Copyright 2011 by MaineHealth, subject to perpetual rights of use by Eastern Maine Healthcare Systems and MaineGeneral Health.

The research team at the University of New England, USM Muskie School of Public Service and Market Decisions who contributed to this report are as follows: Ronald Deprez, PhD, MPH+, Principal Investigator David Hartley, PhD^, Co-Investigator Kira Rodriguez, MHS+, Project Manager Brian Robertson, PhD~, Survey Research Director John Gale, MS^, Research Associate Carry Buterbaugh, MS+, Research Associate Hank Stabler, MPH+, Research Associate Mary Louie+, Project Coordinator
+ ^

UNE Center for Community and Public Health University of Southern Maine (USM) Muskie School of Public Service ~ Market Decisions, Inc. We wish to thank many others who advised us in completing the project and report. They include: The OneMaine Steering Committee
MaineHealth Deborah Deatrick Julie Osgood Tim Cowan Eastern Maine Healthcare Systems Jerry Whalen Jean Mellett Kathie Sewall MaineGeneral Health Natalie Morse Gail Evans

The OneMaine Advisory Committee

Carol Bell Kelly Bentley Gail Dana-Sacco, PhD

Patricia Hart
Barbara Leonard Becca Matusovich

Lisa Miller
Dora Mills Elizabeth Mitchell Trish Riley Brian Rines, PhD Rachel Talbot-Ross Edward (Ted) Trainer Shawn Yardley

TABLE OF CONTENTS
I. EXECUTIVE SUMMARY ................................................................................................................................................ 6 Introduction and Objectives ................................................................................................................................................. 6 Methodology ......................................................................................................................................................................... 6 Findings and Recommendations ........................................................................................................................................... 7 II. INTRODUCTION ............................................................................................................................................................ 13 III.OBJECTIVES ................................................................................................................................................................... 14 IV.METHODOLOGY ........................................................................................................................................................... 15
HOUSEHOLD SURVEY ................................................................................................................................................................ 17

Questionnaire Design ......................................................................................................................................................... 17 Sampling Methodology ....................................................................................................................................................... 18 Survey Response Rates and Weighting ............................................................................................................................... 18 Precision ............................................................................................................................................................................. 19 SECONDARY DATA .................................................................................................................................................................... 22 Population Estimates and Demographics........................................................................................................................... 22 Births and Mortality ........................................................................................................................................................... 22 Hospital Inpatient and Emergency Department (ED) Data ............................................................................................... 22 Cancer Registry .................................................................................................................................................................. 22 State Infectious Disease Data ............................................................................................................................................. 23 Maine Integrated Youth Health Survey (MIYHS) ............................................................................................................... 23 Maine BRFSS...................................................................................................................................................................... 23 FINDINGS .................................................................................................................................................................................. 23 V. KEY POPULATION HEALTH STATUS FINDINGS ................................................................................................. 24 Age Profile .......................................................................................................................................................................... 24
HEALTH-BASED SOCIAL AND ECONOMIC CHARACTERISTICS ..................................................................................................... 26 ACCESS TO CARE ...................................................................................................................................................................... 30 POPULATION AND DEMOGRAPHIC PROFILE ............................................................................................................................... 24

Access to Quality Health Care ........................................................................................................................................... 30 Barriers to Medical Care.................................................................................................................................................... 32 QUALITY AND EFFECTIVENESS OF CARE.................................................................................................................................... 35 HEALTH STATUS AND WELLNESS ........................................................................................................................................... 38 VI.KEY FINDINGS FOR SPECIFIC AREAS OF HEALTHCARE ................................................................................ 42
CARDIOVASCULAR HEALTH ...................................................................................................................................................... 42

Behavioral Risk Factors ..................................................................................................................................................... 42 Medical Risk Factors for CVD ........................................................................................................................................... 43 Mortality and Morbidity ..................................................................................................................................................... 44 RESPIRATORY HEALTH.............................................................................................................................................................. 49 Risk Factor Prevalence....................................................................................................................................................... 51 DIABETES HEALTH .................................................................................................................................................................... 55 Risk Factor Prevalence....................................................................................................................................................... 57 CANCER HEALTH ...................................................................................................................................................................... 62 Risk Factors ........................................................................................................................................................................ 62 Overall Incidence and Mortality......................................................................................................................................... 63 Lung Cancer ....................................................................................................................................................................... 65 Colorectal Cancer .............................................................................................................................................................. 66 Prostate Cancer .................................................................................................................................................................. 67 Breast Cancer ..................................................................................................................................................................... 68 REPRODUCTIVE HEALTH ........................................................................................................................................................... 72 MENTAL HEALTH ...................................................................................................................................................................... 74 Introduction ........................................................................................................................................................................ 74 Mental Health Burden and Risk Factors ............................................................................................................................ 75 Mental Health Prevalence .................................................................................................................................................. 76

Mental Health Service Utilization Rates............................................................................................................................. 77 Mental Health Outcomes Suicide Mortality .................................................................................................................... 78 SUBSTANCE ABUSE ................................................................................................................................................................... 84 Introduction ........................................................................................................................................................................ 84 National and State Context ................................................................................................................................................. 84 Prevalence of Substance Abuse across Maine Counties ..................................................................................................... 85 Past and Current Substance Abuse Problems .................................................................................................................... 86 Patterns of Alcohol Abuse .................................................................................................................................................. 87 Patterns of Illicit Drug Use (Including Street Drugs and the Non-Prescription Use of Prescription Drugs) ............... 87 Hospital and Emergency Department Admission Rates ..................................................................................................... 88 Mortality Rates ................................................................................................................................................................... 89 YOUTH HEALTH ........................................................................................................................................................................ 98 Risk Behaviors Substance Abuse ..................................................................................................................................... 98 Risk Behaviors - Obesity ..................................................................................................................................................... 99 Youth Mental Health ........................................................................................................................................................... 99 Other Youth Health Indicators ......................................................................................................................................... 100 Patterns Clusters of Risk ............................................................................................................................................... 100 COMMUNITY PERCEPTIONS OF HEALTH AND HEALTH SERVICE NEEDS..................................................................................... 103 Health Issues of Concern to Residents and Providers ...................................................................................................... 103 Health Service Needs ........................................................................................................................................................ 103 INTERPERSONAL VIOLENCE/ABUSE ......................................................................................................................................... 108 ARTHRITIS, BONE AND JOINT HEALTH ..................................................................................................................................... 110 INFECTIOUS DISEASE .............................................................................................................................................................. 112 Hepatitis C ........................................................................................................................................................................ 112 HIV and Sexually Transmitted Diseases ........................................................................................................................... 112 Influenza ........................................................................................................................................................................... 113 VII.PRIORITY HEALTH ISSUES ................................................................................................................................... 116 VIII.RECOMMENDATIONS.............................................................................................................................................. 125 Access to Care .................................................................................................................................................................. 125 Quality and Effectiveness of Care .................................................................................................................................... 126 Primary Prevention Services ............................................................................................................................................ 127 Care for Chronic Conditions ............................................................................................................................................ 128 Substance Abuse and Mental Health Services .................................................................................................................. 129 Cancer Health................................................................................................................................................................... 131 Youth Health Issues .......................................................................................................................................................... 131 IX.APPENDICES ................................................................................................................................................................ 133 APPENDIX 1: STEERING & ADVISORY COMMITTEE MEMBERS.............................................................................. 133 APPENDIX 2: MAP OF MAINE COUNTIES ...................................................................................................................... 135 APPENDIX 3: CIAP PROCESS ........................................................................................................................................... 136 APPENDIX 4: HEALTH STATUS PROFILE ...................................................................................................................... 137 APPENDIX 5: ANNOTATED SURVEY INSTRUMENT ....................................................................................................... 147 APPENDIX 6: SURVEY METHODS TECHNICAL ........................................................................................................... 229 APPENDIX 7: DATA SOURCES AND YEARS.................................................................................................................. 245 APPENDIX 8: SELECTED DEFINITIONS OF INDICATORS .............................................................................................. 246 APPENDIX 9: DETAILED DATA SOURCES AND HOSPITAL DISCHARGE CODES ................................................................... 252

OneMaine Community Health Needs Assessment 2010

I. EXECUTIVE SUMMARY Introduction and Objectives The OneMaine Health Collaborative (OneMaine) is a partnership among MaineHealth, Eastern Maine Healthcare Systems and MaineGeneral Health. It was created in 2007 to share information more efficiently among the three systems and to work as a group to better understand the community health needs of the communities served by our systems. In January, 2010, OneMaine contracted with the University of New Englands Center for Community and Public Health (CCPH) to conduct a Statewide Community Health Needs Assessment (CHNA). The assessment, conducted in collaboration with the University of Southern Maine and Market Decisions, Inc., was designed to identify the most important health issues in the state, both overall and by county, using scientifically valid health indicators and comparative information. The assessment also identifies priority health issues where better integration of public health and healthcare can improve access, quality, and cost effectiveness of services to residents of Maine. This project represents OneMaines efforts to share information that can lead to improved health status and quality of care available to Maine residents, while building upon and strengthening Maines existing infrastructure of services and providers. The 2010 OneMaine Community Health Needs Assessment has four objectives: Develop a comprehensive profile of health status, quality of care and care management indicators for residents of Maine overall and for residents by county. Identify a set of priority health needs (public health and health care) for follow-up. Provide recommendations on strategies that can be undertaken by healthcare providers, public health staff, communities, policy makers, and others to follow-up on the information provided with actions that may improve the health status of Maine people. Provide access to the CHNA data and assistance to stakeholders who are interested in using it.

Methodology A modified version of CCPHs Community and Institutional Assessment Process (CIAP) was used to conduct the CHNA. The CIAP is a comprehensive planning process that identifies salient healthcare related issues in the community through a systematic analysis of scientifically derived health indicators and comparative and best practice information. Indicators are computed from an extensive set of health-related data and a community household telephone survey. The CIAP starts with a comprehensive epidemiological-based health profile organized by health domain or condition such as cardiovascular health, respiratory health, cancer health, etc. Indicators for most domains are further organized by risk factors, prevalence (or incidence) of disease or condition, care management indicators and care outcomes. The analysis of indicators within each domain provides information to identify, and subsequently explore, which aspects of the healthcare delivery system may be over- or under-performing for that particular domain (e.g. primary prevention, secondary prevention, etc.). This results in a list of priority health issues and 6

OneMaine Community Health Needs Assessment 2010 questions for follow-up with providers, community leaders, agencies and the public, to determine delivery system strengths and deficits that may be driving the indicators. Findings and Recommendations Community health needs assessments are designed, in part, to identify issues where changes in the healthcare delivery system can improve both patient care and preventive services for those at risk for health problems. This section presents an overview of the findings in the report and recommendations based on those findings. The latter address Maine as a whole, some may not apply to local health delivery systems in the state. Maine has several underlying socio-demographic characteristics that impact many of the health indicators in this report. For example, Maine has the oldest population in the U.S. i.e., a very high proportion of elderly (65+) compared to the U.S. While being older does not necessarily equate to having poor health, the reality is that aging populations use more health services than younger populations. When older age is combined with other adverse factors, like poverty or unemployment, health status is often poorer than in younger and higher income populations. Maine has a lower median income than the U.S., but the proportion of Maine residents living below the Federal poverty line is slightly lower than the rest of the country. However, in the states northern and central counties a greater proportion of residents live below the Federal poverty line than the state as a whole or the U.S. Unemployment is an important demographic predictor of health. Compared to the rest of the U.S., Maine has a lower unemployment rate, but several Maine counties individually have high rates of unemployment, many well over 10%. Educational attainment is relatively good in Maine, as measured by the proportion of the population with a high school diploma. However, several counties have high numbers of residents without a high school diploma. Access to Health Care: Access to care in Maine, especially in regard to health insurance coverage is better than the US as a whole. Maine has a relatively low percentage of uninsured residents (13%), as well as a low percentage of residents without a usual source of care (13%), relative to the U.S. (14% and 24%, respectively). However, access to care as measured by several health use indicators is a significant issue in most of the state. Maine residents as a whole and in many counties have high rates of emergency department (ED) and preventable hospitalizations. The 2010 CHNA data provides a disturbing view of high ED and hospital use by patients with symptoms and conditions that could be prevented with care provided in primary care settings. The issue is complex and could be due in part to a maldistribution of primary care providers (PCPs), the inability of patients to be seen on a timely basis or the methods of financing primary care providers. It also reflects the inability of some populations (especially MaineCare participants and the uninsured) to locate or obtain a PCP as their usual source of care. Access to dental care continues to be a high priority for the state, with a low ratio of providers to population, especially for rural residents and low-income residents. Twenty-four percent (24%) of residents report no dental visit in the past two years. This was highest in Aroostook, Oxford, 7

OneMaine Community Health Needs Assessment 2010 Piscataquis, Somerset and Washington counties. Oral health is the most commonly cited service for which residents report having to travel outside of the service area. Insurance coverage in Maine (and the U.S.1) is still a major issue. Given the uncertainty about the implementation of federal health reform (The Accountable Care Act or ACA) and potential cuts in coverage for many Maine residents currently on Medicaid (MaineCare), it is recommended that Maine follow the example set by other New England states and develop its own plan to replace or expand upon federal health insurance reform should ACA be reversed. To accomplish this will require outstanding leadership, vision, and objective data and information, and should be based on the known experiences of western democracies in health insurance coverage.2 Furthermore, it is recommended that access to oral health care be considered in any coverage expansion efforts, and increased attention be given to developing innovative training and placement programs for dentists and dental hygienists throughout the state. Primary Care Quality and Effectiveness: Access to, and availability of, high quality primary care, especially for those with chronic health conditions, is a continuing challenge in Maine. This is an issue in many Maine counties and may be due to inadequate availability of providers, lack of health insurance, or lack of patient self management, among other patient, health system or population issues. Maine has many experiments underway attempting to improve the quality, effectiveness and cost efficiency of care.3 The establishment of an information clearinghouse to review and publish findings from these varied experiments in Maine is recommended. The data provided from a clearinghouse could also help determine how to permanently sustain the successful experiments. Behavioral Risk Factors: Behavioral health risk factors such as smoking, overweight, and sedentary lifestyle continue to be priority health issues in several, mostly rural, counties, as well as in the state. Smoking rates are still high in Maine (22%), and appear to have leveled off from previous declines. Prevalence of obesity is 28% in Maine, with several counties well above the state. Leading a sedentary lifestyle is very prevalent in many counties. Smoking and obesity remain major preventive health issues across almost all age and gender groups. To reduce both will require much bolder approaches than are currently in place, coupled with additional policies and resources. It is recommended that initiatives to reduce obesity, for example, address both children and adults and focus on the underlying causes of the problem. Approaches should be comprehensive and include use of tax policies. Local resources are needed to enhance access to exercise, nutrition, and treatment modalities including stress management. Approaches should integrate Maines developing local public health infrastructure, community based resources, local providers, patients and families.

The 2010 National Healthcare Quality Report produced by AHRQ indicates that improvement on only 40% of the 22 measures of access to care, such as the number of people younger than 65 with health insurance. 2 TR Reid. The Healing of America. Penguin Books, 2009. 3 Examples are the Maine Patient Centered Medical Home pilot; the new Beacon Community at Eastern Maine Healthcare Systems; the CMS Maine Multi-Payer Advanced Primary Care Practice Demonstration; and a number of developing pilot Accountable Care Organizations.

OneMaine Community Health Needs Assessment 2010 Cardiovascular Health: Prevalence rates (population %) of medical risk factors for cardiovascular disease are of concern in several counties, as are high rates of morbidity and mortality in several counties that do not have high disease prevalence. This seeming disconnect needs to be better understood and addressed as it may reflect reduced access and quality of care. Elevated prevalence of high blood pressure is seen in Aroostook, Piscataquis, Somerset, and Washington counties. High stroke hospital admission rates are seen in Aroostook, Hancock, Knox, Lincoln, Piscataquis, Somerset, and Washington counties. Elevated prevalence of hyperlipidemia (high cholesterol) is seen in Androscoggin, Oxford, and Washington counties. High heart attack (AMI) rates are observed in Aroostook, Hancock, Kennebec, Piscataquis, Somerset, Waldo, and Washington counties. Counties with higher prevalence of high blood pressure and high cholesterol are more likely to have a higher prevalence of obesity. Respiratory Health: Maine continues to have a high prevalence of respiratory disease risk factors and respiratory disease. The proportion of the population that continues to smoke is high in Aroostook, Oxford, Somerset, Washington, and York counties. Asthma prevalence (diagnosed) in Maine is 10%, with elevated prevalence in Androscoggin, Aroostook, Somerset, and Waldo counties. Somerset, Waldo, and Washington counties have elevated COPD prevalence rates compared to the state. Washington County has high ED and inpatient hospital use rates for asthma and bronchitis, despite not having elevated (diagnosed) prevalence of these conditions. Diabetes: Diabetes prevalence rates continue to increase in Maine. Overall, diabetes prevalence statewide is 10%, but the rate is elevated in Aroostook, Oxford, Piscataquis, and Washington counties. For most counties, diabetes prevalence is associated with high rates of obesity and sedentary lifestyle. Thus lifestyle factors and care management of diabetes continues to be priority health issue for Maine. Inpatient admissions and ED visit rates for diabetes appear to correlate with diabetes prevalence and risk factors, but not with estimated levels of evidence based diabetes care management measures. Aroostook, Franklin, Hancock, Kennebec, Oxford, Somerset, and Washington counties have high diabetes mortality compared to the state. Care for Chronic Conditions: Approximately 90 million Americans are living with at least one chronic disease, and chronic disease contributes to over 70% of deaths in the U.S. each year. The majority of U.S. adults with high cholesterol and about half of adults with high blood pressure do not have their conditions under control. Despite the relatively low cost and proven effectiveness of treatments for these common and preventable - but potentially deadly - conditions, many Americans are not getting better.4

Released in February 2011 as a Centers for Disease Control and Prevention Vital Signs report, High Blood Pressure and Cholesterol Out of Control found that two out of three U.S. adults with high cholesterol and about 50 percent of adults with high blood pressure are not being treated effectively and are therefore at increased risk for heart attacks, strokes and other problems. The report calls on health professionals to manage high blood pressure and high cholesterol at every patient visit and to remind patients about follow-up care. Moreover, policy-makers should develop policies that reward effective disease prevention and chronic disease management and develop policies that allow other health care professionals to have a more active role in managing high blood pressure and cholesterol.

OneMaine Community Health Needs Assessment 2010 Public policy changes and a much higher level of private-public partnering will be needed to improve care and care outcomes (as well as address the cost of care) for these conditions. Efforts to date to improve chronic disease prevention and treatment may be insufficient. Changes in how care is reimbursement by public and private insurers may be required.5 6 It is also recommended that policies and practice changes be implemented to improve patient self management. Changes need to address core competencies around how to deliver patient centered care; how to partner with patients, providers and the community; and how to improve medication management and adherence. Use of community care teams that include patients in treatment decisions, and continued quality improvement using evidenced based guidelines, coupled with changes in reimbursement policies may be required. Policy initiatives and state level programs and resources to assist practices and communities in achieving these changes will be needed. Cancer Health: Maine continues to have among the highest age-adjusted cancer incidence and mortality rates in the U.S. In 2007, Maines age-adjusted cancer incidence rate (515 cases per 100,000 population) was the highest in the nation.7 Further, while US incidence rates have been declining in recent years, Maines rates have remained high. The reason Maines rates are high is not clear, but may be a reflection of improved screening rates. Although Maines all-cancer mortality rate has been declining, the 2005-2007 mortality rate was the 7th highest in the nation.8 Higher mortality rates due to cancer are largely the result of higher incidence rates in Maine and its counties. However, several counties have higher mortality rates for specific cancers despite not having high incidence rates. Overall cancer incidence is high in Hancock, Piscataquis, and Washington counties, as are the incidences of three of four most common cancers. Aroostook, Lincoln, Oxford, Piscataquis, and Washington counties have comparatively high cancer mortality rates. Differences in mortality/incidence ratios (an indicator designed to measure potential disparities in access to screening and/or treatment) are highest in Aroostook, Franklin, Knox, and Oxford counties compared to Maine overall. Improved education and screening for preventing cancer is recommended, as well as follow-up on treatment access and availability in several counties. A major challenge for Maine is determining the specific contribution of risk factors that contribute to high incidence rates. Behavioral risk factors such as smoking, poor nutrition, and obesity are likely contributors, as are
Payment reform is a key issue at the federal level as there is agreement that many of the cost and quality problems in health care today are either caused by or exacerbated by the way we pay for healthcare services. Center For Healthcare Quality and Payment Reform (http://www.chqpr.org ) 6 A federal response to address the cost and quality issues in the US healthcare system is through the formation of accountable care organizations that are being promoted in the ACA. There has been growing interest in finding ways to encourage health care providers to take greater accountability for the overall cost as well as the quality of healthcare delivered to patients. An Accountable Care Organization consists of a healthcare provider or group of providers that accepts accountability for the total cost of care received by a population of patients. " Center For Healthcare Quality and Payment Reform (http://www.chqpr.org ) 7 Maine Comprehensive Cancer Control Plan: 2011-2015. Maine Cancer Consortium c/o American Cancer Society, Topsham, ME; October 2010. 8 Cancer mortality data for 2005 to 2007, from Centers for Disease Control and Prevention; presented in Americas Health Rankings- 2010 Edition 2010 United Health Foundation.
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OneMaine Community Health Needs Assessment 2010 heredity, income, and other social-demographic determinants. We do not currently know enough why Mainer experiences such high rates of cancer incidence, even when age is controlled for. We recommend that the state undertake a major epidemiological and policy study to guide planning and intervention to address this issue.9 Substance Abuse and Mental Health Services: Mental health problems affect a large portion of Maines population, and are frequently seen in populations with physical health issues and substance abuse (SA) problems. Close to 11% of Maine residents report experiencing 11 or more days (in the past month) in which their mental health was not good. Five percent (5.0%) of Maines population reported that they had needed mental health treatment in the past year but had not received it. More than 7.0% are at risk for clinical depression, based on responses to key questions in the household survey. In fact, 22% of Maine residents have been diagnosed with depression at some time in their lives, and nearly 15% have a current diagnosis of depression. Over 13% have been diagnosed with some other psychiatric disorder in their lives. Maine residents also show high patterns of ED utilization for a wide range of mental health issues, including senility and organic mental disorders, major depressive disorders, bipolar disorders, schizophrenia, and anxiety disorders. This suggests potential access issues to mental health services across Maine. Many counties have high rates of their populations with more than one mental health risk factors (i.e., percentage with 11 or more days of poor mental health in last month, percentage needing but not getting mental health treatment in last 12 months, and percentage at risk for clinical depression). Others have high rates of populations with multiple mental health problems (i.e., rates of lifetime depression, current depression, lifetime other psychiatric disorders, or developmental delays or learning disabilities). Overall, Maine has a suicide death rate higher than the US rate. Substance abuse (SA) of alcohol and drugs takes a high human and financial toll in Maine The States Office of Substance Abuse estimated the total costs of SA to exceed $898 million in 2005. In Maine, alcohol is the most commonly used substance. Rates of problem drinking behavior such as binge and heavy drinking among Maine residents are comparable to national averages, at 15% and 6% respectively. Nearly 5.0% of Maine residents have been diagnosed with a SA problem in their lifetime, and nearly 2.0% have a current SA disorder. Males in Maine also exhibit higher rates of mortality for alcohol-related issues and alcohol-related motor vehicle accidents than do women. Substance abuse in general, and alcohol and prescription drug misuse in particular, require three levels of intervention prevention, screening and detection. All three require concerted, collaborative action involving the public health, education, health care, and criminal justice systems at the community level to have an impact.
In October 2010, the Maine Cancer Consortium published the Maine Comprehensive Cancer Control Plan: 20112015. This plan is intended to be a roadmap for a collaborative approach to minimizing the impact of cancer in Maine. It highlights opportunities to impact different parts of the cancer continuum, including (1) Primary Prevention; (2) Early Detection; (3) Treatment; (4) Rehabilitation and Survivorship; and (5) Palliation and End-ofLife Care. The county-level data presented in this report can help identify which strategies highlighted in the Maine Comprehensive Cancer Control Plan may be most applicable for select geographic regions.
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OneMaine Community Health Needs Assessment 2010

Recommendations to address these issues are: Implement broad-based, collaborative prevention programs at the community level using evidence-based strategies that target specific populations and age groups. These initiatives should involve a full range of community stakeholders, including public health, health care providers, schools, the criminal justice system, parents, and adolescents. Provide primary care providers (PCPs) and ED providers education programs related to substance abuse diagnosis, treatment tools, and protocols. The highest priority would encourage expanded use of evidence-based screening tools such as Screening, Brief Intervention, Referral, and Treatment (SBIRT). Fund the development and implementation of strategies to coordinate the delivery of substance abuse services at the local level, and provide access to expanded referral and consultative resources for PCPs. Youth Health: Significant numbers of adolescent Mainers engage in a variety of health risk behaviors. Childhood obesity and teenage drinking place Maine youth at both immediate and future risk of poor health, and suggest a need for prevention interventions involving local organizations and stakeholders. High rates of two or more youth risk behaviors were identified in Aroostook, Franklin, Lincoln, Piscataquis, Waldo, and Washington counties. Hospital admissions rates of youths for depression and suicidal ideation are highest in Androscoggin, Cumberland, Lincoln, Piscataquis, Sagadahoc, and Waldo counties. Nutrition and physical activity are the primary determinants of obesity, both of which can lead to diabetes. Smoking is implicated in many preventable deaths, and most smokers start in their teens. Similarly, alcohol and drug use behaviors are established early in life, usually before the age of majority. We find these risk behaviors in clusters - i.e., counties with high rates of one risk behavior often have high rates of others. Recommendations to address these issues are: Health care providers, school officials, and the states regional public health district coordinating councils take the lead in monitoring the Maine Integrated Youth Health Survey (MIYHS) to identify trends in youth health risk behaviors. Working through the district coordinating councils, Maine CDC and Maine Office of Substance Abuse provide technical assistance to local coalitions to help them develop environmental prevention initiatives tailored to their communities, their children, and the behavioral issues identified through monitoring the MIYHS. In counties with clusters of very high rates of youth health risk behaviors (identified in this report), Healthy Maine Partnerships and the district coordinating councils should place a priority on the development and implementation of prevention initiatives.

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OneMaine Community Health Needs Assessment 2010 II. INTRODUCTION The OneMaine Health Collaborative (OneMaine) is a partnership among MaineHealth, Eastern Maine Healthcare Systems and MaineGeneral Health. It was created in 2007 to more efficiently share information among the three systems and to work as a group to better understand community health needs of the communities served by the systems. In January, 2010, OneMaine contracted with the University of New Englands Center for Community and Public Health (CCPH) to conduct a Statewide Community Health Needs Assessment (CHNA). The assessment, which CCPH conducted in collaboration with the University of Southern Maine and Market Decisions, Inc. was designed to identify Maines most important health issues, both overall and by county, using scientifically valid health indicators and comparative information. It was also designed to provide the states public and private health providers with information to assess essential public health, preventive care and medical services. Additionally, the assessment identifies key services where better integration of public health and health care can improve access, quality and cost effectiveness. This project represents OneMaines collaborative efforts to share information that can lead to improved health status and the quality of care available to Maine residents, while building upon and strengthening Maines existing infrastructure of services and providers.

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OneMaine Community Health Needs Assessment 2010 III. OBJECTIVES The 2010 OneMaine Community Health Needs Assessment (CHNA) has four objectives: 1. Develop a comprehensive profile of health status, quality of care and care management indicators for residents of Maine overall and by county; 2. Identify a set of priority health needs (public health and health care) for follow-up; 3. Provide recommendations on strategies that can be undertaken by health providers, public health, communities, policy makers and others to follow up on the information provided, so as to improve the health status of Maine people; and 4. Provide access to the data and assistance to stakeholders who are interested in using it.

