rather than actual measures of risk.”

7. National Center for Health Statistics, National Vital Statistics Reports, Vol. 54, No. 13, April 19, 2006.

8. Tennessee’s Racial Disparity in Infant Mortality: Special Report 2006, Tennessee Department of Health

9. CDC http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_05.pdf

10. Three area mental health hospitals, Moccasin Bend Mental Health Institute, FHC Cumberland Hall, and Valley Hospital, account for 94% of all admissions for mental disorders.

11. Not all hospital admissions were to Hamilton County residents. 2004 JAR data show that 45% of people admitted to Hamilton County hospitals were not residents of Hamilton County.

12. Tennessee Department of Health, CDC and US Census. http://www.cdc.gov/nchs/fastats/aids-hiv.htm. Rate per 100,000 computed using US Census estimates for 2003.

13. http://apps.nccd.cdc.gov/brfss/Trends/trendchart. asp?qkey=10010&state=US

14. http://www.cdc.gov/nccdphp/dnpa/obesity/faq.htm#how

15. Overweight and obesity are determined by calculating body mass index, a measure of body weight relative to height. Overweight is defined as having a body mass index (BMI) between 25 and 29.9. Obesity is defined as a BMI of 30 or greater. BMI describes body weight relative to height and is strongly correlated with total body fat content in adults. According to the guidelines, a BMI of 30 is about 30 pounds overweight and is equivalent to 221 pounds in a 6’ person and to 186 pounds in someone who is 5’6”. The BMI numbers apply to both men and women. Some very muscular people may have a high BMI without health risks. To compute BMI: [Weight / height (inches squared)] x 704.5. (National Institutes of Health). National overweight and obesity prevalence is based on median of 54 reporting states and territories. 2002 is the most recently available year for national overweight and obesity prevalence.

16. National data are based on median of 51 reporting states and territories. CDC 2005 BRFSS.

17. The Centers for Disease Control (CDC) classifies adolescents at risk for overweight if their BMI falls between the 85th and 94th percentile for their age and gender, and overweight if their BMI is at the 95th percentile or higher. While the CDC does not have a definition for underweight, based on conversations with local dieticians, the Community Research Council set the threshold for underweight at the 25th percentile or below.

18. 2002 Hamilton County YRBS

19. Huffing is defined as sniffing glue, breathing the contents of aerosol spray cans, or inhaling any paints or sprays to get high.

20. Other than a few sips.

21. The question is phrased “During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is within a couple of hours?”

22. http://lungaction.org/reports/stateoftheair2005.html

23. Chattanooga-Hamilton County Air Pollution Control Bureau

24. Ibid.

25. 2004 Hamilton County BRFSS; 2005 National BRFSS (CDC)

26. Nationally in 2004, 8.1% of babies had low birth weight.

27. Charity care includes charges classified as charity and medically indigent.

28. Office of National Drug Control Policy Drug Policy Information Clearinghouse, State of Tennessee Profile of Drug Indicators, April 2006.

29. SAMHSA, Treatment Episode Data Set (TEDS), 2004.

30. “Orange” days indicate the air for that pollutant is considered unhealthy for sensitive groups