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OneMaine Community Health Needs Assessment 2010 IV. METHODOLOGY Understanding the health needs of a community allows public health and health care organizations to design and implement cost-effective strategies that improve the health status of the populations they serve. A comprehensive data driven assessment process can identify, with a high degree of accuracy, priority health needs and issues related to prevention, diagnosis and treatment. Assessment tools also may assist in pinpointing access to care barriers, utilization of evidence based guidelines, and utilization of health services. For the 2010 OneMaine CHNA a modified version of CCPHs Community and Institutional Assessment Process (CIAP) was used. Appendix 3 provides a flow diagram of the full CIAP process. The CIAP uses epidemiological modeling of demographic, health access, utilization and related population based health and health related indicators, together with qualitative information from health service providers and the community, to identify health status and service need issues in a geographic area and population. The CIAP starts with a comprehensive epidemiological-based health profile organized by health domain or condition such as cardiovascular health, respiratory health, cancer health, etc. Indicators for most domains are organized by risk factors, prevalence (or incidence) of disease or condition, care management indicators and care outcomes. The analysis of indicators within each domain provides information to identify and subsequently explore which aspects of the health care delivery system may be over- or under-performing for that particular domain (e.g. primary prevention, secondary prevention, etc.). This results in a list of priority health issues and questions for follow-up with domain related providers, community leaders, agencies and the public, to determine delivery system strengths and deficits that may be driving the indicators. Specific service needs of the overall population and the sub-populations within the community (e.g. age group and gender where appropriate) are identified, where data permit, using a combination of quantitative data and qualitative information obtained from interviews. The process leads to an understanding of the health service issues facing a community. With additional information from the literature, the assessment also identified health policy and delivery system change recommendations. Recommendations are based, in part, on what programs or policies have been successful elsewhere and might be appropriately adapted to the local delivery system. It is important to note that actual planning, program development and/or implementation comes after the CHNA. For the OneMaine CHNA the CIAP methodology was used to produce a list of priority health issues and questions for follow-up, with recommendations for next steps to address these issues. The OneMaine health systems will take this information to their individual communities to gain insight on the specific delivery system issues that might be the focus of change in each community. The goal is to eventually improve results for these indicators. Indicators within each domain are produced as actual population rates or proportions. They are not adjusted for age, gender or other population artifacts. Unadjusted or crude rates capture the true burden of disease in a population - that is, the estimated size of the population that the health care system needs to consider. This information is critical for health services planning and is lost if rates are adjusted. To better understand the status of a health domain in a population, the actual rates are analyzed by the following sub-populations: gender; age groups; and/or race and ethnicity, provided the data are available and it is appropriate from a population health or clinical perspective. In the CIAP one generally does not test for statistical significance of rates between two or more populations. This assessment is not hypothesis testing research, and much of the information leading to the identification of priority health issues is by
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OneMaine Community Health Needs Assessment 2010 examining a pattern of indicators for a particular health condition. The fact that any one rate in a series of indicators is statistically significant does not add additional information for identifying or planning health interventions for a population. Once a pattern of indicators that taken together suggests a follow-up analysis is warranted, one might want to consider statistical testing in special circumstances to further examine a particular area of the population. The One-Maine assessment focuses on the state as a whole, and on each of Maines 16 counties. Thus, the Health Status Profile (Appendix 4) contains 18 columns of indicators - one for the state and one for each county. National indicators are in an additional column, and compare Maine to the US. However, the number of US indicators is limited in part by the difficulty of obtaining unadjusted national data. Due to the overwhelming number of data points, analyzing indicators by domains for 16 counties and the state presented a challenge. To identify domain and sub-domain differences by county that are different from the state and thus require additional follow-up, the study team adopted the use of the 10% rule10. The application of this rule meant that indicators 10% or more above or below the state are worth noting for follow-up. Generally, the domain specific analyses in the report used this rule. In sum, the CHNA methodology using CIAP is a systematic analysis of scientific based health and health related indicators about a population that informs the development of better health services planning. The analysis conducted using the above approach is meant to tell a story, a story based on a series of indicators that define the dimensions of health in a population. This leads to an initial identification of priority health issues for further action. Follow-up with qualitative information from key informants leads to the identification of specific actions and services which, if implemented, are likely to improve the indicators for that domain, thus improving care and the health status of the population. To help guide the process used for the OneMaine assessment, a CHNA Steering Committee with representatives from the three OneMaine health systems was convened. This committees role was to provide input on: (a) identification of existing data sources for the study; (b) content of the community household telephone survey questionnaire; (c) interpretation of survey findings; (d) review of recommendations, and; (e) data dissemination and a follow-up plan. The CHNA Steering Committee (Appendix 1) also ensured that information from other local health assessments was integrated into the OneMaine CHNA. In addition to the OneMaine CHNA Steering Committee, an Advisory Committee was convened with statewide representation from a diverse group of stakeholders. Committee members represented public health, state government, businesses, foundations, and multicultural organizations. The Advisory Committee provided critical input into the needs assessment, from initial concept to how the data would be shared with communities. The OneMaine Health Collaborative formed the Advisory Committee to ensure that the data would meet the needs of end users. The Health Status Profile created for the state and for each county, required a comprehensive set of indicators to measure critical aspects of Maines health care delivery system, including health status, access to care, and quality of care. Health status - the present state of wellness or illness in a community is defined by indicators of beneficial and harmful health behaviors, the presence of symptoms and conditions indicative of illness and wellness, measures of the burden of illness in a community, the prevalence and incidence of specific diseases, and mortality. Because health status is the most important factor driving the demand for health care services, the first step in this assessment was to describe the health status of Maine and its 16 counties. To accomplish this, a comprehensive set of health and medical
10

When there is a 10% or more difference between two populations, it is worth noting, as there is likely some clinical or population reason that explains this difference.
16

OneMaine Community Health Needs Assessment 2010 indicators for each of the 16 counties and the state was constructed and analyzed. (Appendix 4 - the Health Status Profile). The set of measures used in this assessment was selected to reflect evolving national and state benchmarks for quality of care, service receipt, risk factors and health status. Most indicators were derived from public data sources, including state birth and death records, hospital inpatient and emergency department (ED) datasets, cancer registry data, U.S. Census data, state infectious disease data, the Maine Integrated Youth Health Survey (MIYHS), and the Behavioral Risk Factor Surveillance System (BRFSS) survey. (A complete list of data sources and years is included in Appendix 7.) Other indicators were derived from a random sample household telephone survey conducted specifically for this study.
HOUSEHOLD SURVEY

Questionnaire Design The household survey questionnaire used in the OneMaine CHNA was developed collaboratively by the OneMaine Health Collaborative, the University of New England Center for Community and Public Health (CCPH), The University of Southern Maine Muskie School of Public Service, and Market Decisions. An initial review of elements contained in prior community health needs assessments was conducted by CCPH, in consultation with the CHNA Steering Committee, to determine specific data needs. A preliminary draft of the survey instrument was submitted to the three hospital systems of OneMaine in April, 2010. In subsequent weeks, refinements to the draft survey were made in a series of meetings with all key constituents, and a final pretest version of the survey was completed and tested. The final survey instrument (Appendix 5) was approved and programmed for data collection on June 6th, 2010. The survey gathered information from Maine residents in the following areas: Health Services Access and Utilization Functional Health Status and Chronic Conditions Chronic Disease Management Youth Health and Health Care Exercise Primary Care Height and Weight Dental Care Mental Health Risk Factors Intimate Partner Violence Health Insurance Health Care Barriers Community Health Needs Wellness Activities and Programs Alternative Therapies End of Life Care Demographics

The data collection phase began on June 17, and was completed by September 16, 2010. A total of 7,099 Maine residents were interviewed during this period.

17

OneMaine Community Health Needs Assessment 2010 Sampling Methodology The sampling process used during the CHNA survey consisted of three steps designed to meet overall statewide targets, as well as specific targets within each of Maines sixteen counties. Target Population The target population consisted of all adults in families living in permanent residences in Maine. Qualified households were considered those in which someone resided at least six months of the year. Persons residing in households where no adult age 18 or over was present were excluded.11 The sampling approach relied on the use of a Random Digit Dial (RDD) land-line telephone sample and a cell phone sample. Sample Definition The goal of the sampling approach was to obtain both statewide and county level population information on a range of health and healthcare issues. The sampling methodology relied on a three stage sampling approach: Stage 1: A stratified RDD sample with 16 independent sampling strata identified by the 16 counties in Maine. This stratification was included in the sampling design to obtain a minimum of 400 completed surveys in each Maine county, and allow analysis of the data at the county level. Stage 2: A statewide cell phone sample including households with only cellular phone service, in order to include households and residents without access to a land-line telephone. Cell phone only samples can currently be designed to target a state or telephone area code but not smaller geographic units within a state. Given this constraint, the study relied on a random sample of cell phone numbers within the 207 area code for a statewide sampling frame. Stage 3: A statewide over-sample of residents aged 18 to 34. One of the concerns in conducting survey research is that those aged 18-34 tend to be under-represented among those completing surveys. To help offset this lack of response for those age 18-34, it was decided to incorporate an over sample of this age group into the overall sampling methodology.

The goal of the sampling strategy was to gather data from a minimum of 6,700 Maine households, with a minimum of 400 residents from each of Maines 16 counties. Within this target goal of 6,700, the sampling methodology was also designed to complete a minimum of 300 surveys with cell phone only households. Survey Response Rates and Weighting The response, cooperation, and refusal rates to the survey are presented in Table 1 for each of the three sampling stages, and within each stage for each independent stratum. Response rate is the ratio of the number of completed interviews divided by the total number of eligible and unknown units in the sample. Cooperation rate represents the proportion of all respondents interviewed of all eligible respondents ever contacted. That is, the percent of identified respondents who ended up completing the interview. This includes cases where a respondent refused to do the survey, began but did not complete the survey, and where a respondent wished to complete the survey at another time but did not end up doing so. The rates reported are based on the standard formulas developed by the American Association for Public Opinion Research (AAPOR) and the Council of American Survey Research Organizations (CASRO).
11 Persons residing in group homes with nine or more persons, group quarters such as dormitories, military barracks, and institutions, and those with no fixed household address (i.e., the homeless or residents of institutional group quarters such as jails or hospitals) were also excluded from this survey.
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OneMaine Community Health Needs Assessment 2010 The AAPOR and CASRO rates differ because they rely on different formulas in calculating response rates. The CASRO rates are comparable to the formulas used in calculating response rates for the Behavioral Risk Factor Surveillance System (BRFSS). As a comparison for the response rates presented in Table 1, the 2009 CASRO Response Rate for the Maine BRFSS survey was 56% (for land-line sample only). Population Size Reflected in the Final Data Set The data has been weighted to adjust for non-response, to match state and county profiles based upon sex and age, and statewide by race and ethnicity. The weighted data set is designed to provide data that can be generalized to the population of Maine and to each county, and allow statements to be made about the state as a whole, the individual counties, and for various sub-populations, with a known standard error and confidence interval. The population size reflected in the final data set is the total adult population of Maine, or 1,045,775 residents age 18 and older. Precision The determination of precision in surveys of this nature is more involved because of the combination of a number of sampling stages, as well as conducting land-line and cell phone only surveys. The sampling approach introduced design effects into the survey process that must be taken into account when calculating the final sampling errors for the study. The design effect can be thought of as the impact of the sample design in terms of the departure from what would be expected from a simple random sample of the same size. The multi-stage design of the sample introduces a design effect because the probabilities of selection are not the same across each of the independent samples. Table 4 provides a summary of the sampling errors for the state as a whole, as well as the sampling error within each County, and include design effect adjustments. Additional detail on data collection protocols, sampling approach, and data imputation and weighting methods can be found in Appendix 6.

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OneMaine Community Health Needs Assessment 2010 Table 1: Summary of Response, Cooperation, & Refusal Rates by Survey Component and Strata
CASRO Response Rate Response Rate (AAPOR RR3) AAPOR Respondent Cooperation Rate (COOP3) AAPOR Respondent Refusal Rate (REF3)

Stage 1: (RDD) Total Androscoggin County Aroostook County Cumberland County Franklin County Hancock County Kennebec County Knox County Lincoln County Oxford County Penobscot County Piscataquis County Sagadahoc County Somerset County Waldo County Washington County York County Stage Total 2 (Cell Phone)

69% 72% 78% 57% 68% 63% 68% 68% 71% 71% 67% 72% 67% 72% 70% 73% 66% 49%

58% 60% 68% 49% 57% 54% 57% 58% 60% 62% 56% 58% 55% 60% 59% 61% 56% 44%

90% 89% 92% 86% 91% 89% 88% 88% 92% 90% 88% 90% 90% 91% 89% 92% 91% 92%

4% 5% 4% 4% 3% 4% 5% 4% 3% 4% 4% 4% 4% 4% 4% 3% 3% 1%

Stage 3 (Aged 18-34 Over 48% 47% 88% 1% Sample) Total RDD 49% 49% 80% 1% Cell Phone 47% 46% 94% 0% Table 2: Number of Completed Surveys by Sampling Stage and Land-Line/Cell Phone Sampling Stage Stage 1 RDD Stratified by County Stage 2 Cell Phone Over Sample Stage 3 Sample Total Aged 18-34 Over Completed via Land Line 6497 0 131 6628 Completed via Cell Phone 97 214 160 471 Total Survey Completed 6594 214 291 7099

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OneMaine Community Health Needs Assessment 2010 Table 3: Number of Completed Surveys by County County Completed Surveys Androscoggin County 426 Aroostook County 415 Cumberland County 433 Franklin County 422 Hancock County 425 Kennebec County 431 Knox County 421 Lincoln County 421 Oxford County 423 Penobscot County 735 Piscataquis County 425 Sagadahoc County 426 Somerset County 424 Waldo County 419 Washington County 425 York County 428 Total 7099 Table 4. Precision for the Maine Community Health Needs Assessment Survey Area/ Maine Androscoggin County Aroostook County Cumberland County Franklin County Hancock County Kennebec County Knox County Lincoln County Oxford County Penobscot County Piscataquis County Sagadahoc County Somerset County Waldo County Washington County York County Precision (+/-) 1.7% 5.5% 5.5% 5.2% 5.6% 5.5% 5.4% 5.5% 5.6% 5.4% 4.1% 5.7% 5.9% 5.3% 5.5% 5.4% 5.2%

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OneMaine Community Health Needs Assessment 2010

SECONDARY DATA

Below are brief descriptions of key secondary datasets used for this assessment. A full list of secondary data sources can be found in Appendix 7. Population Estimates and Demographics Population data for each county by age was accessed from the US Census using 2008 Census estimates. These estimates were also used to determine all rates (e.g. hospitalization rates) that included population based denominators. Since inter-census population estimates do not include education, income and employment breakdowns, 2000 Census data was used for the education indicator. Although preliminary 2010 Census data were released in early 2011, only overall state population figures are available, not information on geographic, gender, or age groups within the state. Median household income was obtained through the Maine State Planning Office data center12, and data for unemployment by county was obtained through the Maine Department of Labor13. The 2004 Health Resources and Services Administration (HRSA) Area Resource File was used to estimate Medicaid participation by county14. Births and Mortality The Office of Data Research and Vital Statistics at the Maine Centers for Disease Control at the Maine CDC15 provided birth and mortality datasets for 2007, 2008 and 2009. Hospital Inpatient and Emergency Department (ED) Data Discharge datasets for inpatient admissions and emergency department visits are from the Maine Health Data Organization16. For each dataset, the two most recent years of available data were acquired. Inpatient admission data is from Q4 2007 through Q3 2009. Emergency department data is for 2007 and 2008. The full list of ICD-9 and DRG codes used in these analyses can be found in Appendix 9. Cancer Registry The Maine Cancer Registry (MCR)17 is a statewide population-based cancer surveillance system. The MCR collects data on all newly diagnosed and treated cancers in Maine residents, except in situ cervical cancer and basal and squamous cell carcinoma of the skin. Data was obtained from the MCR for 2005 through 2007 to compute incidence rates and staging levels of selected cancers.

12 13

http://www.maine.gov/spo/ http://www.maine.gov/labor/index.shtml 14 HRSA County Comparison Tool: http://arf.hrsa.gov/arfwebtool/Counties_search.asp 15 http://www.maine.gov/dhhs/boh/phs/odrvs/vital-records/vrfaq.html 16 http://www.maine.gov/mhdo/ 17 http://www.maine.gov/dhhs/bohdcfh/mcr/
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OneMaine Community Health Needs Assessment 2010 State Infectious Disease Data The Maine CDC Division of Infectious Disease18 provided incidence rates for HIV/AIDS, sexual transmitted diseases, and viral hepatitis. Chlamydia/Gonorrhea: 2008 data, from the Maine CDC Division of Infectious Disease, HIV, STD and Viral Hepatitis Program.19 Hepatitis C: 2007-2009 data. HIV: from the 2009 Annual Surveillance Report Maine CDC Division of Infectious Disease Maine Integrated Youth Health Survey (MIYHS) The Maine Integrated Youth Health Survey (MIYHS) is designed to assess the health status of Maines youth, and determine the positive and negative attitudes and behaviors that influence healthy development. Topics include: substance use; bullying and violence; unintentional injuries; sexual behavior; health status (including oral health) and disabilities; physical activity; weight control and nutrition; suicide/depression; and developmental assets. The MIYHS is a collaborative effort of the Maine Center for Disease Control and Office of Substance Abuse in the Department of Health and Human Services, and the Department of Education. It replaces the Youth Risk Behavior Survey (YRBS), the Maine Youth Drug and Alcohol Use Survey (MYDAUS), the Youth Tobacco Survey (YTS) and the Maine Childs Health Survey, and incorporates questions from Search Institutes Assets Survey. Data from the 2009 Maine Integrated Youth Health Survey was used to determine indicators related to the health status of Maine youth. Maine BRFSS Maines Behavioral Risk Factor Surveillance System (BRFSS) is a population-based survey conducted throughout the year with robust sampling for state-level estimates. However, for many county-level estimates, more than one year of data must be combined in order to get an adequate sample size at this geographic level. Since BRFSS questionnaires are revised annually, and many questions are not asked every year, the two most recent years of data collection for all BRFSS indicators needed were identified and combined for estimates. The specific two years used for each BRFSS variable is included in the right-hand column of the Health Status Profile in Appendix 4.
FINDINGS

The findings presented in the following sections are based on analyses of the quantitative indicators compiled for the assessment. For example, Preventive Health Services are assessed based on screening and patterns of behavioral risk factors (e.g., smoking, insufficient physical activity, overweight). Detection Services are based on patterns of medical risks (e.g., prevalence of diagnosed hypertension), while Treatment Services are based on significant clinical outcomes (e.g., hospitalizations and deaths due to heart attacks). Explanatory notes and definitions to clarify the findings presented in this report are included in Appendix 7 (data sources), and Appendix 8 (definition of indicators and defining codes).

18 19

http://www.maine.gov/dhhs/boh/ddc/ (http://www.maine.gov/dhhs/boh/ddc/hiv-std/publications.shtml#std)
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OneMaine Community Health Needs Assessment 2010 V. KEY POPULATION HEALTH STATUS FINDINGS
POPULATION AND DEMOGRAPHIC PROFILE

FINDINGS: Maine experienced a 4.0% increase in total population between 2000 and 2010. Compared to the U.S., Maine continues to have a higher percentage of adults age 65 years and older, which has implications for service delivery and demand. The State of Maine experienced a 4.2% increase in population between 2000 and 2010, about half the U.S. rate of growth of 9.7% for this same period. Maine has the oldest population in the country, with a median age of 42.2 years. At least 14% of the population in each Maine county is age 65 and older, compared to 12.9% nationwide

An understanding of the health of a community begins with a comprehensive analysis of demographic characteristics and trends. Population and demographic data are used throughout the CHNA to better understand indicators of current disease burden, and more precisely project future service needs. To accomplish this, a population profile of Maine and its counties was developed and analyzed based on 2000 and 2010 U.S. Census data, and 2008 U.S. Census estimates. Although Census 2010 population data became available in early 2011, no demographic estimates beyond total population by county and State has been released yet. The Maine State Planning Office provides 10- and 20-year projections of population growth. The most recent projections available had a base year of 2008, which means the projections were for 2018 and 2028. The 2010 Census data for Maine indicates a total of 1,328,361 Maine residents in 2010. This estimate is higher than both the Maine State Planning Office projections for 2018 and the U.S. Census estimates for 2008, but until revised projections are released it will be difficult to determine which specific county populations are diverging from earlier projections. For this reason, population projections were omitted from this report. Age Profile All Maine counties contain a disproportionately elderly population, relative to other age demographics. Maine is currently the oldest state in the U.S., with a median age of 42.2 well above the U.S. median age of 36.5. The counties with the highest proportion of people age 65 and older are in the North and East, with Lincoln (19%), Aroostook (18%), Knox (18%), Washington (18%), Piscataquis (18%), and Hancock (17%) all well above the state percentage of 15% (Figure 1). All Maine counties have a greater percentage of residents 65 years and older compared to the national percentage of 12.9%. The proportion of youths under the age of 18 is also under the national average (24%), both statewide (21%), and per Maine county. The counties with the lowest percentage are Knox, Lincoln, and Hancock, all with 19%. The counties with the highest percentage under age 18 are Androscoggin and Somerset, at only 22%. Counties with the lowest proportion include Konx, Lincoln, and Hancock (all 19%) The presence of a large elderly population will undoubtedly have an impact on the health of Maine communities, as well as the future provision of healthcare in Maine. Healthcare consumption increases

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OneMaine Community Health Needs Assessment 2010 dramatically after the age of 65 requiring, on average, three to five times the number of physicians per capita as compared to the number of physicians required for infants or children20. Currently, the health care industry is the largest employment sector in Maine, with approximately 84,200 positions in 2008. Nursing and residential care positions account for the majority of health care employment in Maine much higher than the national percentage - due primarily to the high ratio of elderly patients21. This trend is expected to continue in both the short- and long-term. The Maine Department of Labor estimates an increase in demand for physician services of 22%, as well as a pronounced increase in demand for specialty care (e.g. cardiologists, other internal subspecialties) within the next two decades22. This demand will be especially explicit in areas that have aging populations and shortages of needed health professionals namely, in rural communities located outside of the metropolitan areas of Portland and Bangor23. Figure 1: Age Demographics by County
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % Population Age 65+ % Population Ages 45-64 % Population Ages 18-44 % Population < 18

Source: US Census estimates, 2008

20

Center for Workforce Research and Information, Maine Department of Labor. Workforce Analysis of Maines Health Services Sector, http://www.maine.gov/labor/lmis/publications/pdf/WorkforceAnalysisMaine%27sHealthServicesSector.pdf 21 Maine Department of Labor. Health Care Employment Trends in Maine, http://www.maine.gov/labor/lmis/publications/pdf/HealthCareProfileSeptember2009.pdf 22 CWRI, ME DOL. Workforce Analysis of Maines Health Services Sector 23 CWRI, ME DOL. Workforce Analysis of Maines Health Services Sector

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OneMaine Community Health Needs Assessment 2010

HEALTH-BASED SOCIAL AND ECONOMIC CHARACTERISTICS

FINDINGS: While Maine compares favorably with the rest of the country in many socioeconomic measures, many of the northern counties are not doing as well in these measures as their southern counterparts. Maine is a well-educated state. The proportion of residents lacking a high school diploma (15%) is below the national percentage (20%). A few counties in Maine - Washington (20%), Somerset (19%), Piscataquis (20%), Aroostook (23%), and Androscoggin (20%) lag compared to the state. The most economically prosperous regions are the coastal counties of York, Cumberland, Sagadahoc, Lincoln, and Hancock. These counties all have comparatively low unemployment, low poverty rates, and high educational attainment. The number of residents living below the federal poverty line varies from county to county. However, the northern and central counties in general have greater proportions of poverty stricken populations than southern coastal counties.

Factors such as income, employment, educational attainment, and insurance status are characteristics, that have been associated with the health status of a population.24 Educational attainment is an important indicator of future success, as those with at least a high school diploma will likely have better employment opportunities. Limited education and employment opportunities also impact other quality of life areas, including access to health care. Poverty and household income level affect whether a person will have an adequate diet, healthy lifestyle and good medical care. Thus, it is important to understand the socioeconomic conditions of a community in order to fully understand the health and well being of its residents. As shown in Figure 2, Figure 3, and Figure 4, Maines northern counties are the least socio-economically prosperous regions of the state. Their populations are more likely to be unemployed, to lack a high school education, and to live below the federal poverty line. This includes the north-western counties of Franklin, Oxford, Androscoggin and Somerset, the north-central counties of Aroostook and Piscataquis, and the northeastern counties of Penobscot and Washington. Although Maine fares well in most of the socioeconomic status measures, its annual average household income (adjusted for inflation) is relatively low ($46,807) as compared to that of the U.S. ($49,777). There are also substantial differences within regions in Maine (Figure 3). For example, average annual household income in Cumberland is $55,647, while Piscataquis and Washington have average annual household incomes of $28,250 and $34,459, respectively. Overall, these findings indicate that socioeconomic conditions in Maine may result in barriers to good health and/or may limit access to health care services in these communities.

24 Mackenbach JP, Kunst AE, Groenhof F. et. al. Socioeconomic inequalities in mortality among women and men: An international study. American Journal Public Health. 1999. 89:1800-1806.
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OneMaine Community Health Needs Assessment 2010 Figure 2: Percentage of Population below Federal Poverty Line by County

25%

Percentage of Persons Below the Poverty Level

20%

15%

U.S. (13.8 %)

10%

5%

0%

Source: Maine SPO Data Center, 2008

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OneMaine Community Health Needs Assessment 2010 Figure 3: Median Annual Household Income by County

$60,000 $ 55,647 $54,099 $54,463

$50,000 $44,545

$4 7,507

$48,232 $46,231 $44 ,863 $42,585 $44,144 $38,9 87 $36,211 $34,459 $46,807

$40,000 $35,999

$38,865

$30,000

$28,25 0

$20,000

$10,000

$-

Median Annual Household Income (to 2008)

Source: Maine SPO Data Center, 2008

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OneMaine Community Health Needs Assessment 2010 Figure 4: Socioeconomic Indicators by County

25%

20%

15%

Labor Force Unemployed, %

Persons Below the Poverty Level, % 10% Population Not Attaining H.S. Diploma (>25 yrs), %

5%

0%

Source: 2008 Maine SPO Data Center, 2009-2010 Maine Department of Labor, 2000 US Census Estimates

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OneMaine Community Health Needs Assessment 2010

ACCESS TO CARE

FINDINGS: Although Maine has a lower rate of uninsured residents than the U.S., there are counties within Maine experiencing high rates of uninsured. The uninsured are more likely to report no usual source of care and to use the Emergency Department. Maine has a relatively low rate of uninsured (13%) compared to the U.S (14%). However, Waldo (17%) and Washington (22%) counties have elevated levels of uninsured compared to both Maine and the U.S. Maine has a higher proportion of residents with a usual source of primary care (87%) than the U.S (76%). However, only 58% of uninsured residents in Maine report having a usual source of primary care, compared with 91% of insured residents. Hancock, Somerset and Washington counties have an elevated proportion of residents reporting no usual source of care compared to the State. One quarter to one fifth of males in these counties report no usual source of primary care. Residents in Androscoggin, Aroostook and Sagadahoc counties are most likely to report using the Emergency Department (ED) as their usual source of care. ED visit rates are comparatively high in Aroostook, Somerset and Washington counties compared to the state.

Access to Quality Health Care Access to quality health care, particularly primary care, is critical for early diagnosis and treatment of medical conditions. Predictors of whether an individual has access to health care include: health insurance; household income level; usual source of primary care; and use of emergency rooms, particularly for ambulatory care sensitive conditions. Data on these indicators suggest access is reasonably good in most Maine counties, although for some counties access to care remains a challenge. Usual source of primary care: The national target for Healthy People 2020 (HP 2020) is that 84% of U.S. adults should have a usual source of care by 2020, representing a 10% increase over the 2007 U.S. rate of 76%.25 Maine already exceeds this target, with 87% reporting a usual source of primary care. However, Hancock, Somerset and Washington counties have lower rates than the state average, at 83-84%. All three counties have a large percentage of males reporting no usual source of care over one-fourth of males in Hancock and Washington counties, and one-fifth in Somerset. (Table 5). Insurance status has a significant impact on whether individuals have a usual source of care. In Maine, 42% of uninsured adults do not have a usual source of care, compared with 9% of those with insurance.

25 Source: Healthy People 2020 (http://www.healthypeople.gov/hp2020/Objectives/TopicAreas.aspx)

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OneMaine Community Health Needs Assessment 2010 Physical exams: In Maine, 90% of respondents to the household survey reported receiving a physical exam within the previous 2 years. Individual counties ranged from a high of 92% (Cumberland) to a low of 87% in Franklin and Knox counties. Males are less likely than females to have had an exam in the past two years, with only 85% of men responding positively, compared to 94% of females. Only 71% of adults in Maine who are currently uninsured have had a recent exam, compared to 93% among those who are insured. Immunizations: Another measure of access to primary care is receipt of age-appropriate vaccinations. The flu vaccine was recommended for all ages in 2009-2010 due to a particularly virulent flu season and the emergence of H1N1 as a public health threat. The household survey included a question about receipt of either a flu shot or the FluMist product in the past year (among adults). 42% of those polled reported receiving a flu shot or FluMist in the prior 12 months. Residents in Franklin, Piscataquis, and Washington counties were least likely to have received flu vaccination, (34%-35%). Cumberland County residents were most likely to have been vaccinated, with almost 50% reporting flu vaccination in the previous year. Pneumococcal vaccine is recommended for all adults over 65 years of age, which makes it an appropriate indicator of access to primary care among this population. In Maine, 73% of residents over the age of 65 have ever received a pneumococcal vaccine. This exceeds the U.S. percentage (60%) but is less than the HP2020 target of 90%. Maine counties range from a low of 59% vaccinated in Waldo County, to a high of 80% of seniors having received a pneumococcal vaccination in Oxford County. Emergency Department (ED) and Hospital Utilization: Individuals who have a usual source of care are more likely to visit a doctors office or clinic instead of an ED or hospital outpatient clinic. Of adults who have a usual source of care, 97% would visit a doctors office or clinic when they were ill and required medical care, and only 2.0% would visit an ED or hospital. In contrast, only 27% of those who do not have a usual source of care would visit a doctors office or clinic when ill, while 62% would visit an ED or hospital. The overall ED utilization rate in Maine is 47,665 ED visits per 100,000 persons. ED utilization is higher in Aroostook (68,196 per 100,000 population), Somerset (78,252 per 100,000 population) and Washington (61,002 per 100,000 population) counties. This difference may be reflective of the fact that people were less likely to have a usual source of care in Somerset and Washington counties. In Aroostook, almost 6.0% of those who reported a usual source of care cited the ED or hospital outpatient department as their source, higher than in any other county. The household survey also asked about ED use in the past year, and these same three counties showed the highest percentage of respondents reporting use of the ED at least once in that time period. More than a third of residents in Somerset, Washington and Aroostook counties self-reported having used the ED in the past year (compared to 28% for the State overall). Statewide, as well as in most counties, the 18-44 year-old population uses the ED at a higher rate than other age groups. Among the 65 and older population ED utilization is highest in Piscataquis, Somerset, and Washington counties. (Figure 5).

31

OneMaine Community Health Needs Assessment 2010 Oral Health: Nationally, research has found that rural Americans suffer heavily from lack of access to dental care. One outcome indicator of the problem is the high percentage of rural adults with total tooth loss. A 2001 national report found rates of total tooth loss to be 27% in large metro counties vs. 36% in rural counties26. As a predominantly rural state, Maine is affected by this trend. Maines dentist to population ratio is one to 2,165 residents, significantly lower than the national ratio of one to 1,656 people. Further analysis shows an even lower ratio - one dentist to every 3,160 residents - when considering only those dentists who are general practitioners (Maine DHHS). Twenty-four percent of survey respondents reported that they have not seen a dentist in the past two years. Not surprisingly, some of Maines most rural counties have the highest rates for not seeing a dentist in the past two years. These include Aroostook (30%), Oxford (34%), Piscataquis (32%), Somerset (33%) and Washington (31%) counties. Barriers to Medical Care

FINDINGS: Barriers to accessing health care and treatment exist for many residents of Maine Approximately 7.0% of Maine residents reported that there was a time in the past year when they needed medical care but could not get it because of cost. The rate of not being able to get access to medical care due to cost was almost twice as high in Washington County (13%) Approximately 7.0% of Maine residents also reported that they had needed prescription drugs within the previous year but were unable to get them because of cost. Rates were highest in Washington (10%), Aroostook (9.0%) and Kennebec (8.0%) counties. Almost 9.0% of Maine residents reported having skipped doses or taken smaller amounts of prescription drugs in past year in order to make them last longer.

The Household Survey asked Maine residents if they had needed medical care or prescriptions in the previous year but had been unable to obtain them due to cost (Figure 6). This indicator can be related to lack of insurance or under-insurance. Medical Care: Approximately 6.5% of Maine residents did not receive needed medical care in the last year due to cost, including 27% of the uninsured. Counties ranged from a low of unmet medical care needs in Androscoggin County (4.9%), to a high in Washington County (12%). Over 8.0% of residents in Aroostook, Oxford, and Penobscot counties reported delaying care due to cost. Prescription Drugs: Approximately 6.6% of Maine residents reported the need for prescription drugs within the past 12 months, but inability to pay for them. Rates were higher in Aroostook (8.6%), Kennebec (8.2%), and Washington (9.6%) counties. Rates were also higher among the uninsured (19%). Residents were also asked if they had skipped doses or taken a smaller dose of medication than prescribed in order to make the current supply last longer. 8.7% of Maine residents reported having done this in the past year. In Aroostook, Kennebec, Penobscot and Piscataquis counties, over 10% reported having tried to make their prescriptions last longer, and almost 13% of respondents in Washington County.

Significant barriers to accessing medical treatment, including medications, exist for a segment of the Maine population. In certain counties, particularly Northern and Eastern rural counties, 10% or more of residents report unmet medical needs. The fact that almost 9% of Maine residents overall report having
Eberhardt, M. S., Ingram, D. D., Makuc, D. M., et al. (2001). Urban and rural health chartbook. Health, United States, 2001. Hyattsville, MD: National Center for Health Statistics.
32
26

OneMaine Community Health Needs Assessment 2010 skipped or reduced doses of their medication due to cost is also alarming. medications have greatly reduced effectiveness if not taken as prescribed. Table 5: Usual Source of Care and Receipt of Preventive Care
gin ook Cu mb erl an d Fr an kli n qu is An dr osc og Ke nn eb ec Pe no bsc o Ha nc ock Lin col n Ox for d Ar oos t Pis cat a

Particularly as many

ash ing to

ad ah oc

ers et

ldo

Kn ox

Yo rk

Sa g

Wa

Ma in

So m

% Without Usual Source of Primary Care 12% Males 18% Females 5.7% % Not Having a Checkup Within the Past 2 Years Males Females % Received Flu Shot or Mist past 12 months % Ever Received Pneumoccal Vaccine (Age 65+) % No Dental Visit Within the Past 2 Years

14% 20% 9.1%

13% 18% 9.1%

14% 18% 9.2%

16% 26% 6.6%

14% 21% 6.9%

11% 17% 6.1%

11% 18% 4.7%

14% 16% 12%

15% 21% 10%

15% 22% 8.3%

10% 14% 5.5%

16% 21% 12%

13% 18% 8.0%

17% 26% 8.6%

10% 13% 7.7%

13% 18% 8.3%

24%* NA NA

8.7% 12% 5.5% 40%

11% 16% 5.7% 37%

8.2% 10% 6.9% 49%

12% 18% 6.4% 35%

13% 21% 4.7% 40%

12% 18% 7.5% 39%

13% 20% 7.2% 44%

11% 16% 5.9% 38%

11% 17% 6.6% 40%

11% 14% 8.4% 43%

9.8% 18% 1.9% 34%

9.7% 12% 7.4% 46%

11% 17% 5.5% 39%

11% 15% 7.5% 36%

11% 18% 5.5% 34%

10% 16% 4.9% 39%

10% 15% 6.4% 42%

NA NA NA 34%**

73% 27%

66% 30%

76% 21%

75% 24%

67% 23%

73% 22%

71% 17%

71% 20%

80% 34%

72% 27%

68% 32%

70% 21%

70% 33%

59% 25%

72% 31%

76% 19%

73% 61%** 24% 13%*

Source: 2010 OneMaine CHNA Household Survey *2007 Medical Expenditure Panel Survey data from Healthy People 2020 **2009 National Health Interview Survey data

Figure 5: ED Visits by Age (rate per 100,000 population)

ED Visit Rate per 100,000

120,000 100,000 80,000 60,000 40,000 20,000 0

Ages <18
Source: MHDO ED Discharge Dataset, 2007-2008 Annualized

Ages 18-44

Ages 45-64

Ages 65+

33

US

OneMaine Community Health Needs Assessment 2010 Figure 6: Percentage of Adults who Face Cost Barriers for Medical Care
Percentage of Adults who Face Cost Barriers

14% 12% 10% 8% 6% 4% 2% 0%

% Needed Medical Care But Could not Afford it: Past Year % Needed Presription Medicines But Could not Afford: Past Year %Skipped Doses/Took Smaller Amt of Prescription Due to Cost: Past Year
Source: 2010 OneMaine CHNA Household Survey

34

OneMaine Community Health Needs Assessment 2010

QUALITY AND EFFECTIVENESS OF CARE

FINDINGS: Despite other indicators showing adequate access to primary care, hospital utilization (both inpatient and ED) for Ambulatory Care Sensitive (ACS) conditions is elevated in several counties compared to the state. ACS rates for inpatient and emergency room admissions in Cumberland, Piscataquis and York counties were low compared to the state. Franklin, Knox and Penobscot counties had higher rates of inpatient ASC admissions but lower rates of ED visits, indicating a potential preference for using inpatient rather than outpatient resources to treat these conditions. Sagadahoc and Waldo counties had lower inpatient admissions than the state, but higher ED ACS admission rates. Aroostook, Somerset and Washington counties were higher than the state in both inpatient and ED admissions. In this section, several measures of quality and effectiveness of care, statewide and by county, are explored. The objective is to get an overall impression of access to high quality care and secondary prevention for populations with one or more chronic health conditions, as measured by rates of inpatient and ER admissions for ambulatory care sensitive (ACS) conditions. Hospitalizations/ED Visits for ACS Conditions: The rates of hospital admissions for ACS conditions are considered an indicator of primary care access and quality in a population. ACS conditions are those that are less likely to result in an inpatient or ED hospitalization when treated on an outpatient basis with high quality primary medical care and patient adherence (See Appendix 8 for a detailed definition). ACS conditions include27: Adult Asthma Angina without Procedure Bacterial Pneumonia Congestive Heart Failure Chronic Obstructive Pulmonary Disease Dehydration Diabetes Short-term Complications Diabetes Long-term Complications Hypertension Lower-extremity Amputation among Diabetics Perforated Appendix Admission Rate Urinary Tract Infection Uncontrolled Diabetes

Higher rates of hospitalizations and ED use for ACS conditions may be an indication that access to and/or quality of primary care in a region needs to be improved. Higher rates may also be due to poorer underlying health status (disease prevalence) in a population, since a higher prevalence of disease can account for elevated ACS hospitalization rates when comparing two geographic areas. The differences in prevalence can be compared to the differences in utilization rates to determine differences in access and/or quality.

27

SOURCE: http://www.qualityindicators.ahrq.gov/pqi_overview.htm (Note: three of the sixteen indicators not included because they are pediatric ACSC measures)
35

OneMaine Community Health Needs Assessment 2010 This analysis suggests that, while overall chronic disease prevalence is higher in some counties for several conditions that go into ACS rates, access to and/or quality of care plays some role in the levels of ACS hospitalizations. In most counties where ACS hospitalization rates were elevated above state rates for some or all adult age groups, they do not appear to be associated with disease prevalence rates in these counties. For others there is an apparent relationship. Compared to the state, overall rates for both inpatient and ED admissions were lower in Cumberland, Piscataquis and York counties compared to the state (Figure 7). This occurred among all age groups except for 65+ age group in York County, where the rate was higher rate than the state. Disease prevalence (3+ chronic conditions), and proportion of the population Not Well was low in Cumberland County but not in Piscataquis or York counties. Franklin, Knox and Penobscot counties had higher rates of inpatient ASC admissions but lower rates of ED admissions. This occurred for all age groups in Franklin County, but not in Knox and Penobscot counties where rates were similar to the state in some age groups. Of note is the age group 65+ in Penobscot, which experienced higher rates of both inpatient and ED admissions. Reasons for the higher inpatient rates compared to ED rates likely vary by county. However, one may be a potential preference for using inpatient setting to treat these conditions rather than the ED setting. Another may be the severity of the condition of the patient who enters the hospital directly or through the ED. Sagadahoc and Waldo counties had lower rates of ACS inpatient admissions than the state, but higher ACS ED rates. This may indicate increased severity of those coming to the ED for these conditions or a propensity to hospitalize these patients in these counties. Aroostook and Washington counties had higher ACS rates than the state in both inpatient and ER admissions overall, as well as for each age group. Somerset Countys overall and 65+ rates for inpatient admissions were comparable to the state, but rates for all other age groups were elevated, which may be due to increased prevalence of ACS conditions as indicated by the percentage not well from the wellness profile. It may also be due to the lack of access to high quality care for chronic medical conditions, including accurate diagnosis, treatment, and patient self-management.

36

OneMaine Community Health Needs Assessment 2010 Figure 7: Inpatient and ED rates for ACS Conditions
8,000 6,960 7,000
Rate per 100,000 population

6,000 5,356 5,000 4,000 3,000 2,085 2,000 1,044 1,000 0 1,510 754 2,226 1,163 1,241 915 415 374 4,786 3,941 3,426 3,359 3,358 2,782 2,789 3,227 2,907 2,129

5,462

3,073 2,144 1,479 990 472 916 967

1,377 922 927

1,069

Ambulatory Care Sensitive Condition (ACSC), Hospital Admission Rate (Overall PQI*) Ambulatory Care Sensitive Condition (ACSC), ED Visit Rate (Overall PQI*)

Source: ORDVS 2007-2009, MHDO Hospital Discharge Dataset Q4 2007- Q3 2009 * Methodology based on combining AHRQs 13 Adult Prevention Quality Indicators (PQI) into Overall PQI

37

OneMaine Community Health Needs Assessment 2010

HEALTH STATUS AND WELLNESS

FINDINGS: Health status, chronic disease burden, and functional health levels vary among Maine counties. In general, residents of those counties with the largest chronic disease burden also report higher levels of poor functional health. 34% of Maine adults are classified as well, with the highest percentage of well in Cumberland, Franklin, and Knox counties. 23% of Maine adults are not well, with the highest percentage in Androscoggin, Aroostook, Oxford, Somerset, and Washington counties. The majority of Maine counties had one-sixth to one-tenth of their adult population reporting fair or poor health. However, Washington and Oxford showed a much higher percentage of adults with fair to poor health. A high percentage of adults in Washington and Oxford Counties also reported mental and/or physical limitations during at least 11 days of the 30 days prior to the date of the survey. Knox County had the lowest chronic disease burden, defined as the proportion of the population with 3 or more chronic diseases. The counties with the greatest chronic disease burden are Washington and Oxford. Counties with higher proportions of people with poor functional health also have higher proportions of individuals with multiple chronic diseases. This includes Washington and Oxford counties, and to a lesser extent Androscoggin, Aroostook, Kennebec, and Somerset counties.

Two measures were used to evaluate the disease burden in the population and overall population wellness. These include: 1. Chronic disease burden as measured by the percentage of the population with three or more diagnosed chronic health conditions; 2. A wellness profile that integrates data on diagnosed chronic health conditions, medical risks, health risk behaviors, and health functioning into a composite measure of overall functional health status of a population. Chronic Disease Burden: Thirteen percent (13%) of Maine residents have been diagnosed with three or more chronic diseases including angina, coronary artery disease (CAD), diabetes, chronic obstructive pulmonary disease (COPD), hypertension, hypercholesterolemia, cancer, arthritis, asthma, depression, substance abuse, and psychiatric conditions other than depression. (See Appendix 8 for a more complete definition of this measure). This is self-reported data from the survey on diagnosed conditions. In general, adults with multiple chronic diseases also exhibit significant risk factors such as smoking and being overweightand have higher health care costs and use. Oxford (17%) and Washington (16%) counties displayed the highest percentage of adults with three or more chronic conditions, followed by Aroostook, Androscoggin, Kennebec, and Somerset counties with 15% each. Knox County (11%) had the lowest burden of chronic disease prevalence.

38

OneMaine Community Health Needs Assessment 2010 Functional Health Status: Indicators of functional health status in this assessment include self reported health status, and the proportion of residents experiencing 11 or more days of poor mental or physical health. The measures of chronic disease burden and wellness profile are also indicators of functional health status. CCPHs wellness measure categorizes respondents into four categories: (1) Well; (2) At Risk for Future Medical Problems; (3) Some Health Problems, and; (4) Not Well: Survey respondents who had never been diagnosed with any of the following long-standing conditions (Hypertension, High Cholesterol, Diabetes, Angina/CAD, COPD, Current Asthma, Current Depression), and who reported their health as excellent, very good, or good, had good functional health, and, if over 35 years old, did not smoke and were not at risk for overweight based on their body mass index were classified as Well. Thirty-four percent (34%) of Maine adults were classified as Well. Survey respondents who had never been diagnosed with any of the following long-standing conditions (Hypertension, High Cholesterol, Diabetes, Angina/CAD, COPD, Current Asthma, Current Depression), but were 35 years of age or older and smoked cigarettes regularly or were at risk for overweight based on their body mass index were classified as At Risk for Future Medical Problems. Eight percent (8%) of Maine adults were classified as At Risk for Future Medical Problems. Survey respondents who reported their health as fair or poor, had reduced functional health, or had been diagnosed with Hypertension, High Cholesterol, Diabetes, Angina/CAD, COPD, Current Asthma, Current Depression were classified as Some Health Problems. Thirty-six percent (36%) of Maine adults were classified with Some Health Problems. Survey respondents who had been diagnosed with three of the following long-standing conditions (Hypertension, High Cholesterol, Diabetes, Angina/CAD, COPD, Current Asthma, Current Depression), or had been diagnosed with at least one chronic disease and reported their health as either fair or poor or experienced significant functional health problems, were classified as Not Well. Twenty-three percent (23%) of Maine adults were classified as Not Well.

Health status is an important factor that drives the demand for health care services. Overall, 15% of Maine adults reported fair to poor health, and is similar to the U.S.: (34%) of Maine adults report good to excellent health. As Figure 8 illustrates, residents in two counties Washington (26%) and Oxford (23%) - were more likely than residents in other counties and the state to describe their overall health as being either fair or poor. Androscoggin, Aroostook, Penobscot, and Somerset counties also had a proportion of their populations who reported fair to poor health that was higher than the state percentage. Cumberland (12%) and Knox (12%) counties had the smallest proportion of residents with poor to fair health. In some cases, poor mental or physical health status results in reduced functioning, or days lost to poor health. Reduced functioning among Maine adults corresponds somewhat closely with reported health status (e.g., percentage who reported they had fair or poor health), especially among the counties with the highest number of respondents with fair to poor health - Washington, Oxford, and Somerset Counties. Eleven percent (11%) of the population in these three counties reported having some sort of physical and/or mental limitation in the 30 days prior to the survey, compared to 8.0% for all of Maine (Figure 8 and Table 6). Poor functional health and high levels of reduced functioning were also common in counties with a high proportion of adults with multiple chronic diseases. Once again, Washington and Oxford counties had the
39

OneMaine Community Health Needs Assessment 2010 highest proportion of adults who reported having three or more chronic illnesses. Clearly, the functional health status for these two counties is impacted by the high chronic disease burden.

Table 6: Health Status

An dr osc og gin Ar oo sto ok Cu mb erl an d Fr an kli n Ha nc oc k Ke nn eb ec Kn ox Ind ica tor W ash ing ton Yo rk Pe no bs cot Pis ca taq uis Sa ga dh oc So me rse t W ald o

Lin col n

Ox for d

% Health Fair to Poor % 11+ Days Lost due to Poor Mental or Physical Health % 3+ Chronic Conditions Wellness Categories: %Well %At Risk for Future Medical Problems %S ome Health Problems %Not Well

17% 18% 11% 15% 15% 15% 11% 14% 23% 17% 20% 14% 17% 15% 26% 15% 7% 10% 7% 8% 8% 7% 8% 6% 11% 9% 7% 7% 11% 10% 11% 6%

15% 8% 13% 34% 8% 36% 23%

15% 15% 12% 12% 12% 15% 11% 13% 17% 14% 14% 13% 15% 13% 16% 13% 30% 28% 39% 38% 35% 31% 37% 29% 32% 32% 31% 36% 29% 36% 22% 35% 9% 10% 7% 7% 6% 10% 7% 6% 7% 8% 8% 6% 9% 7% 8% 8%

35% 37% 35% 34% 38% 35% 37% 45% 32% 36% 36% 39% 34% 33% 40% 36% 26% 26% 19% 22% 22% 24% 18% 19% 29% 24% 25% 18% 28% 23% 30% 21%

Source: 2010 OneMaine CHNA Household Survey

Figure 8: Functional Health Status by County

30%

25%
Percentage with Health Risk

20%

15%

10%

5%

0%

% 3+ Chronic Conditions

% Health Fair to Poor

Reduced Functioning (11+ Days Lost)

Source: 2010 OneMaine CHNA Household Survey

40

Ma ine

OneMaine Community Health Needs Assessment 2010 Figure 9: Wellness Profile by County
100% 90% 80%
Percentage of Residents

70% 60% 50% 40% 30% 20% 10% 0%

%Well

%At Risk for Future Medical Problems

%Some Health Problems

%Not Well

Source: 2010 OneMaine CHNA Household Survey

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OneMaine Community Health Needs Assessment 2010

VI. KEY FINDINGS FOR SPECIFIC AREAS OF HEALTHCARE

CARDIOVASCULAR HEALTH

Behavioral Risk Factors FINDINGS: Risk factors for chronic disease vary considerably by county. Obesity rates continue to rise and smoking levels remains somewhat stagnant or may be rising. Prevalence of smoking in several counties is higher than smoking prevalence in Maine (estimated by the OneMaine survey at 22%), with particularly high prevalence in Aroostook, Oxford, Somerset, Washington and York counties. Smoking prevalence is below 20% in Cumberland, Hancock, Knox, and Lincoln counties. Prevalence of adult obesity in Maine is 28% with Oxford, Penobscot, Piscataquis and Washington counties at 10% or more above the state. Cumberland, Hancock, Sagadahoc and York had the lowest rates of adult obesity. Sedentary lifestyles were most prevalent in Aroostook, Oxford, Piscataquis, Somerset, Waldo and Washington counties. Cardiovascular disease (CVD) is a category of disorders affecting the heart and blood vessels, and includes coronary heart disease, diseases of the heart, arteriosclerosis, hypertension, and cerebrovascular disease (stroke). The major behavioral risk factors for CVD are smoking, physical inactivity, hypertension, and overweight/obesity. Diabetes is a medical risk factor for CVD. Behavioral risk factors for cardiovascular disease are high in many counties, and in Maine as a whole. (Table 7). Smoking: Smoking is widely regarded as the single most preventable cause of disease and death in the U.S. The prevalence of smoking, while declining overall, is high in Maine compared to many other states in the northeast. During 2009, the median adult smoking prevalence among all 50 states and the District of Columbia was 17.9% % (range: Utah at 9.8% - West Virginia at 25.6%).28 The adult smoking prevalence in Maine has been around 22% for the lastseveral years29. However, the prevalence of current cigarette smoking was particularly high in Aroostook, Oxford, Somerset, Washington and York counties (10% or more higher than Maine). Smoking prevalence in Cumberland, Hancock, Knox, and Lincoln counties is below 20% in the adult population. None of the counties in Maine currently meet the nations goal of 12% adult smokers. (Figure 10). Physical activity: The proportion of adults who reported engaging in at least 30 minutes of physical activity five or more times a week was stable, with Androscoggin as the only county 10% below the state rate (22% and 26% respectively). Twenty-one percent (21%) of Maine adults have a sedentary lifestyle, as measured by adults who report no physical activity. Sedentary lifestyles were most prevalent for adults in Aroostook, Oxford, Piscataquis, Somerset, Waldo and Washington counties, and lowest in Cumberland (16%) and Franklin (18%) counties (Figure 10).
28 Americas Health Rankings, 2009. http://www.americashealthrankings.org/Measure/2010/List%20All/Prevalence%20of%20Smoking.aspx 29 The 2010 OneMaine survey estimates adult smoking in Maine at 22%. The 2009 Maine BRFSS estimated adult smoking at 18%. The major differences in results for the two surveys were due to higher levels of smoking among the 35-64 age groups in the OneMaine survey. These smoking differences may be due to differences in sampling frames of the two surveys or to actual increases in smoking in these age groups.

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OneMaine Community Health Needs Assessment 2010 Obesity: Risks related to being overweight and obese are a significant concern. Currently, approximately 112,000 adults in Maine are obese, having a body mass index greater than or equal to 30 (28% of all adults). This is comparable to the U.S. rate of 28%. Oxford, Penobscot, Piscataquis and Washington counties had rates 10% or more above the state. Cumberland (24%), Hancock (22%), Sagadahoc (23%), and York (23%) counties had the lowest rates of adult obesity. Medical Risk Factors for CVD FINDINGS: The prevalence of diagnosed high blood pressure and high cholesterol continues to be a significant risk factor in large segments of the population. Aroostook, Piscataquis, Somerset, and Washington counties have the highest prevalence of adults with diagnosed high blood pressure in the state. Androscoggin, Oxford, and Washington counties have the highest prevalence of diagnosed high cholesterol in the state. Those counties with a higher prevalence of high blood pressure or high cholesterol are more likely to have higher adult obesity, smoking and sedentary lifestyle rates.

Approximately three in ten adults in Maine (29%) have been diagnosed with high cholesterol.30 The prevalence of diagnosed high cholesterol compared to the state average is highest in Androscoggin, Oxford and Washington counties. The only county 10% or more below the state rate was Waldo (25%). Cholesterol screening rates in all counties are within 10% of the state rate (63%); thus the variation in diagnosed prevalence in counties is not likely due to lack of screening. However, improved screening rates could lead to higher prevalence rates. (Figure 14). High blood pressure or hypertension, a major risk factor for stroke and heart disease, has no physiological symptoms - regular blood pressure measurements are needed for detection and control. Approximately 30% of the Maine adult population and of the U.S. adult population reports having been diagnosed with high blood pressure by a medical provider. The prevalence of high blood pressure within counties is slightly more variable in Maine, with Aroostook, Piscataquis, Somerset and Washington counties having higher levels than Maine overall. (Table 7 and Figure 11) Behavioral risk factor prevalence is higher in those counties with a higher prevalence of high blood pressure or high cholesterol. This has implications on how well patients with high blood pressure and high cholesterol are able to manage their conditions. The combined effect of behavioral and medical risk factors for CVD also puts patients at risk for additional health problems and disease complications. Findings on the prevalence of behavioral risk factors among those diagnosed with high blood pressure and high cholesterol include the following: The prevalence of obesity among those with high blood pressure is 44%, while the prevalence of obesity is 21% among those who do not have high blood pressure. Obesity prevalence ranges from almost 50% in Kennebec and Washington counties, to 35% in Cumberland, Sagadahoc and Somerset counties.

30 High Cholesterol is defined as having a cholesterol level exceeding 240 miligrams per deciliter (mg/dL).
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OneMaine Community Health Needs Assessment 2010 The prevalence of obesity is 37% among those diagnosed with high cholesterol, while the prevalence of obesity is 24% among those without high cholesterol. Those with high blood pressure or high cholesterol are also slightly more likely to be sedentary. Among those diagnosed with high blood pressure, 27% lead sedentary lifestyles. Among those diagnosed with high cholesterol, 25% lead sedentary lifestyles. Meanwhile, only 19% of those who have not been diagnosed with either disease lead sedentary lifestyles. Mortality and Morbidity FINDINGS: Compared to risk factors, many more counties have higher rates of heart disease morbidity and mortality than the state. Counties also vary widely with respect to access to rehabilitation services after a heart attack or stroke. Morbidity as measured by hospitalization for an acute myocardial infarction (AMI) or heart attack, congestive heart failure (CHF), cerebrovascular disease or stroke (CVD) or Coronary Artery Bypass Graft (CABG) surgery are elevated in Androscoggin (CABG), Aroostook (AMI, CHF, CVD, CABG), Franklin (CHF, CABG), Hancock (AMI, CHF, CVD, CABG), Kennebec (AMI), Knox (CVD), Lincoln (CVD) Piscataquis (AMI, CVD, CABG), Somerset (AMI, CHF, CVD), Waldo (AMI), and Washington (AMI, CHF, CVD, CABG) counties compared to the state. Mortality rates for heart disease (specifically for AMI and CVD) vary widely by county compared to the state.

In this section, cardiovascular health is assessed through morbidity and mortality rates for various forms of heart disease. The focus is on overall rates and rates among the age groups that are most at risk for cardiovascular health events, which include adults age 45-64, and seniors 65 years and older. Morbidity for CVD: Of the cardiovascular medical hospitalizations in Maine, adults are hospitalized most frequently for congestive heart failure (CHF) followed by AMI, and cerebrovascular disease (stroke). CABG (coronary artery bypass graft), a surgical admission ranks lower than medical admission rates. Hospital admission rates in Androscoggin (CABG), Aroostook (AMI, CHF, CVD, CABG), Franklin (CHF, CABG), Hancock (AMI, CHF, CVD, CABG), Kennebec (AMI), Knox (CVD), Lincoln (CVD) Piscataquis (AMI, CVD, CABG), Somerset (AMI, CHF, CVD), Waldo (AMI) and Washington (AMI, CHF, CVD, CABG) counties are 10% or more above the state. In Penobscot County the CHF rate for the age groups 45-64 and 65 + are 10% higher than the state, although the overall CHF rate is not. Hospital admission rates for acute myocardial infarction (AMI) are considered a good indicator for heart attack incidence, as most people with serious chest pain end up going to a hospital for possible diagnosis of an AMI. Based on this assumption, Aroostook (431) and Washington (477) counties experienced by far the highest AMI incidence rates in Maine (211), followed by Piscataquis (359), Hancock (325), Waldo (281), Somerset (258) and Kennebec (272) counties. Cumberland County (108) has the lowest rate by far , followed by Sagadahoc (128), Oxford (135), Lincoln (158), Androscoggin, (172) and York (180) counties. The U.S. rate is 192 per 100,000 population.

44

OneMaine Community Health Needs Assessment 2010 CABG surgery rates overall are elevated compared to the state in Androscoggin, Aroostook, Franklin, Hancock, Lincoln, Penobscot, Piscataquis, and Washington counties. Among those 65 and older, rates are elevated in Androscoggin, Aroostook, Franklin, Hancock, Lincoln, Penobscot, and Piscataquis counties. In the 45-64 age group, CABG surgery rates are elevated in Androscoggin, Aroostook, Franklin, Hancock, Kennebec, Oxford, Penobscot, Sagadahoc and Waldo and Washington counties. (Figure 12). Mortality: The burden of heart disease mortality is highest in the same counties that experience high CHF, AMI and cerebrovascular disease (stroke) admissions rates. Thus, regardless of the great strides in medical technology available to reduce deaths from heart disease, the populations in the lowest resource counties in Maine experience the highest morbidity and death due to heart disease. The source of this apparent disparity in outcomes is not well known. Prevention: Taking aspirin regularly has been shown to reduce the risk of heart attack and stroke in some populations. Among the age 35+ population, the rate of respondents who said they currently take aspirin to reduce their risk of heart attack or stroke is similar across counties, compared to the state. Only Androscoggin (41%) and Aroostook (40%) counties exceed the state rate (35%) In general, the cardiovascular health profile of populations in Maine suggests that primary prevention activities to reduce behavioral and medical risks for heart attacks and strokes, as well as secondary prevention to continue to improve treatment outcomes for patients with cardiovascular disease are priority health issues. Table 7: Selected Cardiovascular Health Indicators by County
n gg i d an is a qu s co s co ng t o s hi k ec t c n ga d ho rs e t ld o

too

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li n

ck

nn eb

n co l

An d ro

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Pi s c at

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Wa

Wa

L in

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Ar

% Current Smokers (Age 18+) % Sedentary Lifestyle (no physical activity) % Obesity (Ages 18+) % High Cholesterol % High Blood Pressure Heart Disease Mortality Rate (Ages 65+) Mortality Rate (Ages 45-64) Cerebrovascular Disease (stroke) Mortality Rate (Ages 65+) Mortality Rate (Ages 45-64) Hospitalizations (Age 65+) Hospitalizations (Age 45-64) Acute Myocardial Infarction (AMI) Mortality Rate (Ages 65+) Mortality Rate (Ages 45-64) Hospitalizations (Age 65+) Hospitalizations (Age 45-64) Coronary Artery Bypass Graft (CABG) surgery Hospitalizations (Age 65+) Hospitalizations (Age 45-64)

20% 20% 31% 34% 31% 1126 128 279 14 734 120 202 35 866 154 245 149

27% 16% 20% 25% 16% 18% 31% 24% 31% 32% 26% 28% 34% 27% 27% 1240 113 312 15 871 136 345 44 1772 316 268 124 976 74 256 8 690 90 142 17 637 61 201 75 1288 96 287 22 710 128 411 41 1222 89 233 128

Fr

19% 20% 22% 30% 31% 1221 115 362 6 854 99 277 55 1487 207 272 76

24% 20% 31% 27% 31% 1117 85 331 10 712 114 275 24 1337 204 213 102

18% 19% 25% 28% 32% 1003 78 262 5 772 113 271 23 905 182 200 89

19% 20% 25% 29% 30% 1010 114 325 17 650 103 158 17 584 120 259 86

25% 24% 33% 35% 31% 1052 92 310 15 692 88 188 18 631 97 194 110

23% 23% 35% 31% 31% 1273 137 321 14 771 117 271 45 1135 199 281 102

21% 20% 26% 26% 20% 26% 33% 23% 28% 32% 28% 32% 35% 29% 35% 1280 130 391 6 814 127 401 101 1530 236 277 59 906 85 499 18 601 123 222 20 573 131 83 114 1141 125 296 19 793 121 296 40 1130 232 219 99

21% 25% 27% 25% 32% 1221 116 324 14 712 110 220 32 1380 179 139 110

31% 25% 22% 25% 20% 21% 33% 23% 28% 33% 28% 29% 40% 28% 30% 1349 122 290 10 886 109 452 30 2057 297 226 94 987 82 227 9 699 98 168 23 909 134 139 51 1101 99 294 11 736 107 232 30 1037 157 212 92

Sources: 2010 OneMaine CHNA Household Survey, MHDO Hospital Discharge Dataset, Q42007-Q32009, ODRVS Mortality 2007-2009 All Rates are per 100,000 unless otherwise stated

45

Yo

Ke

Pe

Sa

So

Indicator

Ma

Kn

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OneMaine Community Health Needs Assessment 2010 Figure 10: Prevalence of Cardiovascular Risk Factors
40%

35%

30%

Percentage of Adults

25%

20%

15%

10%

5%

0%

% Current Smokers (Age 18+)

% Sedentary Lifestyle (no physical activity)

% Obesity (Ages 18+)

Source: 2010 OneMaine CHNA Household Survey

Figure 11: Prevalence of High Blood Pressure, High Cholesterol, and Heart Disease by County
45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

% High Cholesterol (ever told)

% High Blood Pressure (ever told)

% Heart Disease

Source: 2010 OneMaine CHNA Household Survey 46

OneMaine Community Health Needs Assessment 2010 Figure 12: CABG Hospitalization Rates
300 268 250
Rate per 100,000 population

272 259 233 201 213 200 194

281

277

245

219

226 212

200 149 124 128 102 100 75 76

150

139 110 89 86 59 102 114 99 83 110 94

139 92 51

50

CABG Hospitalization Rate (Age 65+)

CABG Hospitalization Rate (Age 45-64)

Source: MHDO Hospital Discharge Dataset Q4 2007- Q3 2009

Figure 13: AMI Hospitalizations and Mortality Rates

2500

2000

Rate per 100,000 Population

1500

1000

500

Mortality Rate (Ages 65+) Hospitalizations (Age 65+)

Mortality Rate (Ages 45-64) Hospitalizations (Age 45-64)

Source: ORDVS Mortality 2007-2009, MHDO Hospital Discharge Dataset Q4 2007- Q3 2009

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OneMaine Community Health Needs Assessment 2010 Figure 14: Stroke Hospitalization and Mortality Rates
1000 900
Rate per 100,000 Population

800 700 600 500 400 300 200 100 0

Mortality Rate (Ages 65+) Hospitalizations (Age 65+)

Mortality Rate (Ages 45-64) Hospitalizations (Age 45-64)

Source: ORDVS Mortality 2007-2009, MHDO Hospital Discharge Dataset Q4 2007- Q3 2009

48

OneMaine Community Health Needs Assessment 2010

RESPIRATORY HEALTH

FINDINGS: Risk for disease from smoking (current and former) is high in many Maine counties; use of the hospital for respiratory health conditions (asthma and COPD) varies by county and in part follows variations in smoking prevalence. Prevalence of smoking in several counties is higher than smoking prevalence in Maine (22%), with particularly high prevalence in Aroostook, Oxford, Somerset, Washington and York counties. Males have higher smoking rates than females in all counties except Washington. In York and Androscoggin counties male and female rates are similar. The high smoking rate in Oxford County is due to the very high male smoking rate (29%). An estimated 43% of Maine adults received a flu shot or mist in the past 12 months Cumberland was the highest (49%). Aroostook (37%), Franklin (35%), Piscataquis (34%), Waldo (36%) and Washington (34%) counties were the lowest. The prevalence of adults diagnosed with current asthma is estimated at 10% statewide. This estimate varies by county with Androscoggin, Aroostook, Somerset, and Waldo counties all 10% or more above the state rate. Counties with a higher asthma prevalence rate also have higher hospital inpatient and ED rates for asthma and bronchitis. Exceptions are Waldo County (high prevalence and low IP/ED rates) and Washington County (high IP/ED rates but not a high asthma prevalence rate). As with smoking rates (current and former), there is wide variation in county-specific lung cancer incidence rates among both males and females. Maines estimated COPD prevalence is 4.2%. Somerset County has the highest COPD prevalence (7.9%) followed by Waldo County (6.6%) and Washington County (6.0%).

According to the World Health Organization, the burden of chronic respiratory diseases (CRDs), including asthma, Chronic Obstructive Pulmonary Disease (COPD), and lung cancer will continue to increase because of tobacco use and population aging.31 Smoking is a risk factor for many respiratory diseases including asthma, lung cancer, COPD,32 emphysema and bronchitis. Current and former smoking levels are therefore important indicators of the risk for respiratory disease in a community. Although the prevalence of current smoking was described earlier, because smoking is such a strong risk factor for respiratory illness, this section will discuss additional issues associated with smoking and smoking cessation.

31 World Health Organization. WHO Strategy for Prevention and Control of Chronic Respiratory Diseases. Geneva, Swizterland, 2002. http://whqlibdoc.who.int/hq/2002/WHO_MNC_CRA_02.1.pdf 32 Chronic Obstructive Pulmonary Disease (COPD) refers to a permanent condition of lung disease with the presence of chronic bronchitis and/or emphysema that has led to the development of an airway obstruction. COPD (chronic bronchitis, emphysema, chronic airway obstruction) is thought to result from direct interaction of lung tissue with environmental agents, of which tobacco smoke is the most significant; cigarette smoking is thus the strongest risk factor for COPD.
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OneMaine Community Health Needs Assessment 2010 Smoking Prevalence: Prevalence of smoking in several counties is higher than smoking prevalenceit is in Maine (22%), with particularly high prevalence in Aroostook, Oxford, Somerset, Washington and York counties. Males generally have higher smoking rates than females in all counties except Washington, York, and Androscoggin, where male and female rates are similar. Among the counties with the highest smoking rates, the Oxford rate is due to the high male smoking rate (29%). Smoking prevalence is below 20% in Cumberland, Hancock, Knox, and Lincoln counties. Lifetime smoking rates (those who have smoked more than 100 cigarettes in their life) are an important indicator because former smokers are also at increased risk for respiratory disease. Lifetime smoking rates are highest in Lincoln (62%) and Washington (61%) counties. Smoking Cessation: Smoking cessation can greatly impact cardiovascular and respiratory health, and health care provider support for current smokers to quit can assist in cessation success. Across Maine, 72% of current smokers reported they have been advised by their health care provider in the past year to quit smoking. Aroostook (76%) Cumberland (78%) and Hancock (76%) county smokers were more likely to receive this advice, while adult smokers in Waldo (54%) and Franklin (58%) counties were least likely. However, 91% of current smokers with three or more chronic conditions have been advised to quit smoking in the past year, ranging from 100% in Washington and Somerset counties, to 66% in Knox County. Just over half (54%) of current smokers have made at least one attempt to quit in the past year, indicating that even though smokers may not be successful in quitting, many are trying to quit. This rate varies considerably by county, with Aroostook (62%), Oxford (61%), Sagadahoc (67%) and York (61%) counties the highest, and Franklin (42%), Hancock (43%), and Lincoln (45%) counties the lowest. Pneumonia and Influenza: An estimated 43% of adults received a flu shot or mist in the past 12 month Cumberland County had the highest rate at 49%. Aroostook (37%), Franklin (35%), Piscataquis (34%), Waldo (36%) and Washington (34%) counties had the lowest. Current hospitalization rates for pneumonia in Aroostook, Hancock, Oxford, Penobscot, Piscataquis, Somerset, Waldo, and Washington counties are at least 10% above the state rate. Asthma: The size of the adult population in Maine currently diagnosed with asthma is estimated at 10%; in the U.S. it is 9%. Androscoggin, Aroostook, Somerset, and Waldo counties are all higher than that at 12-13%. These counties also represent the counties with the highest levels of hospital admission for asthma and bronchitis, along with Penobscot County, which has the 3rd highest hospital admissions rate for asthma and bronchitis. Aroostook, Hancock, Piscataquis, Somerset and Washington counties have the highest ED visit rate for asthma and bronchitis. For most of these the rates are higher for all age groups. Because most patients can be effectively managed on an outpatient basis, pediatric and adult asthma is considered an ACS condition that should not typically require hospitalization(s). ACS respiratory related conditions - conditions where hospitalizations can be averted by proper outpatient care and good patient adherence - include Chronic Obstructive Pulmonary Disease (COPD), adult asthma, congestive heart failure (CHF), and bacterial pneumonia. Thus, hospitalization rates for asthma give us insight into how well asthma is being managed (e.g., self management, access to care and services) in the region.

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OneMaine Community Health Needs Assessment 2010 COPD: COPD refers to two lung diseases, chronic bronchitis and emphysema, that are characterized by obstruction to airflow that interferes with normal breathing. COPD cannot be cured and does not improve. It can be managed to prevent increased severity. The major risk factor by far for COPD is current or former smoking. Overall the prevalence of diagnosed COPD in Maine is estimated at 4.2%. Several counties have higher prevalence, and these counties tend to have higher hospitalization and ED visit rates for COPD. The prevalence of COPD was highest in Somerset County (7.9%) and lowest in Knox County (2.0%) (Figure 16). COPD, like asthma, is an ACS condition. COPD hospitalization rates in a population are therefore strong indicators of the health systems ability to manage COPD patients and patient ability to self-manage. Table 8 shows that COPD hospital inpatient rates are high in those counties with high prevalence rates. However, Kennebec and Waldo counties are exceptions, with high prevalence rates but low hospital inpatient rates, even though both counties have high ED visit rates compared to the state. Franklin County, on the other hand, has a low prevalence rate but a high inpatient hospital COPD rate and a low ED rate. Piscataquis has a prevalence rate similar to the state, but high inpatient and ED hospital use rates. Smoking-Related Cancers: Lung cancer incidence, especially among men, is higher in Aroostook, Hancock, Oxford, Piscataquis, Somerset and Washington counties, compared to the state (106 new cases a year per 100,000 population). Among females, the rates in Hancock, Lincoln, Penobscot, Piscataquis, Somerset and Washington counties are high compared to the state (86 new cases a year per 100,000 population). (Table 8) Franklin County is the only county in Maine where lung cancer mortality for women is higher than the state, yet the incidence rate is low. Otherwise the mortality rates generally track incidence rates. In Maine the smoking-related neoplasm mortality rates (e.g., mortality from cancers of the lung, bladder, throat, etc.) are 177 per 100,000 population. The rates in Aroostook, Lincoln, Oxford, Piscataquis, Somerset, and Washington counties are elevated compared to the state. Male rates in Knox County, and female rates in Hancock, and Somerset counties are also higher than the state. Risk Factor Prevalence Despite the known harmful effects of smoking as the leading cause of respiratory illnesses, the proportion of the population with COPD or asthma who continue to smoke is high in most regions. Patients suffering from these conditions who continue to smoke will have difficulty keeping their disease from getting worse, and/or managing exacerbations of their illness. Smoking prevalence is higher among those with diagnosed respiratory illnesses, especially COPD and asthma. Across the state, 36% of patients with COPD and 25% of patients with asthma continue to smoke. The highest proportion of patients with COPD who continue to smoke are in Kennebec (46%), Sagadahoc (49%), Waldo (42%) and Washington (53%) counties. Among adults who currently have asthma, Kennebec (36%), Sagadahoc (42%), Washington (43%) and York (39%) counties have the highest.. Cumberland (9.3%) has the lowest smoking prevalence among those with current asthma, followed by Knox (15%), Waldo (17%), and Androscoggin (17%) counties.

51

OneMaine Community Health Needs Assessment 2010 The respiratory health profile of the populations of Maine suggests that risk factors, disease morbidity and mortality are high in many Maine counties, especially in the more rural ones. Smoking continues to be a challenge in many areas of Maine, and explains a large proportion of the disease and death rates. Access to and availability of primary prevention and treatment modalities for COPD and other lung diseases are priorities for follow-up. Table 8: Selected Respiratory Health Indicators by Study Region
An dr osc og gin Ar oo sto ok Cu mb erl an d Fr an kli n Pe no bs cot Pis cat aq uis Sa ga dh oc So me rse t Ke nn eb ec Kn ox W ash ing ton Yo rk

Ha nc ock

Lin col n

Ox for d

W ald o

Indicator

% Smokers (Male) % Smokers (Female) % Asthma (18+) % Ever Asthma (Ages 0-17) % COPD Bronchitis and Asthma, ED Visit Rate Bronchitis and Asthma, Hospital Admission Rate COPD, ED Visit Rate COPD, Hospital Admission Rate COPD, Mortality Rate % Ever Received Pneumoccal Vaccine (Ages 65+) Lung Cancer Mortality (Males) Lung Cancer Mortality (Females) Lung & Bronchus Cancer Incidence (Males) Lung & Bronchus Cancer Incidence (Females)

20% 20% 12% 10% 4% 1064 127 1264 307 72 73% 73 59 101 86

31% 23% 13% 7% 6% 1292 120 2638 455 67 66% 37% 117 67 163 80

19% 13% 10% 2% 3% 860 74 407 194 47 76% 49% 67 52 87 71

20% 19% 9% 3% 3% 544 94 754 502 74 75% 35% 104 69 95 72

19% 18% 7% 11% 4% 1371 91 536 261 49 67% 40% 71 76 141 118

26% 22% 11% 8% 6% 931 65 208 61 73% 39% 76 62 103 82

19% 18% 8% 5% 2% 872 86 280 59 71% 44% 82 47 109 92

21% 17% 11% 6% 4% 763 52 822 276 72 71% 38% 85 68 86 101

29% 20% 11% 7% 7% 987 87 401 73 80% 40% 88 73 123 91

25% 22% 11% 8% 5% 935 117 381 50 72% 43% 84 69 108 99

21% 20% 9% 6% 4% 1636 74 318 77 68% 34% 95 43 131 105

22% 18% 9% 6% 6% 656 68 479 281 67 70% 46% 65 79 93 66

28% 23% 13% 6% 8% 1495 103 337 83 70% 39% 86 57 133 111

24% 19% 12% 3% 7% 879 74 252 57 59% 36% 71 63 105 89

30% 31% 11% 9% 6% 1556 102 439 87 72% 34% 114 88 188 110

25% 26% 8% 5% 3% 921 70 652 218 49 76% 39% 67 52 82 79

23% 20% 10% 6% 4% 988 87 998 284 58 73% 42% 78 61 105 86

1167 1151

1306 1175 1316

1915 1244 1360

% Received Flu Shot or Mist past 12 months (Ages 65+) 40%

Sources: 2010 OneMaine CHNA Household Survey, MHDO ED Discharge Dataset 2007- 2008, MHDO Hospital Discharge Dataset, Q42007-Q32009, ODRVS Mortality 2007-2009 All Rates are per 100,000 unless otherwise stated

52

Ma ine

OneMaine Community Health Needs Assessment 2010 Figure 15: Smoking Prevalence by County
35% 31% 30% 27%

Percentage of Adults Currently Smokers

25% 20% 20% 16% 15%

24%

25% 23% 21%

26%

25% 22%

21% 20%

20%

19%

18%

19%

10%

5%

0%

Source: 2010 OneMaine CHNA Household Survey

Figure 16: Asthma and COPD Prevalence by County

14% 12% 10% 8% 6% 4% 2% 0%

Percentage of Adults

% Asthma (18+)
Source: 2010 OneMaine CHNA Household Survey

% COPD

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OneMaine Community Health Needs Assessment 2010 Figure 17: ED Rates for Respiratory Conditions
3000

2500
ED Visits per 100,000 Population

2000

1500

1000

500

Bronchitis and Asthma, ED Visit Rate

COPD, ED Visit Rate

Source: MHDO ED Discharge Dataset 2007- 2008

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OneMaine Community Health Needs Assessment 2010

DIABETES HEALTH

FINDINGS: Diabetes in Maines adult population is a persistent and growing health issue among all age groups. Risk factors for diabetes, such as being overweight or having a sedentary lifestyle, correlate with diabetes prevalence in the counties. Counties with higher incidence of obesity and sedentary lifestyles also exhibit higher rates of diabetes prevalence. Overall diabetes prevalence in Maine is 10% (U.S. 8.0%), with higher rates in Aroostook (13%), Oxford (12%), Piscataquis (13%), and Washington (13%) counties. With few exceptions, these are also the counties with the highest prevalence of obesity and sedentary lifestyles. Management of diabetes is fairly consistent across the state, with the exception in Franklin and Oxford counties, which have poorer care. Diabetes self-management education is inconsistent across the state, with Hancock, Kennebec and Knox counties doing better than the state, while Franklin, Lincoln, Somerset and Washington counties are doing poorer. With few exceptions, rates of inpatient admissions and ED visits for diabetes track with prevalence and risk factors but not with diabetes care indicators. Several counties, in particular Aroostook, Franklin, Hancock, Kennebec, Oxford, Somerset and Washington counties, have high diabetes mortality rates compared to the state.

Diabetes is the leading cause of end-stage renal disease among adults of all ages, and is also the leading cause of blindness among working age adults. Diagnosed diabetes prevalence is 8.0% in the U.S. and 10% in Maine - up from 7.5% in 2007. Mirroring national and statewide trends, diabetes prevalence continues to increase in regions where there are high risk factors such as obesity and sedentary lifestyles (Table 9). Currently, an estimated 109,000 adults in Maine have been diagnosed with diabetes (10%). Elevated rates occur in certain counties and for specific age groups (Table 9): Overall diabetes prevalence is higher than the state in Aroostook (13%), Oxford (12%), Piscataquis (13%), and Washington (13%) counties. In the 18-44 age group, several counties exceed the state prevalence (3.0%), with especially high rates in Kennebec (9.0%), Piscataquis (8.0%) and Washington (6.0%) counties 21% of adults 65+ in Maine have been diagnosed with diabetes, with higher rates in Kennebec (24%), Oxford (26%), and Sagadahoc (28%) counties.

The estimated prevalence figures may under-represent the true burden of diabetes. Diabetes has historically been under-diagnosed, although improved surveillance systems and detection measures are expected to improve accuracy in the estimation of a regions diabetes burden.

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OneMaine Community Health Needs Assessment 2010 Approximately 90% of adults with diabetes have Type II (adult onset) diabetes. Several factors contribute to Type II diabetes. These include behavioral elements (increased fat consumption and other nutritional factors, decreased physical activity, obesity, demographic changes (aging, growth of at-risk populations), and the limited effectiveness of interventions to change individual, community, or organizational behaviors.33 The aging of the Maine population, as described earlier, potentially increases disease burden. However, the increased onset in the 18-44 age group suggests risks such as inactivity and obesity are the prime drivers. These risk factors are high in Maine overall and in those counties with the highest prevalence of diabetes (Table 9). Conversely, with one or two exceptions, those counties with the lowest diabetes prevalence in all age groups have the lowest percentage of population with a sedentary lifestyle or obesity. Primary prevention targeting diet and exercise is a priority health issue throughout Maine and especially several counties. Management of diabetes is fairly consistent across the state, with the exception of Franklin and Oxford counties, which have poorer care. In general, residents of these counties with diabetes are less likely to receive appropriate diabetes care, including retinal eye exams, foot exams or A1C testing. Overall the data suggests, however, that diabetes is well managed in the state (Figure 20). It should be noted that the sample size available from the survey to calculate these estimates is small, so caution in interpretation is warranted. Diabetes-related hospital admissions are high in Aroostook, Penobscot, Piscataquis and Washington counties. In general, rates of diabetes-related hospital admissions are high in those counties with high prevalence rates. The only exception is Penobscot County, which has a high use rate but a prevalence rate equal to the state. These counties also tend to have diabetes related ED admissions rates and diabetes mortality higher than the state. In addition, Kennebec County has high diabetes related mortality rates overall and for the age groups 45-64 and 65+. Short-term complications are curable symptomatic conditions that can be overcome through proper management of diabetes, and include hypoglycemic coma, ketoacidosis, and hyperosmolarity. Secondary prevention plays an important role in preventing short term complications. Diet, exercise, and proper self administering of medications help mitigate the development of short-term complications. Short-term complications are most often treated in an outpatient setting. ED utilization rates for short-term diabetes complications are high in the counties with high prevalence; this includes Aroostook, Oxford, Somerset, Waldo and Washington counties. Long-term diabetes complications are permanent conditions that cannot be cured but may be prevented. These include complications that affect kidney functioning, eyesight, neurology of patients, and may contribute to the development of stroke or heart disease. In addition, amputations are often a response to complications arising from long-term complications. Ed visit rates for long-term complications are higher than the state in Aroostook, Franklin, Knox, Piscataquis, Somerset, Waldo and Washington counties. Typically, those who have had diabetes for a longer period of time and who manage their disease inadequately are more likely to develop long term complications. Additionally, the more frequent the onset of short-term complications, the more likely one will experience long-term complications.

33

US Government Printing Office, Healthy People 2010, http://www.healthypeople.gov/document/HTML/Volume1/05Diabetes.htm

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OneMaine Community Health Needs Assessment 2010 Risk Factor Prevalence The disconnect between patient and provider in effecting lifestyle changes that will both assist in disease management and/or prevent diabetes is often cited as a reason behind continued elevated diabetes prevalence and morbidity/complication rates in this population. The association between obesity, dietary choices and lifestyle habits with diabetes has been widely accepted, yet improvements in reducing the proportion of the population with Type II diabetes have not been observed in this study. While prevalence and trends in risk factors help us understand why diabetes prevalence remains high in the different service areas, indicating a need for addressing primary prevention issues, secondary prevention also needs to be addressed. Elevated ED and hospital admission rates, and increased mortality rates from complications associated with diabetes prevalence, indicate that patients with diabetes are not managing their condition effectively. According to survey findings, 54% of adults diagnosed with diabetes in Maine are obese. Adults with diabetes are twice as likely to be obese compared to those without diabetes. This varies widely by county, with almost 70% of adults with diabetes in Franklin County being obese compared to 33% in Cumberland County. Additionally, sedentary lifestyle prevalence among those with diabetes (32%) is somewhat higher than those without the disease (25%). Overall testing (A1c, eye exams, est.), utilization and related data indicate that the population with diabetes are not effectively managed by the health care delivery system in many counties of Maine. A focus on primary prevention through diet and exercise is indicated to address lifestyle-related risks for the onset of diabetes. In addition, outpatient diabetes management services, including diabetes selfmanagement education and support and secondary prevention practices are priority health issues, especially in the Aroostook, Piscataquis, Penobscot and Washington counties.

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OneMaine Community Health Needs Assessment 2010 Table 9: Diabetes Indicators

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An d ro

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Pi s c at

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% Sedentary Lifestyle (measured by no pysical a 20% % Overweight (Age 18+) 39% % Obesity (Age 18+) % Diagnosed Diabetes Ages 18-44 Ages 45-64 Ages 65+ % Reported hemoglobin A1c measurement (at least once) in past year (Age 18+) % Reported pupil dilation eye exam in past year (Age 18+) % Reported foot examination in past year (Age 18+) % Reported ever taken diabetes self management course (Age 18+) Diabetes, Hospital Admission Rate Ages 18-44 Ages 45-64 Ages 65+ Diabetes Short-term Complications, ACSC ED Visit Rate Diabetes Long-term Complications, ACSC ED Visit Rate Diabetes Uncontrolled, ACSC ED Visit Rate Diabetes, Mortality Rate Ages 45-64 Ages 65+ 31% 11% 3% 16% 23% 77% 78% 77% 59% 84 57 137 129 53 85 11 25 21

25% 38% 31% 13% 4% 17% 20% 82% 70% 74% 56% 93 104 86 169 38 107 17 33 23

16% 36% 24% 9% 2% 12% 21% 97% 79% 83% 51% 64 62 57 121 31 61 7 20 19

18% 38% 31% 10% 3% 14% 16% 81% 65% 60% 35% 77 127 33 128 44 76 12 49 44

20% 38% 22% 8% 1% 8% 23% 93% 80% 75% 65% 82 66 79 128 44 77 31 33 15

20% 34% 31% 12% 9% 18% 24% 93% 79% 78% 70% 70 63 75 112 35 84 13 31 20

19% 38% 25% 9% 2% 11% 17% 91% 78% 67% 63% 73 32 89 160 22 115 9 19 13

20% 34% 25% 10% 6% 10% 15% 84% 76% 86% 47% 72 57 60 133 29 94 7 23 9

24% 36% 33% 12% 5% 12% 26% 78% 84% 67% 56% 84 92 52 172 35 87 11 34 22

23% 34% 35% 10% 3% 14% 21% 92% 79% 80% 54% 102 90 99 201 61 94 6 26 24

26% 38% 33% 13% 8% 14% 20% 89% 65% 71% 51% 150 219 110 293 65 156 15 29 34

20% 39% 23% 10% 0% 12% 28% 84% 70% 75% 58% 74 54 75 185 31 76 1 13 3

26% 40% 28% 11% 4% 12% 22% 91% 70% 81% 36% 82 120 70 119 49 65 20 33 17

25% 36% 27% 11% 3% 14% 18% 85% 70% 74% 60% 84 102 57 182 46 69 16 28 22

25% 39% 33% 13% 6% 14% 21% 72% 78% 73% 29% 103 92 84 226 38 123 46 61 36

20% 37% 23% 9% 3% 10% 21% 92% 73% 85% 53% 71 64 61 151 39 68 4 20 17

Yo

Ke

Fr

Pe

Sa

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Indicator

21% 37% 28% 10% 3% 13% 21% 89% 76% 78% 54% 79 75 75 150 41 81 11 26 20 126

120 133 103 233 166 147 71 103 162 128 98 74 175 133 251 96 Sources: 2010 OneMaine CHNA Household Survey, MHDO ED Discharge Dataset 2007- 2008, MHDO Hospital Discharge Dataset, Q42007-Q32009, ODRVS Mortality 2007-2009

58

Ma

Kn

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OneMaine Community Health Needs Assessment 2010 Figure 18: Diabetes Prevalence among adult Maine Residents by County
14% 13% 12% 12% 11% 10% 9% 8% 8% 10% 10% 10% 9% 12% 11% 13% 13%

11%

10%

10%
Percentage of Population

9%

6%

4%

2%

0%

Source: 2010 OneMaine CHNA Household Survey

59

OneMaine Community Health Needs Assessment 2010 Figure 19: Diabetes Hospitalization and ED Visit Rates

160 150 140

120

Rate per 100,000 Population

102 100 84 80 64 60 77 93 82 70 73 72 84 74 82 84

103

79 71

46 40 31 20 17 11 7 0 12 13 9 7 11 6 1 20 15 16 11 4

Diabetes Uncontrolled, ACSC ED Visit Rate

Diabetes, Hospital Admission Rate

Source: MHDO ED Discharge Dataset 2007- 2008, MHDO Hospital Discharge Dataset, Q42007-Q32009

60

OneMaine Community Health Needs Assessment 2010 Figure 20: Diabetes Management among Maine Residents by County
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Percentage of Population

% Reported hemoglobin A1c measurement (at least once) in past year (Age 18+) % Reported pupil dilation eye exam in past year (Age 18+) % Reported foot examination in past year (Age 18+) % Reported ever taken diabetes self management course (Age 18+)

Source: 2010 OneMaine CHNA Household Survey

61

OneMaine Community Health Needs Assessment 2010

CANCER HEALTH

The burden of cancer in a population or a community is influenced, in part, by prevention of modifiable risk factors, screening and early detection, appropriate treatment, and patient and family involvement in care decisions and end-of life issues. (Genetics and environmental risk exposure also contribute.) Differences in the prevalence of population risk factors and health system screening and detection practices impact both the incidence rate and detection stage of cancer. This section of the CHNA report examines population-based indicators on cancer risk factors, screening and detection, incidence and mortality, in order to gain an overview of the current burden of the disease on populations in Maine and the type of follow-up that may be necessary to improve the cancer heath status of a population. The three leading cancers with the highest incidence rates among males in Maine are prostate, lung, and colorectal cancer. Among women, the leading cancers are breast, lung and colorectal cancer. These four cancers (breast, prostate, colorectal and lung) are further described in this report based on high incidence rates, knowledge of major causal factors, and/or the availability of effective screening tests that can detect these cancers at an early stage. In general, the incidence of these cancers is influenced by modifiable risk factors and can be treated successfully when detected at an early stage of the disease. Risk Factors FINDINGS: Behavioral risk factors for cancer such as smoking, obesity rates and sedentary life styles are generally high in Maine, and higher still for many counties in Maine. These risk factors also appear to be remaining steady or increasing for the state and some counties over time, while they are decreasing for others. Many cancers can be prevented by eliminating associated risk factors. Modifiable health behaviors associated with the development of cancer (and many other conditions) include tobacco use, physical inactivity, obesity, poor diet, and to a lesser extent, alcohol use. Several of these health behaviors are elevated in Maine; smoking has remained steady at approximately 22% for adults, obesity affects 28% of the adult population, and 21% of Maine adults live a sedentary life style. These risk factors, discussed in prior sections of the report, will be briefly reviewed again here. Smoking prevalence in Maine has not declined for several years. In some counties, notably Washington, Aroostook, Oxford and Somerset it still afflicts 25% or more of the population. These rates, combined with a high proportion of former smokers (31% statewide) put residents at increased risk for cancer. Only Cumberland, Hancock, Knox and Lincoln counties have a smoking prevalence under 20%. The prevalence of obesity is also elevated in many counties, but unlike smoking, the rates continue to increase. In 2007 the obesity rate in Maine was 22% compared to 27% in 2010. Compared to 2001 data, where the 65+ age group had a higher proportion of obesity, increasing obesity rates among the 18-44 age group are driving the increase in overall obesity within Maine. This is a worrisome trend that needs to be addressed in order to mitigate the development of health problems, including cancer, in this group as they age. A large proportion of the state population continues to maintain sedentary lifestyles with no physical activity. This figure has not changed over the past five years, despite research showing the positive effects of physical activity and vigorous physical activity. Several counties have elevated rates for three or more of these risk factors, making them at higher risk for cancer. These include Aroostook (smoking and sedentary life style), Oxford (smoking, sedentary life
62

OneMaine Community Health Needs Assessment 2010 style and obesity), Piscataquis (former smoking, sedentary life style and obesity) and Washington (smoking, sedentary life style and obesity) counties. Overall Incidence and Mortality FINDINGS: Cancer incidence rates are high in several counties compared to the state, however there is greater variation in mortality rates by county. Mortality/incidence ratios indicate possible disparities in the availability and access to cancer screening and treatment in several counties. All cancer incidence rates are high for Hancock, Piscataquis, and Washington counties compared to the state. Hancock, Piscataquis, and Washington counties also have higher than state incidence for three of the four leading cancers (breast, prostate, lung and colorectal cancer). Aroostook, Lincoln, Oxford, Piscataquis, and Washington counties all have elevated cancer mortality rates compared to the state. Mortality/incidence ratios in Aroostook, Franklin, Knox, and Oxford counties are high compared to the state, and indicate possible disparities in the availability of and access to cancer screening and treatment

Maine continues to have among the highest age-adjusted cancer incidence and mortality rates in the U.S. In 2007, Maines age-adjusted cancer incidence rate (515 cases per 100,000 population) was the highest in the nation34. Further, while US incidence rates have been declining in recent years, Maines rates have remained elevated; the reason Maines rates have remained high is not clear, but may be a reflection of improved screening rates35. Although Maines all-cancer mortality rate has been declining, the 20052007 mortality rate was the 7th highest in the nation36. Cancer Incidence: Cancer incidence rates include all new cases of cancer observed over a period of time and are calculated based on the total population of each study region.37 The incidence rate for all cancers in Maine is 629 cases per 100,000 population. Cancer incidence rates for all types of cancers are high for Hancock (744), Piscataquis (779), and Washington (787) counties compared to the state. Androscoggin, Cumberland, and Sagadahoc counties have the lowest all cancer incidence rates in Maine. Hancock, Piscataquis, and Washington counties also have higher than state incidence for three of the four leading cancers (breast, prostate, lung and colorectal cancer). Washington County has a lower than state rate for breast cancer incidence, while the Hancock County rate for colorectal cancer is at the state rate. Cancer Mortality: Mortality rates for all cancers are elevated compared to the state (234 deaths per 100,000 population) for Aroostook, Lincoln, Oxford, Piscataquis and Washington counties. The highest rates were observed in Washington (307 deaths per 100,000 population), Piscataquis (296), and Aroostook (285).

34

Maine Comprehensive Cancer Control Plan: 2011-2015. Maine Cancer Consortium c/o American Cancer Society, Topsham, ME; October 2010. 35 IBID 36 Cancer mortality data for 2005 to 2007, from Centers for Disease Control and Prevention; presented in Americas Health Rankings- 2010 Edition 2010 United Health Foundation. 37 Rates reported here are unadjusted and provide an estimate of disease burden.
63

OneMaine Community Health Needs Assessment 2010 Cancer Mortality/Incidence: Several measures are used to assess access and availability of cancer services for the population diagnosed with cancer. One measure is the cancer mortality-to-incidence ratio (Table 10). This ratio predicts the likelihood of death in a population newly diagnosed with cancer. The higher the ratio, the higher the likelihood of death due to that condition. If a county level ratio is higher than the state ratio (or any other standard) it indicates that more people who are diagnosed with new cancers are more likely to die from that condition compared to the state. This ratio can serve as an indication of potential disparities in access to cancer management and treatment. It can also indicate potential disparities in screening and detection of early stage diagnosis. CCPH developed this measure for use in health care assessment and planning. While the measure has not been validated, it has proven useful in identifying potential care access issues for specific cancers.38 It should be noted, however, that the mortality-to-incidence ratio is constructed using cumulative index data collected during the period 2005-2007, and cumulative mortality data collected between 2007 and 2009. The measure is not a mortality metric for any given cohort, so subjects in the mortality data may not be the same subjects as are in the incidence data. In cases where the ratio is equal to 100%, the number of deaths may have exceeded the incidence for that county. Although imperfect, the measure does provide a reasonable measure of a countys cancer mortality risk, since incidence and mortality rates do not drastically differ from year to year. Overall in Maine the likelihood of dying from any cancer is 37%. It is marginally higher in Franklin (41%), Aroostook (43%), Kennebec (40%), Oxford (40%), and Somerset (40%) counties. From a risk perspective Aroostook County residents with cancer are 16% more likely to die than residents with cancer in the state overall. In Franklin, Kennebec, Oxford, and Somerset counties it is 11%, 8.0%, 8.0% and 8.0% elevated risk over the state, respectively. It is important to note that these are not the counties with the highest incidence rates. Hancock, Piscataquis, and Washington counties had the highest all cancer incidence rates - all significantly higher than the state. Aroostook, Lincoln, Oxford, Piscataquis, and Washington counties had higher mortality rates than the state, with Washington County the highest overall. Despite the high mortality rate in Washington County, it had an overall mortality/incidence ratio only slightly above the state. This suggests that Washington County cancer patients have nearly the same likelihood of dying from cancer as cancer patients in the state. Conversely, mortality/incidence ratios are highest in Aroostook County, indicating that those who are detected with cancer in Aroostook County have less likelihood of survival. In addition to mortality/incidence ratios, cancer staging data are used as indicators of how early cancer is being detected for the population through screening or other techniques. Cancer staging measures the proportion of cases detected at the local stage or before the cancer has spread to the surrounding tissues (regional) or to distant sites (organs, bones, etc). In general, when cancer is detected at the local stage, survival rates tend to be higher, provided access to care is not an issue. Thus, the stage of diagnosis can affect the mortality rate in the area and the mortality-to-incidence ratio. When viewed in conjunction with mortality/incidence ratios, staging data indirectly measures access and availability of cancer treatment and detection in different regions. Typically, a high percentage of cancers detected at the local stage suggest more widespread cancer screening and early detection. This study reports on cancer staging for specific cancer sites, since that is most meaningful for planning.

38

The mortality incidence ratios are reasonable stable when based on statewide data as the number of cases are large. It is less stable for county specific data, especially for site specific county populations, because it is based on a smaller number of cases. Its results are meant to raise questions about potential issues in cancer care.
64

OneMaine Community Health Needs Assessment 2010 In the sections that follow, there will be a closer look taken at specific cancers, in order to better elucidate differences between the study regions. Lung Cancer FINDINGS: Counties with higher lung cancer incidence rates do not always have higher mortality rates compared to the state. Rates for both incidence and mortality vary in many counties by gender. The proportion of lung cancer detected at the local stage is high in several counties but there is some variation by gender, indicating that early detection may not be consistent by county or by gender within the counties. Lung cancer incidence and mortality rates for men and women vary by county when compared to the state. Lung cancer mortality/incidence ratios are the highest of all cancer sites in this study. Lung cancer mortality/incidence ratios vary across counties and by gender within several counties. Lung cancer mortality/incidence ratios are highest in Franklin (96%), Lincoln (81%), and Sagadahoc (91%) counties compared to the state (73%). The M/I ratio for females is higher than males in Aroostook, Hancock, Oxford, Sagadahoc, Waldo, and Washington counties. Early lung cancer detection, while differing by county, does not differ much by gender.

Smoking is the most significant risk factor associated with lung cancer. Modifying this risk can significantly impact the incidence of this cancer. Epidemiological evidence suggests that smokers who quit before middle age can substantially benefit from this behavior change, and can avoid 90 percent of the excess risk of lung cancer linked to tobacco use. While Maine as a whole and many counties are still at increased risk for cancer from high rates of smoking, several counties in Maine have smoking rates significantly higher than the state, as reported under the respiratory health section of this report. Lung cancer incidence and mortality rates for men and women vary by county when compared to the state. Aroostook, Hancock, Oxford, Piscataquis, Somerset, and Washington counties all have high male lung cancer incidence rates compared to the state. Hancock, Lincoln, Penobscot, Piscataquis, Somerset, and Washington counties all have high female lung cancer incidence rates compared to the state. Lung cancer mortality/incidence ratios are the highest of all cancer sites in this study, with the statewide risk of death being 73% of those with lung cancer. Mortality/incidence ratios are highest in Franklin (96%), Lincoln (81%), and Sagadahoc (91%) counties. The M/I ratio for females is higher than males in Aroostook, Hancock, Oxford, Sagadahoc, Waldo, and Washington counties. However, these need to be interpreted with caution, as they are based on small numbers of cases in these counties. Early lung cancer detection, while differing by county, does not differ much by gender. Early stage detection of lung cancer is still very infrequent in Maine; only 16% of lung cancer in males and 21% in females are detected in the local stage. Almost half of all lung cancers in Maine (50% in males and 47% in females) are detected in the distant stage. The counties with the lowest percentage of lung cancers detected in the early stage are Kennebec, Knox, Lincoln, Sagadahoc, Washington, and York counties for males; and Cumberland, Kennebec, Lincoln, and Oxford counties for females. (Table 12).

65

OneMaine Community Health Needs Assessment 2010

Colorectal Cancer FINDINGS: Colorectal cancer incidence and mortality rates vary considerably by county in Maine. Approximate half of all cases are diagnosed early, but this varies considerably by county as well. Screening rates are fairly consistent across counties and appear unrelated to incidence and mortality rate variation. Incidence rates for colorectal cancer are highest in Aroostook, Franklin, Oxford, Penobscot, Waldo, and Washington counties. They are lowest in Cumberland, Kennebec, and Sagadahoc counties. Mortality rates are highest in Aroostook, Franklin, Lincoln, Oxford, Piscataquis and Somerset counties. They are lowest in Androscoggin, Cumberland, Sagadahoc, and Washington counties. Mortality/incidence ratios are highest in Kennebec, Lincoln, and Somerset counties compared to the state. There is a large variation by gender. 47% of all colorectal cancer is diagnosed in the early stage in Maine. Aroostook (52%) and Washington (54%) counties have the highest local stage diagnoses rates. Franklin (41%), Lincoln (41%), Oxford (28%), Sagadahoc (41%), and Waldo (41%) counties have the lowest percentage diagnosed at early stage. 63% of the population age 50+ report being screened for colorectal cancer in the past five years.

Across the US approximately 50,000 people will die from colorectal cancer in 2011 (American Cancer Society). Colorectal cancer is the third most commonly diagnosed and the third leading cause of cancer death. Approximately one-quarter of more of the colorectal cancer diagnosed could be prevented though lifestyle modification can be prevented though changes in lifestyle (obesity, red meat consumption, processed meat consumption, smoking, alcohol use). Additionally physical activity, calcium intake and Milk consumption reduce the risk of colorectal cancer (ACS). Most colorectal cancer deaths are preventable if the cancer is diagnosed at an early stage using existing knowledge and established screening tests. Maine has the 12th highest incidence rate and the 27th highest mortality rates in the US among males (Non-Hispanic White). Among females, Maine has the 4th highest incidence rate and has the 5th highest mortality rate (Non-Hispanic White).39 Colorectal Cancer incidence and mortality rates are elevated in several counties in Maine compared to the state. Incidence rates for colorectal cancer are higher in Aroostook, Franklin, Oxford, Penobscot, Waldo, and Washington counties compared to the state. They are lowest in Cumberland, Kennebec, and Sagadahoc counties. Mortality rates are highest in Aroostook, Franklin, Lincoln, Oxford, Piscataquis, and Somerset counties. They are lowest in Androscoggin, Cumberland, Sagadahoc, and Washington counties. There is a wide range in colorectal incidence rates across regions for both men and women.

39

Colorectal Cancer Facts & Figures 2011-2013, American Cancer Society

66

OneMaine Community Health Needs Assessment 2010 Despite low incidence rates, mortality/incidence ratios are high in Kennebec, Lincoln, and Somerset counties compared to the state. There is a large variation by gender, with higher rates for females than males in Aroostook (49% to 24%), Kennebec (47% to 34%) and Sagadahoc (50% to 22%) counties; and higher rates for males than females in Franklin (48% to 26%), Lincoln (53% to 34%), Oxford (45% to 25%), and Somerset (48% to 38%) counties. These data indicate possible gender disparities in diagnosis and treatment. Approximate half of all cases are diagnosed early but this varies considerably by county as well. 47% of all colorectal cancer is diagnosed in the early stage in Maine. Aroostook (52%) and Washington (54%) counties have the highest local stage diagnoses rates; Franklin (41%), Lincoln (41%), Oxford (28%), Sagadahoc (41%), and Waldo (41%) counties have the lowest % diagnosed at early stage. Screening rates are fairly consistent across counties and appear unrelated to incidence and mortality rate. 63% of the population age 50+ report being screened for colorectal cancer in the past 5 years with a colonoscopy or sigmoidoscopy. The lowest rate of screening is in Hancock (56%), Somerset (51%), and Waldo (56%) counties. Prostate Cancer FINDINGS: Prostate cancer incidence and mortality rates are elevated in many counties compared to the state. Screening and detection rates are not associated with lower mortality rates.

Prostate cancer incidence rates are elevated in Hancock, Lincoln, Piscataquis, Sagadahoc, and Washington counties and lowest in Aroostook County compared to the state. Prostate cancer mortality rates are elevated in Hancock, Kennebec, Knox, Oxford, Sagadahoc, and Washington counties, and lowest in Aroostook County compared to the state. The mortality/incidence ratio is low overall in the state (12%), with the highest in Franklin (14%), Hancock (16%), Kennebec (14%), and Knox (17%) counties. Just over three quarters of prostate cancer is detected at the local stage statewide (76%), with Waldo the highest (85%) and Penobscot (68%) and Piscataquis (61%) counties the lowest. Over two-thirds of men age 50+ report having a Prostate Specific Antigen (PSA) test in the past 2 years; Cumberland, Kennebec and York county men have the highest rates, and those in Franklin and Somerset counties the lowest. 67% of men 50+ statewide report having a digital rectal exam (DRE) in the past 2 years, with the highest in Lincoln County (75%) and the lowest in Franklin (57%) and Somerset (53%) counties.

Prostate cancer is the most frequently diagnosed cancer among the male population. Prostate cancer incidence rates are elevated in Hancock, Lincoln, Piscataquis, Sagadahoc, and Washington counties, and lowest in Aroostook County compared to the state. Incidence rates have increased in Maine over the past 10 years as the population ages. Some counties with high incidence rates are those with higher mortality rates (Hancock, Sagadahoc and Washington counties), while others with high mortality rates do not have high incidence rates (Kennebec, Knox, and Oxford counties). The incidence rate in Aroostook County is significantly lower than the state. (Table 11).
67

OneMaine Community Health Needs Assessment 2010 There is a wide range in mortality/incidence ratios across the state, indicating potential inter-regional differences in prostate cancer detection and management. The mortality/incidence ratio is low overall in the state (12%), with the highest in Franklin (14%), Hancock (16%), Kennebec (14%), and Knox (17%) counties. Cancer staging data reveals that a relatively high percentage of males are detected at the early stage of the disease. 76% of prostate cancer is detected at the local stage statewide, with Waldo County the highest (85%), and Penobscot (68%) and Piscataquis (61%) counties the lowest. The Prostate-Specific Antigen (PSA) test rates for men 50+ are generally lower than the state (69% of men statewide in the past 2 years). High levels of PSA in the blood indicate a greater likelihood that cancer is present, although there is great controversy in the use of this test to predict prostate cancer. Men in Cumberland, Kennebec and York counties have the highest PSA test rates; men in Franklin and Somerset counties have the lowest. While less sensitive than the PSA test, a digital rectal exams (DRE) is another screening test that can detect prostate cancer. The proportion of the male population 50+ who have received a digital rectal exam in the past two years is higher than the PSA test rate. Statewide, 67% of men 50+ report having a digital rectal exam (DRE) in the past 2 years, with the highest in Lincoln County (75%) and the lowest in Franklin (57%) and Somerset (53%) counties. However, it should be noted that according to the U.S. Preventive Services Task Force, PSAs and DREs are not recommended as a routine screening procedure for detecting prostate cancer. Breast Cancer FINDINGS: The counties where breast cancer incidence rates are high are not those where mortality rates are high with one exception (Knox). Screening and early detection for breast cancer is consistent across all counties with one exception (Somerset). Mortality/incidence ratios vary by county.

Breast cancer incidence rates are high in Hancock, Knox, Lincoln, and Piscataquis counties compared to the state. Breast cancer mortality rates are high in Aroostook, Kennebec, Knox, Oxford, and Washington counties compared to the state. 66% of all breast cancer cases are detected in the early stage. These rates are similar across the counties. Reported mammograms in the past year among 40+ year old women is almost 70%. All counties except Somerset (60%) have similar rates. Mortality/incidence ratios for breast cancer are generally low (Maine 18%) but Aroostook and Washington counties have somewhat higher rates (26% and 24% respectively).

Breast cancer is the most common cancer diagnosed among females. There is a relatively wide range of breast cancer incidence rates across the counties. Compared to the state, breast cancer incidence rates are high in Hancock, Knox, Lincoln, and Piscataquis counties. Breast cancer mortality rates are high in Aroostook, Kennebec, Knox, Oxford, and Washington counties compared to the state.
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OneMaine Community Health Needs Assessment 2010

66% of all breast cancer cases are detected in the early stage. These rates are similar across the counties, with Franklin and Piscataquis having the highest rates (71% and 72 % respectively). Mortality/incidence ratios for breast cancer are generally low in Maine (18%) and are somewhat consistent across the counties. The exceptions are Aroostook and Washington counties, which have somewhat higher rates (26% and 24% respectively) and Lincoln and Piscataquis, with lower rates (10%) compared to the state. Table 10: Cancer Mortality to Incidence Ratios and Confidence Intervals
An dro sco g gi n Ar o os t oo k d k Ke nn ebe c Kn ox Cu mb er Ha nco c Ox for d nob sc ank li Pi s ca t a shi ng t on lan qu is ot dh oc n co l n ers e t ldo Ma in Yo rk e

Sa ga

So m

Wa

Cancer Site BLADDER CANCER

Value

Lower 95% CI M/I Ratio Upper 95% CI Lower 95% BREAST CANCER CI M/I Ratio Upper 95% CI Lower 95% CERVIX UTERI CI CANCER M/I Ratio Upper 95% CI Lower 95% COLORECTAL CI CANCER M/I Ratio Upper 95% CI LUNG AND BRONCUS Lower 95% CI CANCER M/I Ratio Upper 95% CI PROSTATE CANCER Lower 95% CI M/I Ratio Upper 95% CI Lower 95% CI ALL CANCER/SITES M/I Ratio Upper 95% CI

0.210 0.104 0.151 0.001 0.161 0.157 0.175 0.156 0.141 0.135 0.132 0.083 0.067 0.040 0.086 0.164 0.194 0.292 0.188 0.196 0.027 0.267 0.234 0.316 0.277 0.235 0.194 0.304 0.214 0.151 0.143 0.190 0.216 0.215 0.385 0.301 0.247 0.142 0.397 0.325 0.487 0.426 0.354 0.265 0.529 0.410 0.276 0.327 0.341 0.274 0.238 0.126 0.198 0.134 0.059 0.103 0.157 0.117 0.052 0.151 0.141 0.038 0.127 0.093 0.094 0.146 0.136 0.162 0.172 0.243 0.161 0.125 0.155 0.201 0.180 0.102 0.213 0.181 0.100 0.210 0.151 0.160 0.239 0.168 0.175 0.227 0.337 0.190 0.224 0.221 0.250 0.260 0.175 0.286 0.226 0.205 0.315 0.225 0.247 0.355 0.203 0.189 0.091 0.147 0.161 0.006 0.004 0.163 0.006 0.013 0.094 0.247 0.000 0.000 0.541 0.055 0.068 0.012 0.270 0.308 0.600 0.313 0.250 0.143 0.400 0.250 0.500 0.667 0.500 0.000 0.000 1.000 0.250 0.500 0.095 0.347 0.614 0.947 0.500 0.806 0.579 0.677 0.806 0.987 0.992 0.753 0.975 0.842 1.000 0.572 0.932 0.304 0.430 0.234 0.288 0.306 0.241 0.200 0.336 0.214 0.319 0.262 0.238 0.212 0.192 0.325 0.203 0.102 0.273 0.313 0.299 0.357 0.351 0.359 0.283 0.405 0.319 0.444 0.347 0.288 0.359 0.305 0.424 0.300 0.172 0.322 0.332 0.371 0.431 0.398 0.489 0.379 0.477 0.440 0.575 0.441 0.342 0.528 0.439 0.528 0.413 0.264 0.374 0.351 0.650 0.700 0.715 0.890 0.500 0.693 0.551 0.714 0.682 0.699 0.449 0.827 0.514 0.599 0.598 0.700 0.712 0.706 0.758 0.750 0.961 0.570 0.743 0.642 0.806 0.751 0.741 0.583 0.908 0.588 0.694 0.681 0.741 0.727 0.757 0.808 0.782 0.992 0.638 0.789 0.727 0.879 0.813 0.781 0.709 0.959 0.660 0.778 0.756 0.780 0.741 0.084 0.074 0.100 0.075 0.114 0.108 0.110 0.074 0.051 0.089 0.037 0.076 0.070 0.063 0.069 0.074 0.112 0.121 0.121 0.123 0.145 0.165 0.144 0.174 0.129 0.092 0.120 0.098 0.132 0.119 0.116 0.121 0.098 0.123 0.166 0.183 0.149 0.244 0.227 0.185 0.256 0.204 0.149 0.157 0.202 0.208 0.187 0.190 0.192 0.125 0.134 0.347 0.400 0.341 0.370 0.317 0.381 0.322 0.338 0.376 0.337 0.332 0.322 0.367 0.333 0.355 0.343 0.366 0.369 0.426 0.354 0.412 0.344 0.401 0.354 0.373 0.404 0.355 0.380 0.359 0.398 0.368 0.390 0.358 0.372 0.391 0.452 0.368 0.454 0.372 0.422 0.387 0.409 0.433 0.373 0.430 0.398 0.430 0.403 0.425 0.374 0.378

Blue indicates significantly lower ratio than state Red indicates signifcantly higher ratio than state
Source: Maine Cancer Registry (Maine CDC) 2005-2007, ODRVS Mortality 2007-2009

69

Wa

Lin

Fr

Pe

OneMaine Community Health Needs Assessment 2010 Table 11: Cancer Incidence & Mortality
An dr osc og gin Ar oo sto ok Cu mb erl an d Fr an kli n Ke nn eb ec Kn ox Pe no bs cot Pis cat aq uis Sa ga dh oc Ha nc ock Lin col n Ox for d So me rse t W ash ing ton Yo rk

W ald o

Indicator All Cancers, Incidence Rate Bladder, Incident Rate Female Breast Cancer, Incidence Rate Female Cervix Uteri, Incidence Rate Colorectal, Incidence Rate Lung and Bronchus Cancer, Incidence Rate Melanoma, Incidence Rate Male Prostate, Incidence Rate All Cancers, Mortality Rate Bladder, Mortality Rate Female Breast Cancer, Mortality Rate Female Cervix Uteri, Mortality Rate Colorectal, Mortality Rate Lung, Mortality Rate Melanoma, Mortality Rate Male Prostate, Mortality Rate

585 35 141 7.9 57 93 25 169 216 10.3 24 2.4 17 66 4.0 20

669 32 151 4.5 84 121 13 149 285 6.0 40 2.7 30 91 2.8 18

580 34 159 7.5 52 79 32 179 205 6.7 26 2.3 18 59 2.9 22

609 41 156 8.7 72 83 15 176 251 1.1 20 2.2 26 86 1.1 25

744 37 198 8.6 66 129 27 231 256 10.0 31 1.2 19 74 8.1 38

609 29 166 8.0 55 92 22 193 244 6.9 33 3.2 22 69 5.0 28

690 31 196 6.4 59 100 39 190 244 9.8 35 1.6 19 64 4.1 33

715 45 203 3.8 60 94 31 228 267 12.5 21 1.9 27 76 5.8 29

684 40 178 3.5 69 107 24 184 277 9.4 38 2.3 24 80 1.8 17

638 35 145 7.0 69 104 19 175 227 6.7 26 3.5 20 77 2.5 21

779 45 232 3.9 77 118 16 243 296 13.7 23 0.0 27 69 3.9 24

582 25 145 3.6 54 79 38 212 209 5.5 30 0.0 16 72 2.7 28

629 34 161 7.7 64 122 15 178 251 5.2 24 8.9 27 72 0.7 21

661 24 171 20.5 70 97 25 199 243 3.5 27 5.1 21 67 4.4 23

787 43 142 8.0 95 148 18 261 307 8.2 34 4.0 16 101 3.1 32

605 38 163 6.8 58 80 29 191 217 8.3 27 0.6 19 60 4.8 19

629 35 162 7.3 62 95 26 187 234 7.5 28 2.5 21 69 3.6 23

Source: Maine Cancer Registry (Maine CDC) 2005-2007, ODRVS Mortality 2007-2009, Population Data from US Census Bureau Estimates 2005-2007

Table 12: Cancer Staging Indicators

An dr osc og gin Ar oo sto ok Cu mb erl an d Fr an kli n Ke nn eb ec Kn ox Pe no bs cot Pis cat aq uis Sa ga dh oc W ash ing t on Yo rk

Ha nc ock

Lin col n

Ox for d

So me rse t

W ald o

Indicator % Stage Female Breast, Local % Stage Female Breast, Distant % Stage Cervix Uteri Female, Local % Stage Cervix Uteri Female, Distant % Stage Colorectal, Local % Stage Colorectal, Distant % Stage Lung and Brunchus Male, Local % Stage Lung and Brunchus Male, Distant % Stage Lung and Brunchus Female, Local % Stage Lung and Brunchus Female, Distant % Stage Prostate, Local % Stage Prostate, Distant

68% 4% 46% 15% 47% 18% 17% 55% 20% 50% 84% 5%

62% 4% 20% 0% 52% 14% 20% 48% 20% 46% 78% 4%

67% 3% 59% 3% 43% 19% 14% 51% 18% 42% 73% 4%

71% 10% 25% 25% 41% 14% 15% 51% 30% 52% 74% 1%

67% 4% 43% 29% 48% 13% 30% 40% 28% 37% 79% 6%

65% 3% 33% 27% 46% 19% 13% 48% 18% 54% 75% 6%

66% 6% 50% 25% 50% 17% 12% 53% 23% 47% 81% 4%

65% 3% 50% 0% 41% 22% 5% 57% 11% 50% 77% 3%

67% 3% 100% 0% 28% 36% 16% 51% 18% 58% 84% 1%

63% 2% 56% 19% 51% 18% 22% 48% 22% 44% 68% 3%

72% 5% 100% 0% 42% 20% 21% 42% 19% 52% 61% 5%

67% 7% 50% 50% 41% 15% 8% 50% 24% 43% 78% 4%

63% 3% 0% 17% 45% 15% 17% 48% 26% 43% 78% 4%

64% 6% 42% 17% 41% 22% 24% 32% 19% 50% 85% 3%

69% 4% 100% 0% 54% 15% 12% 54% 20% 49% 77% 4%

63% 5% 71% 10% 45% 16% 9% 58% 21% 49% 79% 3%

66% 4% 52% 14% 47% 17% 16% 50% 21% 47% 76% 4%

Source: Maine Cancer Registry (Maine CDC) 2005-2007

Table 13: Cancer Screening Indicators

An dr osc ogg in Ar oo sto ok nd Wa shi ng ton Yo rk Pe no bsc ot Pi s cat aq uis Sa gad ho c

Cu mb erl a

eb ec

So me rse t

Fr an k li n

Ha nco ck

Lin col n

Ox for d

Indicator % Diagnosed Cancer (Age 18+) % Reported Mammogram past year (40+) % Reported Pap Smear past 2 years % Reported Blood Stool Test Past Year (Age 50+) % Reported Having Sigmoid/Colonoscopy Past 5 Yrs (Age 50+) % Reported Prostate Exam (PSA test) past 2 yrs (males Age 50+) % Reported Digital Rectal Exam past 2 years (males Age 50+)

6% 69% 67% 23% 67% 65% 71%

8% 73% 72% 15% 57% 68% 65%

6% 69% 70% 17% 69% 75% 73%

8% 74% 72% 25% 59% 60% 57%

9% 68% 72% 25% 56% 64% 71%

8% 72% 77% 20% 68% 77% 67%

10% 66% 69% 23% 60% 68% 63%

10% 71% 72% 20% 63% 65% 75%

9% 70% 68% 27% 61% 72% 66%

6% 67% 68% 22% 59% 62% 63%

8% 69% 75% 23% 58% 63% 65%

8% 65% 72% 19% 67% 69% 69%

10% 60% 64% 21% 51% 55% 53%

9% 68% 73% 20% 56% 68% 68%

8% 68% 69% 22% 58% 65% 65%

7% 68% 70% 18% 66% 75% 69%

7% 69% 70% 20% 63% 69% 68%

Source: 2010 OneMaine CHNA Household Survey (except Blood Stool Test from BRFSS 2006 & 2008 combined)

70

Ma in e

Ke nn

W ald

Kn ox

Ma in

Ma ine

OneMaine Community Health Needs Assessment 2010 Figure 21: Cancer Incidence and Mortality Rates
900 800
Rate per 100,000 population

744 669 585 580 609 609 690

779 715 684 638 582 629 661

787

700 600 500 400 300 216 200 100 0

605

629

285 205

251

256

244

244

267

277 227

296 251 209 243

307 217 234

All Cancers, Incidence Rate

All Cancers, Mortality Rate

Source: Maine Cancer Registry (Maine CDC) 2005-2007, ODRVS Mortality 2007-2009, Population Data from US Census Bureau Estimates 20052007

Figure 22: Cancer Screening by County

100% 90% 80%

Percentage Screened

70% 60% 50% 40% 30% 20% 10% 0%

% Reported Mammogram past year (40+) % Reported Having Sigmoid/Colonoscopy Past 5 Yrs (Age 50+) % Reported Digital Rectal Exam past 2 years (males Age 50+)

% Reported Pap Smear past 2 years % Reported Prostate Exam (PSA test) past 2 yrs (males Age 50+)

Source: 2010 OneMaine CHNA Household Survey

71

OneMaine Community Health Needs Assessment 2010

REPRODUCTIVE HEALTH

FINDINGS: Overall, reproductive health status among women in Maine is favorable. However, several counties show patterns of less favorable reproductive health behaviors and outcomes. Further research is needed to determine if there is adequate access to preventive and prenatal services in these regions. Birth outcomes for Maine are generally better than for the U.S., and exceed HP2020 targets for the nation. Maines overall infant mortality rate is lower than U.S. rates and the HP2020 target. Somerset County has the highest infant mortality rate at 8.3 per 1000 live births, and the highest post-neonatal mortality rate (4.5 per 1000 live births), both exceeding the state rates. Androscoggin, Lincoln, and Kennebec counties also have infant mortality rates that appear elevated compared to the state rate. Waldo, Kennebec and York counties have the highest neonatal mortality rates (deaths within 1st month of life). Teen birth rates are highest in Androscoggin, Franklin, Piscataquis, Somerset, and Waldo counties, although all of these county rates are lower than the U.S. teen birth rate. High risk hospital admissions are elevated in Androscoggin, Piscataquis, and Somerset counties compared to the state as a whole. Piscataquis and Somerset counties also have a lower percentage of mothers receiving adequate prenatal care compared to the state. Both low birth weight and prematurity are elevated in Lincoln County.

Teen Birth Rates: Teens birth rates are a key indicator of the reproductive health of a community because adolescents who become pregnant are less likely to obtain adequate prenatal care, are more likely to have adverse pregnancy outcomes, and are more likely to raise their children in poverty. Overall, Maine has a much lower teen birth rate (4.1) compared to the U.S. (8.9), but several counties, including Androscoggin, Franklin, Piscataquis, Somerset, and Waldo are elevated compared to the state. Lincoln, Sagadahoc, and York counties have the lowest teen birth rates. High Risk Hospital Admissions: High risk pregnancy hospital admissions were elevated in Androscoggin, Piscataquis, and Somerset counties compared to other regions and the state as a whole. Knox, Lincoln, and York counties had a relatively low rate of high risk hospital admissions compared to the state. Prenatal Care: An important measure of prenatal care is the adequacy of prenatal care, as measured by the Kessner Index. The Kessner Index is based on the number of prenatal care visits that a woman receives in relation to the duration of her pregnancy and the age of the fetus at the time of the first visit. It classifies prenatal care as being adequate, intermediate, or inadequate (See Appendix 8 for a complete explanation of the Kessner Index). Approximately 91% of women in Maine receive adequate prenatal care (as measured by the Kessner Index). This result did not vary much between counties, although Piscataquis and Somerset counties had the lowest adequate prenatal care rates with 86% and 84%, respectively. These two counties also had the highest high risk pregnancy hospital admission rates and elevated teen birth rates compared to the state, suggesting a need for further exploration of access to prenatal care, particularly among young mothers.
72

OneMaine Community Health Needs Assessment 2010

Low Birth Weight and Infant Mortality: The Healthy People 2020 objective for the percent of low birth weight babies (less than 2500 grams) born is 7.8%, representing a 5.0% improvement from the 2007 U.S. Baseline of 8.2%. Maine has a relatively low percentage of babies born with low birth weight (6.4%) compared to the U.S; however, the rate of low birth weight babies was greater than 7.0% in Lincoln and Piscataquis counties, and almost 8.0% in Waldo County. The percentage of babies born prematurely (less than 37 weeks) was relatively low for the state (8.7%) compared to the U.S. (13%). However, in Lincoln, Penobscot, and Somerset counties the rate of premature babies was slightly elevated at about 10%. Infant mortality rate was highest in Somerset County (8.3 per 1,000 births), 1.5 times above the state rate (5.5 per 1,000 births), and 1.2 times higher than the U.S. rate (6.7 per 1,000 births). This finding for Somerset County appears to be driven by a high post-neonatal mortality rate (4.5 per 1000 births) that is more than twice the states rate. Lincoln, Androscoggin, and Kennebec counties also have higher infant mortality rates than the state, although they are below the U.S. rate. Neonatal mortality rates were elevated in Waldo and Kennebec counties compared to the state and the U.S. These infant mortality rates are based on very few deaths, so caution is advised in interpretation of the findings. Despite this county variation, infant mortality in Maine is lower than both the U.S. rate and the Healthy People 2020 targets. Overall reproductive health among women in Maine was generally favorable. However, the patterns in counties exhibiting higher teen birth rates accompanied by elevated high risk hospital admissions and low rates of adequate prenatal care warrants further exploration. Table 14: Measures of Reproductive Health by County compared to Maine and US
An dr osc og gin Ar oo sto ok Cu mb erl an d Fr an kli n Pis cat aq uis Sa ga da ho c Ke nn eb ec So me rse t Pe no bs co Ha nc ock W ald o W ash ing to Lin col n Ox for d t n Yo rk Ma ine Kn ox

Teen Birth Rate Per 1,000 Females (10-17yrs) High Risk Pg, Hospital Admission Rate Per 100,000 Females (10-44 yrs) C-Section Rate Per 100 births % Adequate Prenatal Care (of live births)

6.9

4.2

3.4

6.1

4.2

5.1

2.2

3.3

3.3

6.2

2.7

6.2

6.7

5.3

2.8

4.1

8.9

499

423

349

383

325

377

238

264

477

294

500

431

501

343

373

275

360

NA

33

32

30

32

27

29

30

29

30

30

26

28

33

33

31

29

30

32

93%

91%

89%

89%

91%

90%

94%

92%

92%

91%

86%

94%

84%

90%

87%

92%

91%

NA

% Low Birthweight (<2500 grams) 6.4% % Prematurity (< 37 weeks) Infant Mortality Rate per 1,000 live births

5.6%

6.4%

7.0%

6.0%

6.2%

4.9%

7.5%

6.1%

6.8%

7.5%

5.8%

8.6%

7.8%

5.9%

6.3%

6.4%

8.2%

8.3%

7.1%

8.9%

8.8%

7.3%

8.2%

7.0%

9.7%

8.2% 10.0% 9.4%

8.0% 10.0% 8.5%

7.7%

9.3%

8.7%

13%

6.2

4.2

5.7

6.1

5.9

6.6

4.2

5.2

4.3

8.3

5.8

5.8

5.5

6.7

Source: ORDVS Births 2007-2009, MHDO Hospital Discharge Dataset Q42007 Q32009, ORDVS Mortality 2007-2009 * Rates based on less than 5 occurrences omitte

73

US

OneMaine Community Health Needs Assessment 2010

MENTAL HEALTH

Findings: Mental health (MH) problems, treatment admissions, and outcomes (i.e. suicide mortality) rates vary substantially across Maines 16 counties. Mental health related admissions are not always positively correlated with risk factors and prevalence rates, suggesting that factors such as the availability of services, stigma, etc., may influence the receipt of treatment. Higher emergency department (ED) utilization for MH-related conditions may indicate access barriers to inpatient, ambulatory, and/or crisis services. Aroostook, Kennebec, Oxford, Penobscot, Somerset, Waldo, and Washington Counties exhibited higher patterns of risk for mental health problems. Franklin, Kennebec, and York Counties had higher patterns of mental health prevalence on at least two or more prevalence indicators. Androscoggin, Kennebec, Knox, Penobscot, and Waldo Counties exhibited consistently high patterns of hospital admission use for a range of mental health conditions. Androscoggin, Cumberland, Lincoln, Penobscot, and Somerset Counties had high patterns of emergency department use for mental health conditions. Overall, Maine appears to have higher rates of suicide mortality (14 per 100,000) than the U.S. as a whole (11.3 per 100,000). Aroostook, Cumberland, Franklin, Knox, Lincoln, Oxford, Piscataquis, Waldo, and York Counties exhibit higher rates of suicide mortality than the remaining Maine counties and the state as a whole.

Introduction Mental health, according to the World Health Organization (WHO), is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.40 Mental disorders are common in the U.S., with more than one in four (26.2%) adults suffering from a diagnosable mental disorder in a given year.41 Although the burden of illness is concentrated among 1 in 17 (6%) adult Americans who suffer from a serious mental illness, one should not ignore the fact that mental disorders are widespread in the general population. Forty five percent of those with a diagnosed mental disorder suffer from two or more disorders; co-occurring mental health and substance abuse disorders are common among this population. According to the National Institute of Mental Health (NIMH), mental disorders are among the leading causes of disability in the U.S. Mental disorders are as common as, if not more common than cancer, diabetes, and heart disease, and are frequently associated with poorer physical health and higher medical utilization.42,43 Among children and young adults (10 to 24 years of age), suicide is the third leading cause of death and the tenth leading cause of death overall. The annual indirect costs of mental illness are estimated to be more than $79 billion, a large part of which reflects lost productivity. Although it is clear that treatment works, it has been estimated that close to two-thirds of

40

Nordqvist, C. (2009, June 18). What is Mental Health? What is Mental Disorder? Medical News Today. Available: http://www.medicalnewstoday.com/articles/154543.php. [2011, January 9]. 41 National Institute of Mental Health. (N.D.). The Numbers Count: Mental Disorders in America. Available: http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml. [2011, January 9]. 42 National Alliance on Mental Illness. (N.D.) Mental Illness: FACTS AND NUMBERS. Available: http://www.nami.org/Template.cfm?Section=About_Mental_Illness&Template=/ContentManagement/ContentDisplay.cfm&C ontentID=53155. [2011, January 9]. 43 ASHA International. (N.D.). Startling Statistics About Mental Illness. Available: http://www.myasha.org/node/12. [2011, January 9].
74

OneMaine Community Health Needs Assessment 2010 those with a diagnosable mental disorder do not seek treatment. The reasons for this include stigma, lack of awareness of available treatment options, lack of access to services, and the affordability of care. Mental Health Burden and Risk Factors Our analysis contains three primary risk factors for mental health problems: the percentage of individuals within the overall population: (1) with poor mental health for 11 or more days in the last 30 days for the overall population; (2) needing but not getting mental health treatment in the past 12 months; and (3) at risk for mental health problems based on a five item version of the Mental Health Inventory (MHI-5).44,45 Seven counties (Aroostook, Kennebec, Oxford, Penobscot, Somerset, Waldo, and Washington) stood out with high patterns of mental health risk factors (i.e., two or more of the three risk factors described above. Somerset, Oxford, and Aroostook Counties exceeded the state rates for all three indicators (Table 15). Kennebec, Penobscot, Waldo, and Washington counties exceeded the state rate for two indicators of mental health risk. For those respondents who reported 11 or more days in the past 30 days in which their mental health was not good, Oxford (14.3%), Somerset (14.1%), and Aroostook (12.0%) counties exceeded the state rate of 10.6% by the greatest margins (Figure 23). Among 18 to 44 year olds, Piscataquis (18.8%), Somerset (16.3%), and Oxford (15.1%) counties exceeded the state rate of 11.7% by the greatest amounts (Figure 24). For 45 to 64 year olds, Oxford (17.4%), Kennebec (15.1%), and Somerset (13.7%) counties exceeded the state rate of 11.6% by the greatest margins. For those 65 and older, Somerset (8.7%) and Waldo (7.6%) counties had the two highest rates with Androscoggin (6.9%), Penobscot (6.9%), and Sagadahoc (6.8%) counties tying for the third highest rate of individuals reporting 11 or more days of poor mental health. Aroostook (6.6%), Kennebec (6.5%), and Oxford (6.0%) counties posted the highest rates in the state for individuals who needed, but did not get, mental health treatment in the last 12 months and exceeded the state rate of 4.8% by the greatest amounts (Figure 23). Oxford (11.9%), Washington (10.0%), and Somerset (9.5%) counties had the highest rates of individuals at risk for mental health problems (including depression, general affective disorders, and anxiety disorders based on MHI-5) (compared to the state rate of 7.2%) followed closely by Franklin (9.2%), Waldo (8.7%), and Penobscot (8.1%) counties.

The MHI-5, also known as the emotional wellbeing scale, is an abbreviated version of the full, 18 item Mental Health Inventory (MHI-18) developed by the Rand Corporation for the Medical Outcomes Study. It has also been incorporated in to the SF-36 short form health survey. Its validity and reliability have been well documented in numerous studies. The MHI-5 was calculated from five questions asked in our household survey in which respondents were asked to report the amount of time during the past month that they: 1) were a nervous person; 2) felt calm and peaceful; 3) felt downhearted and blue; 4) were a happy person; and 5) felt so down in the dumps that nothing could cheer them. 45 Berwick, D., Murphy, J., Goldman, P., Ware, J., Barsky, A. and Weinstein, M. (1991). Perfomance of a five-item mental health screening test, Medical Care 29(2): 169-76.
75

44

OneMaine Community Health Needs Assessment 2010 Mental Health Prevalence For this assessment, five measures were selected to assess the prevalence of mental health problems. These measures including the percentage of individuals: Receiving outpatient mental health treatment in past 12 months; Ever diagnosed with depression (age 18+); Currently diagnosed with depression (age 18+); Ever diagnose with Other psychiatric disorder (age 18+); and Diagnosed with developmental delays/learning disabilities (ages 0-17).

In the United States, depression and other mental health disorders are major causes of illness and death. They are also associated with increased levels of disability, reduced quality of life, and lower levels of social functioning. Based on the results of the 2009 National Survey on Drug Use and Health, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that 19.9% of adults (18 and older) had a mental disorder (excluding developmental and substance abuse disorders) in the past year, of sufficient duration to meet diagnostic criteria specified within the DSM-IV. 46 The Centers for Disease Control and Prevention (CDC) found that in 2006, 15.7% of people had been told by a health care provider that they had depression at some time in their life.47 Using data from the 2006 and 2008 optional depression modules, the CDC found that 9.0% of the population had a current diagnosis of depression.48 Using data from the National Survey of Childrens Health, Altarac and Saroha found that the lifetime prevalence of learning disability among U.S. children (under age 18) was 9.7%.49 Franklin, Kennebec, and York counties exceeded the state rate for at least two of the five prevalence measures (Figure 25). Franklin County exceeded the state rates for those ever diagnosed with other psychiatric disorders, at 15.4% (compared to the state rate of 13.1%), and for those diagnosed with developmental delays/learning disabilities, at 6.0% (compared to the state rate of 4.5%). At 13.6%, Kennebec County exceeded the state rate (11.4%) for those who received outpatient mental health treatment in the last 12 months, and at 16.7%, those with a current diagnosis of depression (state rate of 14.9%). At 18.0% and 5.5%, York exceeded the state rates for those with a current diagnosis of depression (14.9%) and those with developmental delays/learning disabilities (state rate of 4.5%) respectively. Although there were no clear patterns across all five indicators of prevalence, there were interesting patterns within each of the indicators. Kennebec (13.6%), Oxford (13.2%), and Sagadahoc (16.9%), counties exceeded the state rate (11.4%) by the greatest margins for those who received outpatient mental health treatment in the past 12 months. Kennebec (23.8%), Sagadahoc (23.4%), and York (24.1%) counties exceeded the state rate of 22.1% by the greatest amounts for those that had ever received a diagnosis of depression. For those with a current diagnosis of depression, Kennebec (16.7%), Waldo (17.2%), and York (18.0%) counties exceeded the state rate of 14.9% by the greatest margins. Aroostook (14.3%), Franklin (16.7%), and Kennebec (14.4%), had the highest rates of those diagnosed with other
46

Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on Drug Use and Health: Mental Health Findings (Office of Applied Studies, NSDUH Series H-39, HHS Publication No. SMA 10-4609). Rockville, MD. 47 Centers for Disease Control and Prevention. (N.D.). Anxiety and Depression. Available: http://www.cdc.gov/features/dsBRFSSDepressionAnxiety/. [January 11, 2011]. 48 Centers for Disease Control and Prevention. (2010, October 1). Current Depression Among Adults: United States, 2006 and 2008. Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5938a2.htm. [January 11, 2011]. 49 Altarac, M. and Saroha, E. (2007, February). Lifetime Prevalence of Learning Disability Among US Children. Pediatrics 119(1), pp. s77-84.
76

OneMaine Community Health Needs Assessment 2010 psychiatric disorders (state rate of 13.1%). Kennebec (9.0%), Piscataquis (9.1%), and Washington (12.8%) counties substantially exceeded the state rate of 4.5%) for those reporting a child (0-17) in household ever diagnosed with a developmental delay or learning disability. Mental Health Service Utilization Rates Inpatient Utilization Rates Androscoggin, Kennebec, Knox, Penobscot, and Waldo counties all exhibit high patterns of inpatient service utilization for a wide range of the inpatient indicators contained in the HSP (Table 16). Penobscot County exceeded the state rates for hospital admission rates (overall and for a number of age groups) for psychoses, senility and organic mental disorders, bipolar disorders, schizophrenia, and anxiety. Androscoggin County exceeded the state admission rates (both overall and by all age groups) for psychoses, major depressive disorders, and bipolar disorders. It also exceeded the state hospital admissions rates for anxiety among those aged 0-17. Kennebec County had higher admission rates than the state for psychoses, bipolar disorders, schizophrenia, and anxiety. Knox County showed high admission rates for psychoses, major depressive disorders, schizophrenia, and anxiety. Waldo County had high patterns of admissions for psychoses for those age 0-17, major depressive disorders, bipolar disorders for those age 18-64 and 65 and older, and anxiety for all but those age 65 and above. These admission patterns are rather difficult to interpret, as they do not always align with county level risk factors and prevalence rates. Higher admission patterns can suggest access barriers to ambulatory, outpatient and other less intensive services or a failure to access treatment until the individuals level of acuity levels has risen to a more critical stage. These patterns suggest that these rates need to be viewed within the context of the service systems in these counties, and potential barriers to access to less intensive treatment modalities. Emergency Department Utilization While emergency departments (EDs) are often used in crisis situations by individuals with mental health disorders, most mental health experts would agree that it is not the ideal source of care for these individuals. High use of EDs for routine and crisis mental health disorders may suggest access difficulties and/or other barriers to inpatient, outpatient, and crisis stabilization care. As such, counties with high ED usage for mental health disorders should explore the specific reasons for these high utilization rates. Androscoggin, Penobscot, and Somerset counties stand out for high patterns of ED use across the five conditions reported in the HSP (Table 17). Androscoggin and Somerset counties each had higher ED utilization rates than the state rates for four of the five conditions, and Penobscot County exceeded state rates for three of the five conditions. Cumberland County exceeded the state rates for two conditions, while Aroostook, Hancock, Kennebec, Oxford, Piscataquis, and Waldo counties exceeded the state rates of ED use for one of the five conditions. The remaining counties exhibited ED use patterns at or below state rates for ED use for all five conditions. For those with senility and organic mental disorders, the state rate per 100,000 population was 28. Piscataquis (41), Hancock (40), Somerset (39), Kennebec (38), Oxford, (37) Androscoggin (34), and Aroostook (32) counties exceeded the state rate by the greatest margin. For those with a major depressive disorder, the state ED utilization rate was 109 per 100,000. Cumberland (179), Waldo (140), Somerset (129), and Androscoggin (127) counties exceeded the state rate by the greatest amount. For bipolar disorders, the statewide ED utilization rate was 166 per 100,000. Androscoggin (277), Penobscot (265), and Somerset (189) counties exceeded the state rate by the greatest amount. For schizophrenia, the state ED utilization rate was 70 per 100,000. Penobscot (112) and Cumberland (101) counties exceeded the state rate by the greatest margin. For anxiety disorders, the state ED utilization rate was 1,618 per
77

OneMaine Community Health Needs Assessment 2010 100,000. Androscoggin (2,132), Penobscot (1,956), and Somerset (1,854) counties exceeded the state rate by the greatest amount for all counties. Mental Health Outcomes Suicide Mortality Suicide is a significant and preventable public health problem. Suicide was the tenth leading cause of death in the United States in 2007, with an overall suicide death rate of 11.3 per 100,000 population.50 Almost four times as many men die from suicide than women. Suicide was the seventh leading cause of death for males and the fifteenth leading cause of death for females. Firearms, suffocation, and poison are the most common methods of suicide, with firearms the most commonly used method among men, and poison the most commonly used method among women. Suicide rates are highest among people age 65 and older, at 14.3 per 100,000, and among young adults (20-24) at 12.7 per 100,000. Rates of suicide in several Maine counties are higher than the state rate of 14 per 100,000 population (Table 18). Piscataquis County had the highest rate in the state at 24 per 100,000, followed by Knox County at 19, Aroostook, Lincoln, and Waldo counties at 18 each, and Franklin County at 16. Among males, the state rate was 23 per 100,000. Piscataquis (36), Lincoln (35), Waldo (32), Aroostook (32), and Knox (30) counties exceeded the state rate by the greatest amounts. Among females, the state rate was 5.4 per 100,000 with Piscataquis (12), Knox (8.1), York (7.1), Oxford (6.9), Cumberland (6.6) and Franklin (6.5) counties exceeding the state rate by the greatest amounts.

50

National Institutes of Mental Health (N.D.) Suicide in the US: Statistics and Prevention. Available: http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml. [January 11, 2011].
78

OneMaine Community Health Needs Assessment 2010 Table 15: Mental Health Risk Factors for Select Maine Counties
Aroostook % 11+ Days MH Not Good Ages 18-44 Ages 45-64 Ages 65+ % needed, but did not get, MH treatment in past 12 months % Adults At Risk for MH Problems (MHI-5) 12.0% 14.7% 11.5% 4.7% 6.6% Kennebec 10.8% 9.4% 15.1% 5.1% 6.5% Oxford 14.3% 15.1% 17.4% 5.2% 6.0% Penobscot 10.0% 9.8% 11.8% 6.9% 5.2% Somerset 14.1% 16.3% 13.7% 8.7% 5.5% Waldo 11.7% 12.9% 12.0% 7.6% 2.7% Washington 11.6% 13.6% 12.3% 6.3% 4.2% Maine 10.6% 11.7% 11.6% 6.1% 4.8%

8.9%

6.8%

11.9%

8.1%

9.5%

8.7%

10.0%

7.2%

Source: BRFSS 2008 & 2009 combined, 2010 OneMaine CHNA Household Survey

Table 16: Inpatient Utilization Rates for Select Counties

Androscoggin Psychoses Hospital Admission Rate Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+ Senility and Organic Mental Disorders, Hospital Admission Rate Ages 65+ Major Depressive Disorder, Hospital Admission Rate Ages 0-17 Ages 18-64 Ages 65+ Bipolar Disorder, Hospital Admission Rate Ages 0-17 Ages 18-64 Ages 65+ Schizophrenia, Hospital Admission Rate Ages 18-64 Ages 65+ Anxiety, Hospital Admission Rate Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+ 911 980 1,184 756 409 7.0 Kennebec 703 527 988 734 256 7.0 Knox 689 372 1,195 606 319 7.3 Penobscot 785 692 989 843 262 14 Waldo 610 776 802 471 269 6.5 Maine 578 484 801 559 246 8.6

42 210

44 151

40 302

78 154

26 193

50 157

132 256 126 599 804 613 222 81 112 19 247 369 523 176 42

51 202 74 329 439 352 82 194 273 74 411 220 1,139 522 71

82 424 120 230 277 247 120 142 202 67 356 246 1,066 448 76

65 200 73 366 525 376 92 216 293 61 365 244 949 523 89

101 246 95 278 618 203 130 106 146 8.7 310 303 732 404 57

85 196 93 280 353 302 88 114 155 39 269 213 662 342 70

Source: MHDO Hospital Discharge Dataset Q42007-Q32009 All rates per 100,000

79

OneMaine Community Health Needs Assessment 2010 Table 17: Emergency Department Utilization for Select Counties
Androscoggin Cumberland Lincoln Penobscot Somerset Maine

Senility and Organic Mental Disorders Major Depressive Disorder Bipolar Disorder Schizophrenia Anxiety Disorder

34 129 277 70 2,132

27 179 169 101 1,511

24 69 154 36 1,224

27 80 265 112 1,956

39 127 189 18 1,854

28 109 166 70 1,618

Source: MHDO ED Discharge Dataset 2007- 2008 All rates per 100,000.

Table 18: Suicide Mortality Rates Per 100,000 Population for Select Counties
Aroostook Overall Males Female 18 32 3.6 Cumberland 13 20 6.6 Franklin 16 25 6.5 Knox 19 30 8.1 Lincoln 18 35 1.9 Oxford 14 20 6.9 Piscataquis 24 36 12 Waldo 18 32 5.1 York 15 23 7.1 Maine 14 23 5.4

Source: ORDVS 2007-2009

80

OneMaine Community Health Needs Assessment 2010 Figure 23: Mental Health Risk Factors - County Differences from State
-0.4%

Androscoggin
-0.8%

0.1% 1.4%

Aroostook
-0.6%

1.7% 1.8%

Cumberland
-2.2%

-1.3% -2.1%

Franklin

-0.9% 2.0% -1.3%

Hancock

-1.3% -1.5% 0.2%

% 11+ Days Mental Health Not Good

1.7%

Kennebec
-0.4% -0.3%

Knox

-0.2% 0.5% 0.2%

% needed, but did not get, mental health treatment in past 12 months % At Risk for Clinical Depression Based on MHI5 (18+)

Lincoln

-0.8% -1.3% 3.7%

Oxford
-0.6%

1.2% 4.7%

Penobscot

0.4% 0.9% 2.6%

Piscataquis

-1.9% -0.5% -0.7%

Sagadhoc

-1.0% -0.4% 3.5%

Somerset

0.7% 2.4% 1.1%

Waldo

-2.1% 1.5% 1.0%

Washington

-0.7% 2.9% -1.0%

York

0.6% 0.1%

Source: BRFSS 2008 & 2009 combined, 2010 OneMaine CHNA Household Survey Central Axis is Maine percentage: 11 or more days in past 30 days mental health was not good= 10.6% Needed, but not getting mental health treatment in the past 12 months= 4.8% At risk for mental health problems based on the MHI-5= 7.2%

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OneMaine Community Health Needs Assessment 2010 Figure 24: Percentage with 11 + Days Mental Health Not Good by Age County Differences from State
-1.5%

Androscoggin

0.2% 0.8% 3.0%

Aroostook
-1.3%

-0.1% 0.3%

Ages 18-44

Ages 45-64

Cumberland

-2.0% 0.3% -0.8%

Ages 65+

Franklin

-3.1% -3.2% 2.7%

Hancock

-5.2% -1.5% -2.3%

Kennebec
-0.9% -0.8%

3.5%

Knox
-0.2%

0.5% 2.2%

Lincoln

-0.3% -0.4% 3.4%

Oxford
-0.9% -2.0%

5.8%

Penobscot

0.2% 0.9% 7.1%

Piscataquis
-1.0% -0.4%

0.4%

Sagadhoc

-1.7% 0.7% 4.5%

Somerset
1.2%

2.0% 2.6%

Waldo

0.4% 1.5% 1.9%

Washington
-2.2%

0.7% 0.3%

York

-0.4% 0.7%

Source: BRFSS 2008 & 2009 combined Central Axis is Maine percentage: The state percentage for 18 to 44 year olds, 45 to 64 year olds, and those 65 and above was 11.7%, 11.6%, and 6.1% respectively.

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OneMaine Community Health Needs Assessment 2010 Figure 25: Mental Health Prevalence - County Differences from State

Androscoggin Aroostook Cumberland

-2.7% -1.2% -0.4% -1.9% -1.6% -2.0% -0.5% -1.2% -0.1% -1.0% -0.1% -0.7% -0.8% -0.8% 0.3% 0.4% 0.5% 0.0% 0.3% 1.2%

1.2%

Franklin Hancock Kennebec Knox Lincoln Oxford

-2.9% -2.7%

1.5%

2.3%

-1.8% -0.9% -2.6% -1.7% -1.1% -2.5% -1.6% -1.0% -0.4% -0.1% -1.4% -1.0% -1.8% -1.8%

2.2% 1.7% 1.3% 1.8%

0.1% 0.2% 0.8%

1.8%

% receiving outpatient mental health treatment in past 12 mos % Diagnosed Depression (ever, 18+) % Diagnosed Other Psychiatric Disorder (ever, 18+) % Developmental Delay/Learning Disability (Ages 0-17) % Current Depression (18+)

Penobscot Piscataquis Sagadhoc Somerset Waldo Washington York

-0.9% -0.9% -0.6% -0.8%

-2.4%

0.0%

-1.2% -1.5% -1.6% -0.6% -2.2% -0.7% -0.2% -1.8%

1.3% 0.3% 0.6% 1.0% 0.3% 0.1% 2.3% 0.4% 0.8% 0.9% 0.8% 2.1% 0.2% 1.0%

3.1%

Source: 2010 OneMaine CHNA Household Survey Central Axis is Maine percentage: The state percentage for those receiving mental health treatment in the past 12 months was 11.4%; ever diagnosed with depression was 22.1%; currently diagnosed with depression was 14.9%; ever diagnosed with other psychiatric disorders was 13.1%; and diagnosed with a developmental delay/learning disability was 4.5%.

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OneMaine Community Health Needs Assessment 2010

SUBSTANCE ABUSE

Findings: Substance abuse (SA) problems, treatment admissions, and substance abuse related mortality rates vary substantially across Maine counties. Alcohol and drug related admissions are not always associated with prevalence rates, suggesting that availability of services, willingness of providers to screen for SA problems, stigma, etc., may influence treatment. Higher emergency department (ED) rates for SArelated conditions may indicate access barriers to inpatient, ambulatory, and/or crisis services. Counties with lower inpatient and ED admission rates typically exhibit higher mortality rates for SA-related problems. Cumberland, Knox, Lincoln, Oxford, Somerset, and Washington counties exhibit higher patterns of substance abuse prevalence across the twelve measures of prevalence selected for the CHNA. Patterns of hospital admission and ED use for substance-related problems suggest that factors other than prevalence influence service utilization, including factors such as service availability and proximity, provider practice in terms of screening for SA problems, rates of health insurance enrollment coverage, and levels of coverage of substance abuse benefits. Aroostook, Franklin, Lincoln, Oxford, Piscataquis, Somerset, and Washington counties exhibit consistently higher rates of substance-related mortality compared to the remaining Maine counties and the state rate. Higher rates of substance-related mortality appear to be positively correlated with lower rates of hospital and ED admissions.

Introduction This section discusses issues related to substance abuse (SA) for Maine residents age 18 and older. It includes a discussion of: Prevalence rates for problem drinking (e.g., chronic heavy or binge drinking within the past month), current SA problems, overdoses, use of street (e.g., illicit) drugs, and prescription drug abuse; Hospital and emergency department admissions for alcohol and drugs; and Mortality rates for alcohol related issues, alcohol liver disease, and motor vehicle accidents.

National and State Context Substance Abuse is a significant public health issue, nationally and in Maine. The National Institutes of Health (NIH) has ranked alcohol and drug disorders second and seventh, respectively, among estimated costs of illness for 33 diseases and conditions.51 The Maine Office of Substance Abuse estimated that substance abuse costs in Maine totaled $898.40 million in 2005 (or $682 for every resident of the state).52 Maines drug- and alcohol-related costs during this time were $214.4 million (or $163 per resident). The total cost of providing treatment for alcohol and drug conditions in 2005 totaled $25.2 million, based on reported annual revenues.

51 Maine Substance Abuse Services Commission. (2010). 2010 Report card on Maine substance abuse services. Available: http://www.maine.gov/dhhs/osa/about/2010SASCReportCard.pdf. Downloaded: December 17, 2010. 52 Maine Office of Substance Abuse. (2007, December). The cost of alcohol and drug abuse in Maine, 2005. Augusta, ME: Maine Office of Substance Abuse, Department of Health and Human Services.
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OneMaine Community Health Needs Assessment 2010 Nationally and in Maine, alcohol is the most commonly used substance. In 2009, 58% of adult (age 18 and older) Maine residents had at least one drink of alcohol within the past 30 days, compared to 54% of all Americans.53 Fifteen percent of adult Maine residents participated in binge drinking (i.e., having five or more drinks (males) or four or more drinks (females) on one occasion in the past 30 days) in 2009, compared to 16% nationally. During the same time period, 6.0% of adult Maine residents participated in heavy drinking (i.e., consuming an average of more than two drinks per day (males) or more than one drink per day (females) - typically measured within a 30 day period - compared to 5.0% of adult Americans. Based on data collected by the 2009 National Survey on Drug Use and Health, almost 9% of Americans age 12 or older reported current (i.e., within the past month) use of illicit drugs.54 Marijuana is the most commonly used drug by 77% of current illicit drug users, and the only drug used by 58% of them. Almost 3.0% of Americans reported the nonmedical use of prescription-type psychotherapeutics (this includes the nonmedical use of pain relievers, tranquilizers, stimulants, or sedatives) within the past 30 days. Prevalence of Substance Abuse across Maine Counties The prevalence of substance abuse among adult (18 and over) Maine residents was assessed by examining rates of CDC-defined chronic heavy drinking and binge drinking, rates of individuals diagnosed at some time in their lives with a substance abuse problem as well as those with a current substance abuse problem, rates of overdoses in the last 12 months, rates of current (i.e., within the past 30 days) street/illicit drug use, and rates of current prescription drugs for non-prescription purposes. Given the relatively small numbers of individuals who are substance abusers (i.e., individuals who have been diagnosed with substance abuse problems, participated in problem drinking behavior such as chronic heavy or binge drinking, overdosed in the last 12 months or used illicit drugs, including the nonprescription use of prescription drugs; it is difficult to interpret small differences in the prevalence rates across counties and in comparison to the state. To examine patterns in the data across counties, a 10% confidence interval around the state rate for all indicators was established, and counties were identified that fell above or below that interval. The counties exhibited a wide variance in prevalence of substance abuse across the twelve measures selected for the Statewide Community Health Needs Assessment (CHNA). These variances will be discussed in the following sections as well as identification of the six Maine counties with high patterns of substance abuse. Based on the twelve measures of substance abuse, six counties stand out with patterns of SA that exceed the state by more than 10% for four or more of the 12 indicators (Table 19). The percentage residents in Cumberland (5.9%), Knox (7.3%), Lincoln (8.7%), Somerset (5.6%), and Washington (5.0%) counties reporting that they had been diagnosed with a substance abuse problem at some point in their lives exceeded the range for the state (4.3-5.2%). The percentage of residents in Cumberland (2.9%), Lincoln (2.2%), and Washington (2.8%) counties suffering from a current substance abuse problem exceeded the range for the state (1.4-1.7%).

53 Centers for Disease Control and Prevention. (2010). Behavioral Risk Factor Surveillance System: Prevalence and Trends Data. Available: http://apps.nccd.cdc.gov/BRFSS/. [2010, December 22]. 54 Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings. (Office of Applied Studies, NSDUH Series H-38A, HHS Publication no. SMA 14586Findings). Rockville, MD.
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OneMaine Community Health Needs Assessment 2010 Cumberland (7.9%), Knox (7.3%), Oxford (7.8%) and Washington (7.8%) counties exceeded the range for the state (5.8%-7%) for chronic heavy drinking. The counties exhibited greater variation in chronic heavy drinking patterns for age groups 18-64 and 65+. Cumberland County remained consistently above the range for the state for both age groups. For the 18 to 64 age group, Oxford, Somerset, and Washington counties also exhibited higher rates of chronic heavy drinking. For the 65 and above age group, Knox, Lincoln, and Oxford exceeded the state rate for this measure. Cumberland, Somerset, and Washington counties exceeded the state range (14-17%) for past month binge drinking at 18% for all three counties. Despite higher overall rates of binge drinking in these three counties, when analyzed by age groups (i.e., 18-44, 45-64, and 65 and older), only Somersets rate of binge drinking by those 65+ exceeded the state. All other age groups across the six counties were consistent with or below the range for the state. Within these six counties, Cumberland, Lincoln, and Oxford Counties exhibited higher rates of overdoses within the past 12 months than the range for the state. Residents of Oxford (7.2%), Somerset (6.0%), and Washington (7.6%) counties showed rates of any street drug use within the past thirty days that were higher than the range for the state (4.7-57%). For rates of past 30 day use of any prescription drug for non-prescription purposes, Knox (2.8%), Somerset (2.5%), and Washington (2.9%) counties exceeded the range for the state (1.6-1.9%). These complex patterns of substance abuse across the six counties suggest the need for county and community level exploration of substance abuse issues to determine the appropriate prevention, legal, and treatment interventions necessary to reduce the level and impact of substance abuse in each county. Although six counties were highlighted with higher patterns of substance abuse problems across a variety of prevalence indicators, the remaining 10 counties also exhibit higher patterns of substance abuse problems for one or more indicators. These patterns are explored in the following sections. Past and Current Substance Abuse Problems Three general indicators related to overall substance abuse problems were drawn from the household survey. Respondents were asked if they were ever told by a health care professional that they had a substance abuse problem with alcohol or drugs. This indicator corresponds to a lifetime problem with alcohol or drugs, as there is no time limit on when they may have received this diagnosis. Those respondents that answered yes to this question were asked if they still had a substance abuse problem (i.e., a current problem). This latter indicator is the more important of the two, as it indicates whether or not an individual currently suffers from a substance abuse problem with either alcohol or drugs. The Maine rate of reported current substance abuse problem is 1.5%, with a range of 1.4 to 1.7% based on the application of the 10% rule described above. Figure 26 shows the variation in the rates of current substance abuse problems across the counties compared to the mean rate for the state as a whole. As can be seen, Aroostook, Cumberland, Lincoln, Sagadahoc, and Washington Counties all have rates of current substance abuse problems that meet or exceed the range for the state. The final general indicator involves the prevalence of overdoses due to drug and alcohol use. The state percentage for reported overdoses due to drugs and/or alcohol was 0.9% of the population with a range of 0.8 to 1.0%. Of those reporting an overdose, 69% called 911 or sought attention from a doctor or hospital for their overdose. Figure 27 shows the extent to which Maine Counties vary from the state in terms of reported overdoses. Cumberland (1.1%), Lincoln (1.9%), Oxford (1.5%), Waldo (1.4%), and York (1.3%) counties exceed the state range for reported overdoses, and Androscoggin (1.0%) and Somerset (1.0%) counties are at the high end of this range.
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OneMaine Community Health Needs Assessment 2010 Patterns of Alcohol Abuse As mentioned earlier, alcohol is the most commonly used substance among Maine residents. Two key indicators of problem drinking behavior (i.e., past month chronic heavy and binge drinking) were included in this assessment. The dangers of both types of problem drinking include long term physical risk, and short term behavioral risks due to impaired judgment. Physical health risks include: impaired brain function; alcohol dependence and addiction; pancreatitis; liver and kidney problems; skin problems; infertility; birth defects in children born to women who drink heavily during pregnancy; hypertension; heart attack and stroke; lung, stomach, and intestinal problems; weight gain and obesity; and cancers of the tongue, mouth, throat, liver, and breast. Binge and heavy drinkers are also likely to suffer from impaired judgment, as well as reduced concentration and coordination. This increases the risk of: participating in risky sexual behavior, driving under the influence, or antisocial or criminal behavior; become a victim of a crime; having an accident; or damaging relationships with family, friends, and employers. Figure 28 and Figure 29 show the variation in chronic heavy and binge drinking across the counties in Maine Cumberland (18%), Piscataquis (19%), Somerset (18%), and Washington (18%) counties exceed the states range for binge drinking. Knox (16%), Oxford (16%), Waldo (16%), and York (17%) counties are on the high end of this range. Patterns of Illicit Drug Use (Including Street Drugs and the Non-Prescription Use of Prescription Drugs) Although the percentage of individuals using illicit drugs is lower on average than those using alcohol, the societal, social, and personal costs of illicit drug use are significant. For purposes of this section, illicit drugs are defined to include street drugs (i.e., drugs that have typically have no or limited medical use), and the non-prescription use of prescription medications. Two indicators of illicit drug use are drawn from the household survey. The first measures the prevalence of current (past 30 days) street drug use, including Marijuana, Cocaine, crack, heroin, hallucinogens, or inhalants. The second measures use of prescription drugs not as directed, or someone elses prescription not prescribed for the respondent. One of the obvious differences between illicit drug and alcohol use is that producing, distributing, obtaining, and consuming illicit drugs are criminal activities. According to the U.S. Department of Justice, drug law violations represent a significant proportion of incarcerations and the most common arrest category.55 In addition, the production process creates both environmental (particularly related to the production of cannabis and methamphetamine) and personal health hazards due to contamination, either intentional or unintentional, of illicit drugs during the production process.56 The criminal nature of illicit drug use also discourages users from disclosing their consumption to health care providers. Finally, the wide range of illicit drugs creates its own problems, as the specific physiological impact varies across major categories of drugs. Figure 30 details the rate of street drug use across Maine counties. Androscoggin (7.9%), Oxford (7.2%), Somerset (6.0%), and Washington (7.6%) counties exceed the states range for street drug use.

55 U.S. Department of Justice, National Drug Intelligence Center. (2010, February). National Drug Threat Assessment 2010. Available: http://www.justice.gov/ndic/pubs38/38661/drugImpact.htm#Consequences. [2010, December 22]. 56 Ibid.
87

OneMaine Community Health Needs Assessment 2010 Prescription drug abuse (.e., the non-prescription use of a prescription drug or the use of a prescription written for someone else) is a growing problem, nationally, with 2.8% of the U.S. population classified as current users of psychotherapeutic drugs (i.e., pain relievers, tranquillizers, stimulants, sedatives, and other prescription drugs) taken non-medically in 2009.57 It is also a recognized problem in Maine.58,59 Figure 31 shows the extent to which Maine counties vary from the state in terms of non-prescription use of prescription drugs. As can be seen, this is an issue for 56% of Maines counties with Hancock (2.2%), Knox (2.8%), Penobscot (2.2%), Piscataquis (3.5%), Somerset (2.5%), and Washington (2.9%) counties exceeding the range for the state. Androscoggin (1.8%), Cumberland (1.8%), and York (1.9%) counties are on the high end of the state range. Piscataquis County (3.5%) stands out with a rate of use that exceeds the state by 1.7%. Hospital and Emergency Department Admission Rates For this needs assessment, a number of indicators were identified related to the management of substance abuse problems, including: Hospital admission rates for SA, acute alcohol-related mental disorders, alcohol-related psychoses, acute drug-related mental disorders, and drug-related psychoses by age groups (i.e., 0-1760, 18-64, and 65 and above); and Emergency department admissions for acute alcohol-related mental disorders, alcohol-related psychoses, acute drug-related mental disorders, and drug-related psychoses by age groups (i.e., 017, 18-64, and 65 and above).

These indicators are expressed in terms of the rate per 100,000 population. Examining the data for the management of substance abuse problems within the context of the prevalence patterns for the counties highlights unusual patterns of service use. There are no consistent patterns linking prevalence rates to hospital admission and ED rates (Table 20). Androscoggin and Penobscot Counties have prevalence patterns that, with limited exceptions (i.e., a higher rate of current street drug use for Androscoggin residents and a higher rate of prescription drugs used for non-prescription purposes among Penobscot residents), are lower than state rates. Despite the comparatively lower prevalence rates in these two counties, hospital admission and ED rates are higher for 12 of the 24 indicators in Androscoggin County, and 16 of the 24 in Penobscot County. In comparison, Cumberland, Somerset, and Washington counties have higher patterns of SA prevalence than other counties, but lower rates of overall rates of hospital and ED admissions. Cumberland County exceeds the state for 11 of the 24 indicators; Somerset County exceeds the state for 7 indicators, and Washington County exceeds the state for 8 indicators. These patterns suggest that factors other than need (i.e., prevalence) may influence admission rates. These factors likely include availability of and proximity to SA services, the extent to which health care providers screen for SA problems among their patients, levels of insurance coverage for SA treatment, and stigma related to admitting and seeking treatment for a substance abuse problem.

57 National Institute on Drug Abuse. (2010, September). Topics in Brief: Prescription Drug Abuse/ 58 Nagle, M. (2010). Razors Edge. Umaine Today. Fall 2010 Orono, ME. 59 Maine Office of Substance Abuse, Department of Health and Human Services. (2010, May). Substance Abuse Trends in Maine. Maine Office of Substance Abuse: Augusta, ME. 60 Alcohol and substance abuse hospital admission data for 0-17 year olds has been suppressed in tables due to low occurrences (ie <5) in this age group for many of the counties
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OneMaine Community Health Needs Assessment 2010 Hospital admission rates for SA are highest in Androscoggin (673 per 100,000), Cumberland (544 per 100,000), and Kennebec (419 per 100,000) counties. When viewed by age group, Androscoggin County has the highest rates of hospital admissions for 0-17 year olds (34 per 100,000) and 18-64 year olds (1021 per 100,000), while Cumberland County has the highest rate for those 65 and above. For hospital admissions for acute alcohol related admissions, Washington (112 per 100,000), Knox (98 per 100,000), Kennebec (91 per 100,000) and Hancock (91 per 100,000) counties have the highest rates among all Maine counties. When viewed by age group, Penobscot County has the highest rate for 0-17 year olds (3.3 per 100,000), Washington County has the highest rate for 18-64 year olds (at 168 per 100,000), and Hancock County has the highest rate for those 65 and above (76 per 100,000). For alcohol-related psychoses, Androscoggin (368 per 100,000) and Cumberland (326 per 100,000) counties have the highest rates of hospital admissions. By age group, Somerset County has the highest rate for 0-17 year olds (4.5 per 100,000), Androscoggin County has the highest rate for 18-64 year olds (566 per 100,000), and Cumberland County has the highest rate for those 65 and older (106 per 100,000). For acute drug-related mental disorders, Washington (95 per 100,000) and Somerset (72 per 100,000) counties have the highest rates of hospital admissions. By age group, Somerset County has the highest rate at 18 per 100,000, followed closely by Androscoggin and Penobscot counties at 15 per 100,000 each. Washington County has the highest rate for 18-64 year olds (143 per 100,000) and 33 per 100,000 among those 65 and older. For drug-related psychoses, Androscoggin County has the highest rate of hospital admissions at 261 per 100,000, followed by Cumberland (157 per 100,000) and Oxford (152 per 100,000) counties. By age group, Androscoggin and Piscataquis counties tie for the highest rate for 0-17 year olds (15 per 100,000), Androscoggin County has the highest rate for 18-64 year olds (393 per 100,000), and Knox County has the highest rate for those 65 and older (113 per 100,000). Rates of ED use for substance abuse and behavioral health disorders are important, as higher than normal rates of ED use for these conditions may indicate inadequate access to inpatient, ambulatory, and crisis services on a timely basis. As such, these rates should be viewed within the context of the overall delivery system at the local and county levels. In terms of ED rates for acute alcohol-related mental disorders, Penobscot (218 per 100,000) and Cumberland (180 per 100,000) counties have the highest rates. For alcohol-related psychoses, Hancock County has the highest rate at 67 per 100,000, followed by Cumberland and Piscataquis counties at 39 per 100,000 each. For acute drug-related mental disorders, Androscoggin (443 per 100,000), Penobscot (411 per 100,000), and Kennebec 311 per 100,000) counties have the highest ED rates. For drug-related psychoses, Piscataquis(100 per 100,000) and Washington (80 per 100,000) counties have the highest ED rates. Mortality Rates The following three measures of substance abuse related mortality were included in this assessment: Rate of alcohol related mortality per 100,000 population (overall and by gender); Rate of alcohol liver disease; and Rate of substance-related motor vehicle accidents (overall and by gender).

Seven of Maines 16 counties stand out for high patterns of substance-related mortality across a number of indicators. These counties include Aroostook, Franklin, Lincoln, Oxford, Piscataquis, Somerset, and Washington (Table 21). Not surprisingly, counties with higher prevalence rates and/or lower hospital admission and ED rates are those with higher patterns of mortality related to substance use. Aroostook, Franklin, Lincoln, Oxford, and Somerset counties meet or exceed the range for the state on all seven indicators. Aroostook, Franklin, and Piscataquis counties stand out for prevalence and hospital admissions
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OneMaine Community Health Needs Assessment 2010 and ED use patterns that are lower than the state, while Lincoln and Oxford counties exhibit somewhat higher prevalence patterns and lower service use patterns. Both Somerset and Washington counties exhibit comparatively higher prevalence and service use patterns. Overall, Lincoln and Oxford counties have the highest alcohol-related mortality rates at 21 per 100,000, each followed closely by Aroostook (19 per 100,000), Franklin (18 per 100,000), and Somerset (19 per 100,000) counties. Oxford and Somerset counties tie for the highest alcohol-related morality rates for males, each at 25 per 100,000, followed closely by Aroostook, Hancock, and Piscataquis Counties, each at 24 per 100,000 and Franklin (23 per 100,000), Lincoln (22 per 100,000), and Washington (23 per 100,000) counties. Females tend to have lower rates of alcohol-related mortality compared to men, with Lincoln (21 per 100,000), Oxford (16 per 100,000), and Aroostook (15 per 100,000) counties exhibiting the highest rates. Oxford (18 per 100,000), Aroostook (17 per 100,000), Franklin (15 per 100,000), Lincoln (15 per 100,000), and Piscataquis (14 per 100,000) counties have the highest mortality rates for alcohol liver disease. As with alcohol-related mortality rates, mortality rates for substance-related motor vehicle accidents is higher in general for males than females. Lincoln has the highest mortality rate in this category at 30 per 100,000, followed closely by Somerset and Washington at 23 per 100,000 each, and Franklin at 21 per 100,000. Lincoln and Washington have the highest mortality rates for men at 47 and 42 per 100,000 respectively, while Lincoln and Somerset tie for the highest rate for women at 13 per 100,000, with Oxford close behind at 12 per 100,000. Table 19: Maine Counties Exhibiting High Patterns of Substance Abuse
Cumberland Knox Lincoln Oxford Somerset Washington Maine

Past Month Chronic Heavy Drinking Ages 18-64 Ages 65+ Past Month Binge Drinking Ages 18-44 Ages 45-64 Ages 65+ Ever diagnosed with SA Problem Current SA Problem Overdose in Past 12 Months Any street drug use in past 30 days Non-prescription use of prescription drugs in past 30 days

7.9% 17% 5.2% 18% 20% 8% 3.0% 5.9% 2.9% 1.1% 4.5% 1.8%

7.3% 15% 6.4% 16% 21% 10% 3.1% 7.3% 1.3% 0.5% 4.5% 2.8%

6.7% 11% 9.4% 14% 24% 14% 2.8% 8.7% 2.2% 1.9% 4.7% 0.9%

7.8% 17% 5.1% 16% 25% 9.4% 3.1% 4.1% 0.9% 1.5% 7.2% 0.9%

7.0% 16% 0.5% 18% 18% 12% 4.7% 5.6% 1.3% 1.0% 6.0% 2.5%

7.8% 17% 2.9% 18% 25% 11% 1.1% 5.9% 2.8% 0.4% 7.6% 2.9%

6.4% 14% 4.5% 15% 26% 14% 3.6% 4.7% 1.5% 0.9% 5.2% 1.8%

Source: BRFSS 2008 & 2009 combined, 2010 OneMaine CHNA Household Survey Bold Face = High Risk: At least 10% above the state.

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OneMaine Community Health Needs Assessment 2010 Table 20: Comparison of Prevalence and Hospital and ED Admissions in Select Counties
Androscoggin Cumberland Penobscot Somerset Washington Maine

% Chronic heavy drinking - Past month Ages 18-64 Ages 65+ % Binge drinking Past month
Prevalence

5.5% 12% 0.8% 15% 24% 12% 3.0% 4.2% 0.7% 1.0% 7.9% 1.8% 673 1021 138 17 27 0.0 368 566 74 27 36 0.0 261 393 64 140 18 443 48

7.9% 17% 5.2% 18% 20% 8% 3.0% 5.9% 2.9% 1.1% 4.5% 1.8% 544 787 220 32 46 15 326 480 106 28 41 3.9 157 220 95 180 39 291 50

4.6% 9.6% 3.7% 14% 22% 14% 2.1% 4.2% 1.2% 0.4% 5.5% 2.2% 286 391 180 86 124 28 79 112 35 67 95 9.5 54 59 104 218 39 411 76

7.0% 16% 0.5% 18% 18% 12% 4.7% 5.6% 1.3% 1.0% 6.0% 2.5% 303 441 137 53 81 12 65 97 25 72 109 0.0 112 153 100 97 25 322 61

7.8% 17% 2.9% 18% 25% 11% 1.1% 5.9% 2.8% 0.4% 7.6% 2.9% 291 421 159 112 168 50 40 58 25 95 143 33 43 53 50 97 20 217 80

6.4% 14% 4.5% 15% 26% 14% 3.6% 4.7% 1.5% 0.9% 5.2% 1.8% 379 553 149 50 73 19 174 260 52 39 56 6.5 117 164 72 131 28 297 57

Ages 18-44 Ages 45-64 Ages 65+ % Ever diagnosed with SA problem % Current SA problem % Overdose past 12 months (households) % Street drugs in past 30 days % Prescription drugs (nonprescribed purposes) - past 30 days SA, Hospital admission rate Ages 18-64 Ages 65+ Acute alcohol-Related mental disorders, hospital admission rate Ages 18-64 Ages 65+ Alcohol-related psychoses, hospital admission rate Ages 18-64 Ages 65+ Acute drug-related mental disorders, hospital admission rate Ages 18-64 Ages 65+ Drug-related psychoses, hospital admission rate Ages 18-64 Ages 65+ Acute alcohol-related mental disorders, ED rate Alcohol-related psychoses, ED rate Acute drug-related mental disorders, ED rate Drug-related psychoses, ED rate

Source: BRFSS 2008 & 2009 combined, 2010 OneMaine CHNA Household Survey, MHDO Hospital Discharge Dataset Q42007-Q32009, MHDO ED Discharge Dataset 2007-2008 Bold Face = High Risk: At least 10% above the state.

Management

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OneMaine Community Health Needs Assessment 2010 Table 21: Substance-Related Mortality Rates for Select Counties
Mortality Rates per 100,000 population Alcohol-Related Males Females Alcohol Liver Disease Motor Vehicle Accidents Males Females
Aroostook Franklin Lincoln Oxford Piscataquis Somerset Washington Maine

19 24 15 17 19 29 11

18 23 13 15 21 32 11

21 22 21 15 30 47 13

21 25 16 18 17 23 12

16 24 7.7 14 16 32 0.0

19 25 13 15 23 33 13

15 23 8.0 11 23 42 4.0

14 19 10 11 14 21 8.0

Source: ODRVS Mortality 2007-2009 Bold Face = High Risk: At least 10% above the state.

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OneMaine Community Health Needs Assessment 2010 Figure 26: Percentage with Current Substance Abuse Problem - County Differences from State
Percentage of Maine Population with a Current Substance Abuse Problem by County
Androscoggin -0.8%

Aroostook

0.2%

Cumberland

1.4%

Franklin

-0.8%

Hancock

-0.6% % Current Substance Abuse Problem

Kennebec

-1.4%

Knox

-0.2%

Lincoln

0.6%

Oxford

-0.7%

Penobscot

-0.3%

Piscataquis

-0.8%

Sagadhoc

1.4%

Somerset

-0.2%

Waldo

-0.5%

Washington

1.3%

York

-0.4%

Source: 2010 OneMaine CHNA Household Survey Central Axis is Maine percentage: Percentage reported current substance abuse problems for the state of Maine is 1.5%

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OneMaine Community Health Needs Assessment 2010 Figure 27: Percentage with a Reported Overdose - County Differences from State
Androscoggin Aroostook Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadhoc Somerset Waldo Washington York
Source: 2010 OneMaine CHNA Household Survey Central Axis is Maine percentage: Percentage reported overdoses for the state of Maine is 0.9%

0.1% -0.4% 0.2% -0.9% -0.2% -0.4% -0.4% 1.0% 0.6% -0.5% -0.4% -0.3% 0.1% 0.5% -0.5% 0.4% % Overdose Past 12 mos (Households)

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OneMaine Community Health Needs Assessment 2010 Figure 28: Percentage Engaging in Chronic Heavy Drinking - County Differences from State

Androscoggin Aroostook Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadhoc Somerset Waldo Washington York -1.8% 1.4% 0.9% -1.8% -0.8% -0.6% 0.6% -2.4% -1.1% -0.3% 0.9% 0.3% 1.4% % Chronic Heavy Drinking - Pa st Month -0.9% -0.9% 1.5%

Figure 29: Percentage Engaging in Binge Drinking - County Differences from State

Androscoggin Aroostook Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadhoc Somerset Waldo Washington York 0.2% 2.2% 1.8% -2.4% 2.4% -1.9% 3.1% -1.9% 0.2% -0.9% -0.3% -1.5% 0.3% % Binge Drinking -Past Month -0.5% -0.2% 2.1%

Source: BRFSS 2008 & 2009 combined Central Axis is Maine percentage: Percentage reported binge drinking for adults in the state of Maine is 15% of the population. Percentage reported chronic heavy drinking for adults in the state of Maine is 6.4% of the population.

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OneMaine Community Health Needs Assessment 2010 Figure 30: Percentage Using Street Drugs - County Differences from State
Androscoggin Aroostook -3.4% Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadhoc Somerset Waldo Washington York
Source: 2010 OneMaine CHNA Household Survey Central Axis is Maine percentage: Percentage reported street drug use by adults in the state of Maine is 5.2% of the population.

2.7%

-0.7% -0.9% 0.2% -0.3% -0.7% -0.5% 2.0% 0.3% -2.0% -0.4% 0.8% -1.3% 2.4% 0.4% % have used any street drugs in past 30 days

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OneMaine Community Health Needs Assessment 2010 Figure 31: Percentage Using Prescription Drugs for Non-Prescribed Purposes - County Differences from State
Androscoggin Aroostook Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadhoc Somerset Waldo Washington York 0.1% -0.3% 1.1% -1.6% 0.7% -0.9% -0.9% 0.5% 1.7% -0.4% -0.7% 0.5% -0.9% 0.1% % have used any prescription drugs for non-prescribed purpose in past 30 days 1.0% 0.0%

Source: 2010 OneMaine CHNA Household Survey Central Axis is Maine percentage: Percentage reported use of prescription drugs for non-prescription purpose by adults in state of Maine is 1.8%

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OneMaine Community Health Needs Assessment 2010

YOUTH HEALTH

Findings: Youth risk behaviors, including smoking, drinking, drug use, and behaviors associated with obesity are prevalent among Maine youth, but rates vary by county. Higher rates of risk behaviors do not consistently co-occur with youth mental health issues. Clusters of high rates of two or more youth risk behaviors are found in Aroostook, Franklin, Lincoln, Piscataquis, Waldo, and Washington counties. Youth mental health issues, including hospital admission for depression and suicidal ideation, are highest in Androscoggin, Cumberland, Lincoln, Piscataquis, Sagadahoc, and Waldo counties. Hospital emergency department (ED) visits for ambulatory care sensitive conditions are highest in Androscoggin, Aroostook, Kennebec, Piscataquis, Somerset, Waldo, and Washington counties.

In this section, indicators for Mainers under age 18 are discussed. While many of these indicators are discussed elsewhere in this document as part of other domains, the focus in this chapter is explicitly on youth. The proportion of Maine youth under the age of 18 is well under the national percentage of 24.3%, both statewide (21%), and for each Maine county individually. The counties with the highest proportion of youths under 18 are Androscoggin and Somerset, with 22%, while the counties with the lowest proportion, Knox, Lincoln, and Hancock, each have 19%. Closely associated with health and risk behavior, child poverty is a relevant indicator for health planning. In 2010, 16% of Maine youth lived in poverty, up from 12% in 2000, as compared with a national percentage of 18%, up from 17% in 2000 (Maine Kids Count, 2010). The highest rates of childhood poverty in 2009 were observed in Piscataquis, Somerset and Washington counties. Risk Behaviors Substance Abuse It is particularly appropriate to group youth indicators that describe risk behaviors, because at-risk young people, especially adolescents, tend to display many risk behaviors. That is, smoking, drinking, driving under the influence, and poor nutrition might all be behaviors of one at-risk teen. For that reason, the discussion begins with risk behaviors. The Maine Integrated Youth Health Survey (MIYHS) is a survey of public middle and high schools that evolved out of the Maine Youth Drug and Alcohol Use Survey. It was first conducted in 2008, and is the basis for much of the youth risk behavior data. Statewide, 35% of children in grades 9-12 had used alcohol in the past month at the time of the survey, 25% have used marijuana, and 11% have used a prescription drug without a prescription (i.e. for recreational purposes). Twenty percent of these youth are current smokers. Table 22 presents those Maine counties with the highest rates for these indicators. It also shows how these risk behaviors are clustered - that is, how some counties have high rates for all of these indicators. For smoking and smokeless tobacco, Lincoln, Piscataquis, and Washington counties have the highest rates. For alcohol use and binge drinking, Franklin, Lincoln, Piscataquis, Waldo, and Washington counties have the highest rates.
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OneMaine Community Health Needs Assessment 2010 For drug use, Lincoln and Waldo counties have the highest rates of marijuana, glue sniffing and prescription drug use. Piscataquis and Hancock have high rates of the latter two substances, but are about average for marijuana, while Franklin is the opposite, with a high rate of marijuana use but average or below average rates of the other two.

One of the worst consequences associated with adolescent substance abuse is motor vehicle deaths. Fortunately, such events are relatively rare in Maine, with only 41 such deaths reported in 2009. As a result, the data do not permit us to compare county rates for this outcome. Risk Behaviors - Obesity When survey respondents were asked what were the biggest health problems facing their communities, after high cost and lack of insurance, the most frequently named issue was obesity. A recent report from the National Center for Health Statistics states that nearly 17% of youth age 2-19 in the U.S. are obese. Childhood obesity has significant long-term consequences in terms of cardiovascular health, diabetes and other chronic illnesses. Based on the MIYHS data, 13% of Maines 9-12 graders are obese, while another 14% are overweight. Risk behaviors that lead to obesity include poor nutrition and lack of physical activity. In Maine, only 15% of middle and high school children consume the recommended amounts of fruits and vegetables, while 29% consume sweetened beverages on a daily basis. Only 39% percent get 60 minutes of physical activity per day at least five days per week. Counties with the highest rates of childhood obesity are Lincoln, Oxford and Waldo. Those with the highest rates of overweight include Aroostook, Franklin, Oxford, Somerset and Washington. While the statewide rate of 15% of children consuming the recommended amounts of fruit and vegetables does not vary much among the 16 counties, Aroostook, Piscataquis, and Washington counties have rates of consuming sweetened beverages that are substantially higher than the state.

Youth Mental Health The MIYHS found that 24% of those surveyed were sad and/or feeling hopeless at the time of the survey, and 14% had seriously considered suicide. Actual numbers of youth suicides in Maine are very low, with only ten in 2009. Other measures of mental health in the youth population include diagnosed mental illness such as depression or bipolar disorder, and hospital admissions for psychiatric illness. Children in Lincoln and Piscataquis counties have considered suicide at rates higher than the statewide percentage of 14%. Youth rates of hospital admission for major depressive disorder are highest in Androscoggin, Cumberland, Lincoln, Sagadahoc, and Waldo counties. Youth rates of hospital admission for bipolar disorder are highest in Androscoggin, Kennebec, Oxford, Penobscot, Somerset, and Waldo counties. Admissions for psychosis age 0-17, are highest in Androscoggin, Penobscot, Somerset, and Waldo counties.

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OneMaine Community Health Needs Assessment 2010 Other Youth Health Indicators While the focus in this section has been on youth risk behaviors, there are several indicators of youth health that provide additional information about the health status of Maines youth. Maine has a relatively low rate of low birthweight births among teen mothers (10-17) at 7.4%, which is below the national rate of 8.2% and also below the Healthy People 2020 target of 7.8%. Other indicators include learning disabilities, children with asthma, and hospital emergency department admissions for conditions that are thought to be avoidable if primary care is adequate (ACS Conditions), especially, asthma and bronchitis. The number of children with developmental or learning disabilities varies considerably among Maines counties, with Hancock, Piscataquis, and Washington counties having significantly higher rates than the rest of Maine. The rates of ACSC visits of children to emergency departments are higher than the state rates in Androscoggin, Aroostook, Kennebec, Piscataquis, Somerset, Waldo, and Washington counties. ED visits for asthma and bronchitis are highest in Androscoggin, Aroostook, Knox, Oxford, Piscataquis, Somerset, and Washington counties.

Finally, an indicator that combines youth risk behavior with maternal and child health is the teen birth rate, the number of births per 1000 women ages 12-17. For Maine, in 2009 the teen birth rate was just 4.1 per 1000. Counties with relatively higher rates of teen births include Androscoggin, Franklin, Piscataquis, and Somerset. Patterns Clusters of Risk Figure 32 shows how different youth risk indicators may cluster at the population level. Knowing that atrisk youth tend to display multiple risk behaviors, the figure draws attention to those counties where such risk patterns exist, particularly Lincoln, Piscataquis, Waldo, and Washington. Table 22: Child/Youth Health Risk Substance Abuse (Grade 9-12)
An dro sco g gi n Ar o os t oo k Cu mb er la n d Fr ank lin Lin col n Pi s ca t aq u is Wa ldo i ng t on sh Wa

% Current Smoker (Past Month)

18% 21% 17% 17% 29% 26% 22% 27% 20%

% Current Smokeless Tobacco User 10% 5.5% 9% 8.5% 14% 13% 13% 12% 9.5% % Alcohol Use (Past Month) % Binge Drink (5+ in a row) Past Month) % Marijuana Use (Past Month) % Sniffed Glue or Other Inhalant (Past Month) % Used Rx Drug w/out Rx (Past Month) 31% 34% 35% 40% 42% 39% 44% 41% 35% 19% 20% 21% 24% 25% 26% 28% 31% 21% 23% 17% 24% 28% 29% 25% 28% 24% 24% 11% 12% 7% 9% 6% 14% 14% 12% 11% 9.3%

7% 11% 11% 17% 16% 13% 12% 11%

Bold Face = High risk: At least 10% above state.

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Ma in

OneMaine Community Health Needs Assessment 2010 Table 23: Youth Overweight/Obesity Risk Factors (Grade 9-12)
An dr osc og gin an d W ash ing ton Ar oo sto ok Cu mb erl Pis cat aq uis Fr an kli n Lin col n W ald o

% Obese % Overweight % Regular Physical Activity (ge 60 min on 5 of last 7 dys) % Consume fruits and vegetables (ge 5 times/day) % Drank sugar sweetened beverage in past week

15% 14% 37% 15%

17% 14% 41% 13%

11% 10% 41% 16%

16% 13% 50% 17%

15% 17% 32% 15% 29%

14% 12% 38% 16% 35%

18% 14% 37% 15% 31%

18% 11% 39% 14% 37%

14% 13% 39% 15% 29%

32% 25% 29% 35% Source: Maine Integrated Youth Health Survey 2009 (Grades 9-12) Bold Face = High risk: At least 10% above (below for physical activity) state.

Table 24: ED Admissions for ACS Conditions, Ages 0-17 Emergency Department Visits for Ambulatory Care Sensitive Conditions (ages 0-17) 2466 2796 1530 1320 1943 2359 2150 1730 2043 1680 2392 1376 3637 2202 3198 1633 1994 Emergency Department Visits for Asthma and Bronchitis (ages 0-17) 1291 1606 987 894 1194 1084 1564 974 1285 1055 1546 627 1625 1035 2028 975 1145

Androscoggin Aroostook Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadahoc Somerset Waldo Washington York Maine

Source: MHDO ED Discharge Dataset 2007-2008 Bold Face = High risk: At least 10% above state. All rates are per 100,000

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OneMaine Community Health Needs Assessment 2010 Figure 32: Percentage of Current Smokers (Past Month), Binge Drinkers (5+ in a row Past Month), & Overweight/Obese by County (Grades 9-12) - County Differences from State
-1.6%

Androscoggin

-2.8% 2.7% 0.8%

Aroostook
-2.7%

-1.1% 5.1%

Cumberland
-5.2% -2.7%

0.0%

Franklin

2.9% 3.2% 2.7% -0.1% -2.1% -0.4% -0.3% -1.6% Data for Knox County Not Available on these indicators

% Current Smoker (Past Month) % Binge Drink (5+ in a row, Past Month) % Overweight or Obese

Hancock

Kennebec

Knox

9.4%

Lincoln
-0.7%

4.0% 5.1%

Oxford

0.3% 6.5% 0.4%

Penobscot

-2.3% 2.0% 5.9%

Piscataquis
-0.7% -1.8% -1.9% 1.4% 2.1%

4.4%

Sagadhoc

Somerset

1.0% 4.0% 1.9%

Waldo
4.7%

6.6% 7.3%

Washington
2.3% 0.2%

9.6%

York

-0.8% -1.8%

Source: 2009 Maine Integrated Youth Health Survey (Grades 9-12) Central Axis is Maine percentage:

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OneMaine Community Health Needs Assessment 2010

COMMUNITY PERCEPTIONS OF HEALTH AND HEALTH SERVICE NEEDS

FINDINGS: Maine residents perceive the cost of health care and access to health insurance as the most significant health issues in their communities across the state. The cost of health care and/or the ability to pay for care were in the top three reported health concerns in every county, with about 1 in 5 residents reporting these as among the biggest health problems in their community. Lack of health insurance was also widely regarded as a significant health issue, with just over 14% of those interviewed citing this as a major health concern. Obesity (12%) and alcohol/drug abuse (11%) were also cited frequently as health concerns. Only about a third of residents in Maine report a need to travel outside their region to access health services, but in Aroostook and Washington counties almost two-thirds report a need to travel for health services. Oral health services, including orthodontics and oral surgery, were the services respondents were most likely to report having to travel outside of their region to access. Cancer treatment was the service for which the most respondents reported a lack of qualified physicians or specialists in their area.

Health Issues of Concern to Residents and Providers In the 2010 OneMaine CHNA household survey, Maine residents were provided with the opportunity to evaluate the public health needs and priorities of their communities, and were asked to name the greatest health issue facing their communities. The overall perception of the residents throughout Maine revealed that the most challenging community health problems were the high expense of healthcare (21%), and access to health insurance (14%) (Table 25). In all of the counties but one, the issue that was perceived as most challenging was the expense of health care and the ability to pay for care. In Washington County, alcohol and drug abuse was the most commonly reported health problem. Alcohol and drug abuse were the second most commonly cited problem in Aroostook, Kennebec and Knox counties. Lack of health insurance was also widely cited as a major health concern, with all of the counties reporting this as one of the top three health problems. Obesity was the second most commonly cited health problem in Androscoggin, Cumberland and Franklin counties. Access to health care and need for more doctors was one of the top five reported problems in every county, and the third most cited problem in Washington County. In Aroostook, Oxford and Washington counties, cancer was cited as the most pressing health concern by over 5.0% of respondents. Health Service Needs Residents were also asked in the 2010 household survey whether there are any health services which they or their family members need but have to travel outside of their area to receive. The most common response in every county was None, indicating that many people in Maine have access to the health services they need within their region. However, there are some differences between counties as to whether residents perceive a need for additional health services. (Figure 33) In Aroostook and Washington counties, more than half of respondents indicated a need to travel outside of their area for health services. Respondents in Androscoggin, Cumberland, and Sagadahoc counties
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OneMaine Community Health Needs Assessment 2010 were most likely to report no need to travel outside of their area to receive any health services. Overall, approximately a third of Maine residents reported a family or personal health need for which they needed to travel outside of their area to access services. In order to analyze the remaining responses to this question, the None responses, which represented the majority of responses in most counties, were removed from the denominator. This provides a better sense of the priority health service needs among respondents who perceived a need. Looking at the state of Maine overall, oral health services, including dental care, orthodontics and oral surgery, was the most commonly cited need for which respondents had to travel outside of their area. This was the number one response in 10 of the 16 counties. There was only one county, Sagadahoc, for which oral health services was not one of the top two most frequent responses. The second most common service for which residents reported needing to travel outside of their area was cardiologic services, including heart surgery. This was the most frequently cited need in Lincoln and Somerset counties, and was in the top five in every county except Androscoggin, Sagadahoc, and Waldo counties. General surgery was the third most commonly cited service for which residents reported needing to travel outside of their area and was the most common response in York and Franklin counties. Surgery was in the top five in every county but Cumberland, Kennebec, and Waldo. Cancer treatment services was the fourth most commonly cited for Maine overall, but was the most common response in Washington County, and the second most common response in Knox and Penobscot counties. Orthopedic services was the fifth most common response overall, and was the third most common response in Aroostook and York Counties. There were health services that were cited in the top three for individual counties, but were not commonly cited for the state overall. Table 27 shows the percentage of responses for the top three most commonly cited health services in each county. Androscoggin, Cumberland, Kennebec, Sagadahoc, and Waldo counties all had health services which they reported in their top three needs for traveling outside of the area that were not in the top five services reported for Maine overall, indicating that these regions may have some unique health service needs and/or lack of access to specific health services within their area. Respondents were also asked about which health services which they would travel outside of their area to receive because of a lack of qualified physicians or specialists. About 43% reported a health service for which there were no qualified physicians or specialists in their area or region. Again, responses varied greatly, depending on the county. Those in Aroostook (71%) and Washington (69%) counties were most likely to report a service for which there were no qualified medical providers, but more than half of respondents in Franklin, Hancock, Knox, Lincoln, Oxford, and Piscataquis counties indicated a service for which there were no qualified providers. Cumberland County (25%) was the least likely to report a lack of qualified physicians or specialists. In Androscoggin and York counties, about a third of respondents cited a lack of qualified medical providers for any service. Among those who did report a lack of qualified physicians or specialists for some service, cancer treatment was the most frequent response overall, with about 17% of responses. Cancer treatment was also the most frequently cited service lacking qualified providers in 10 of the 16 counties. Cardiologic services, including cardiac surgery, was the second most commonly cited service for which there is a lack of qualified medical providers, with 13% of responses. Cardiologic service was the most frequent response in the other six counties not citing cancer treatment. Surgery was the third most frequent response overall for Maine, and was the second or third most frequent response in every county.
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OneMaine Community Health Needs Assessment 2010 Table 25: Maine Residents Perceptions of Most Challenging Community Health Problem
Community Health Problem Health care too expensive/Ability to pay for care Lack of insurance Obesity % of Responses Reporting Problem 21% 14% 12% Most commonly cited problem in every county except for Washington county One of top 3 problems reported in all counties 2nd most commonly cited problem in Androscoggin, Cumberland, and Franklin counties 2nd most commonly cited problem in Aroostook, Kennebec and Knox counties. Most commonly cited problem in Washington county One of the top 5 problems in all counties, 3rd most pressing problem in Washington County More than 5% of residents in Aroostook, Oxford, and Washington counties cited this as a major health concern.

Alcohol/Drug Abuse

11%

Access to healthcare/Need more doctors

5%

Cancer
Source: 2010 OneMaine CHNA Household Survey

4%

Table 26: Maine Residents Perceptions of Need To Travel Outside of Area for Health Service
Need to Travel Outside of Area to Access Health Service Oral Health including dental care, orthodontics, and oral surgery % of Responses Reporting Need to Travel Outside of Area for Service* 12% Comments One of top two most commonly cited services in every county except for Sagadahoc One of top 5 most commonly reported services reported in all counties except Androscoggin, Sagadahoc, and Waldo counties One of top 5 most commonly reported services in all counties except Kennebec, Penobscot and Waldo counties One of top 5 most commonly reported services in 10 of 16 counties. Most commonly cited need in Washington county. One of top 5 most commonly reported services in 6 of 16 counties. 3rd most commonly reported in Aroostook and York counties.

Cardiologic Services including heart surgery

8%

General Surgery

7%

Cancer Treatment Services

6%

Orthopedics

6%

Source: 2010 OneMaine CHNA Household Survey *Note: Percentages calculated among all respondents who reported a need for any service i.e. None responses excluded from denominator

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OneMaine Community Health Needs Assessment 2010 Table 27: Maine Residents Perceptions of Need To Travel Outside of Area for Qualified Physicians or Specialist
Need to Travel Outside of Area for Qualified Physicians or Specialists to Provide Service % of Responses Reporting Need to Travel Outside of Area for Qualified Physicians or Specialist* One of top two most commonly cited services in every county except for Oxford. #1 in Androscoggin, Cumberland, Hancock, Kennebec, Knox, Penobscot, Sagadahoc, Waldo, Washington and York Counties One of top 3 most commonly reported services reported in all counties. #1 in Aroostook, Franklin, Lincoln, Oxford, Piscataquis and Somerset counties One of top 3 most commonly reported services in all counties.

Cancer Treatment

17%

Cardiologic Services including heart surgery

13%

General Surgery

12%

Source: 2010 OneMaine CHNA Household Survey *Note: Percentages calculated among all respondents who reported a lack of qualified medical provider for any service i.e. None responses excluded from denominator

Table 28: Perception of Need to Travel Outside of Area for Service Top 3 by County
An dr o sco gg Ar in oo sto ok Cu mb erl and Fr a nk lin Ha nco ck Ke nn ebe c Kn ox Lin col n Ox for d Pe no bsc ot Pis cat aqu is Sa gad aho c So me rse t Wa ldo Wa shi ng ton Yo rk

Cancer Treatment Cardiologic Services Diabetes Eye Care Infant/Pediatric Services Lung/Pulmonary Services Mental Health Neurological Services Oral Health Services Orthopedics Specialists Surgery Other
11% 8% 7% 10% 8% 10% 8%

12% 7% 11% 15% 8%

9% 7% 11% 9% 6%

10% 14% 6%

11% 8%

10% 11% 12% 9% 8% 7% 7% 12% 8% 7% 7% 7% 9% 8% 9%

18% 15% 10% 11% 11% 11% 14% 10% 12% 14% 12%

Source: 2010 OneMaine CHNA Household Survey *Note: Percentages calculated among all respondents who reported a need for any service i.e. None responses excluded from denominator

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OneMaine Community Health Needs Assessment 2010 Figure 33: Percentage reporting have to travel outside area/region for needed health service
70% 60% 50% 40% 30% 20% 10% 0% 21% 57% 48% 46% 41% 38% 38%37% 34% 30% 19% 42% 39% 32% 26% 62%

22%

Source: 2010 OneMaine CHNA Household Survey

Figure 34: Percentage reporting at least one health service lacking qualified physicians or specialists in area/region
80% 70% 60% 50% 40% 30% 20% 10% 0%
34% 25% 59% 57% 48% 39% 37% 32% 59% 60% 54% 60% 50% 46% 71% 69%

43%

Source: 2010 OneMaine CHNA Household Survey

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OneMaine Community Health Needs Assessment 2010

INTERPERSONAL VIOLENCE/ABUSE

Findings: Incidence of intimate partner violence is generally low in Maine, but rates vary. Respondents reported higher rates of having ever experienced intimate partner violence in Androscoggin, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Waldo, and Washington counties. Respondents in Androscoggin County reported intimate partner violence in the past year at more than twice the rate for the state.

This section reports on the survey responses to questions concerning intimate partner violence. Telephone surveys have been found to be more reliable for such questions than face-to-face interviews, due to the anonymity afforded the respondent. Since the reliability of respondents answers to these questions has been shown to rely on the specific wording of the questions, the actual questions are shown here, along with the population estimates for Maine. The next questions are about violence in relationships with an intimate partner. By an intimate partner, I mean any current or former spouse, boyfriend, or girlfriend. Someone you dated would also be considered an intimate partner. QUESTION: IPV-02 Has an intimate partner EVER hit, slapped, pushed, kicked, or physically hurt you in any way? (population estimate, 12% yes) QUESTION: IPV04 In the past 12 months, have you experienced any physical violence or had unwanted sex with a current or former intimate partner? Physical violence includes being hit, kicked, punched, choked or otherwise physically hurt. (population estimate 1.2 % yes). While these rates are relatively low, there is some variability, with several counties having an elevated rate of experienced violence on the first question, and Androscoggin County having a rate of reported violence in the past year that is more than double than that of the state. (Table 29)

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OneMaine Community Health Needs Assessment 2010 Table 29: Percentage Reporting Having Experienced Intimate Partner Violence EVER experienced physical violence? Androscoggin Aroostook Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadahoc Somerset Waldo Washington York Maine 15% 10% 9% 11% 11% 11% 16% 14% 15% 14% 14% 10% 9% 14% 18% 10% 12% Experience physical violence or unwanted sex in past year? 2.8% 1.0% 1.0% 0.0% 1.6% 1.4% 0.8% 0.9% 1.2% 1.4% 0.4% 0.7% 0.2% 0.7% 1.4% 1.2% 1.2%

Source: 2010 OneMaine CHNA Household Survey

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OneMaine Community Health Needs Assessment 2010

ARTHRITIS, BONE AND JOINT HEALTH

Findings: Arthritis rates in Maine are above average while related bone procedures are comparatively low, but rates vary. About 32% of Maines residents have been diagnosed with arthritis, and about 59% of those over the age of 65, and 39% of those aged 45-64. Maines rate of hip procedures is 93 per 100,000, well below the national rate. Lincoln, Oxford, and Washington counties appear to have high rates of hip procedures in the non-elderly population.

Arthritis and other rheumatic conditions are among the most common diseases in the US, and are among the leading causes of disability and health-related limitations of daily activities among adults. The CDC estimates that 22% of the US population has been diagnosed with arthritis, based on the National Health Interview Survey. In evaluating the burden of disease, it is important to assess prevalence of arthritis as well as other indicators of bone and joint health, such as hospital admissions for common orthopedic procedures. Overall, 32% of Maines population has been diagnosed with arthritis, while the rate for those over age 65 is now 59%. It is not surprising that Maines overall rate exceeds the national rate, since Maine has, by recent measures, the oldest population in the nation. Perhaps of greater concern is the rate for those in the 45-64 age bracket, where statewide prevalence is now 39%. Oxford, Piscataquis, Waldo and Washington counties have the highest rates for this age group. Statewide, the rate of hip procedures is 93 per 100,000 population. This compares with a recently reported rate of 145 per 100,000 at the national level.61 The pattern for hip procedures is also subject to an age breakdown. That is, we expect more frequent hip procedures among the elderly, and the overall rate of procedures for the population is driven by the rate of procedures for the elderly. Where the over65 rate is closer to the state rate, one would expect the total population rate to also be close to the state rate. That is not the case, however, in Lincoln, Oxford and Washington counties, where population rates are high, but over-65 rates are not. Population rates for head/brain procedures are highest in Androscoggin, Cumberland, Hancock, Knox, and Oxford counties, with the highest rates for seniors in Cumberland, Franklin, Hancock, Kennebec, Knox, and Oxford counties.

61

Singh, JA et al. A Population-Based Study of Trends in the Use of Total Hip and Total Knee Arthroplasty, 1969-2008. Mayo Clinic Proceedings, 2010
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OneMaine Community Health Needs Assessment 2010 Table 30: Arthritis, Bone and Joint Health
An d ro sco gg in Ar oo s to ok Cu mb erl and Fra nk l in Pis cat aq uis Sa ga da ho c So me rse t Ke nn ebe c Lin col n Ox fo r d Pe no bsc ot ck Wa ldo ing ton

Ha no

Wa sh

Kn ox

% Diagnosed with Arthritis

31% 32%

29% 37% 56%

30% 40% 53%

32% 35% 56%

32% 37% 66%

36% 36% 65%

34% 33% 55%

35% 44% 62%

29% 38% 63%

42% 45% 61%

32% 35% 59%

31% 40% 63%

37% 44% 62%

35% 44% 60%

31% 32% 39% 39% 56% 59%

Ages 45-64 40% 38% Ages 65+ 61% 65% Hip Procedures, Hospital Admission Rate Ages 65+ Head Brain Injury, Hospital Admission Rate Ages 65+

94 473

94 418

93 483

92 500

114 499

105 527

101 393

108 473

120 493

81 404

112 505

83 388

106 525

94 469

114 443

70 363

Yo rk

93 452

64 180

53 161

68 238

60 233

66 200

55 199

76 200

53 148

72 210

51 139

41 146

50 194

50 94

44 104

49 125

47 156

57 180

Source: BRFSS 2007 & 2009 combined, MHDO Hospital Discharge Dataset Q42007-Q32009 Bold face = 10% or more above state. Arthritis prevalence expressed as percentage, all other rates are per 100,000

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OneMaine Community Health Needs Assessment 2010

INFECTIOUS DISEASE

Findings: Incidence of infectious and sexually transmitted diseases (STD) is generally low in Maine, but rates vary. Vaccination rates for influenza are generally good, but again, rates vary. New cases of Hepatitis C were lower in 2009 as compared to the previous four years. The highest rates were observed in Androscoggin, Cumberland, and Oxford counties. Androscoggin and Cumberland counties have consistently higher rates of STDs than other counties. Maines rate of influenza vaccinations is right at the national percentage, but several counties have significantly lower rates, including Aroostook, Franklin, Piscataquis, Waldo and Washington.

Hepatitis C Hepatitis C is a contagious liver disease that results from infection with the Hepatitis C virus (HCV). It is most commonly spread when blood from a person infected with the Hepatitis C virus enters the body of someone who is not infected. Today, most people become infected with Hepatitis C by sharing needles or other equipment to inject drugs. Before widespread screening of the blood supply began in 1992, Hepatitis C was also commonly spread through blood transfusions and organ transplants. An estimated 3.2 million people in the United States have chronic Hepatitis C. Most are unaware of their infection. Each year, about 17,000 Americans become infected with Hepatitis C. Chronic Hepatitis C is a serious disease that can result in long-term health problems, including liver damage, liver failure, and liver cancer. Approximately 12,000 people die every year from Hepatitis C-related liver disease62. There is currently no vaccine to prevent Hepatitis C. HCV infection was added to the list of nationally notifiable conditions in January 2003. Many who are affected are not aware of their condition. According to a 2001 report, of the estimated 15,000 persons infected with HCV in Maine at that time, fewer than 2,000 had been diagnosed. Maine CDC reports the current (2009) incidence rate to be 62 persons per 100,000, down from a rate of 90 per 100,000 in 2006. This rate varies considerably among Maines counties, from a low of 35 cases in Penobscot County, to a high of 91 in Androscoggin County. In addition to Androscoggin County, rates are especially high in Cumberland (89) and Oxford (78) counties. However, it should be repeated that these rates have declined in the past four years. (Figure 35) HIV and Sexually Transmitted Diseases HIV is the human immunodeficiency virus. It is the virus that can lead to acquired immune deficiency syndrome, or AIDS. AIDS is the late stage of HIV infection, when a persons immune system is severely damaged and has difficulty fighting diseases and certain cancers. Before the development of certain medications, people with HIV could progress to AIDS in just a few years. Currently, people can live much longer - even decades - with HIV before they develop AIDS. This is because of combinations of medications that were introduced in the mid 1990s.63

62 63

CDC Hepatitis C General Fact sheet, 2008 USDHHS, CDC, http://www.cdc.gov/hiv/default.htm accessed January 4, 2011
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OneMaine Community Health Needs Assessment 2010 At the end of 2009, there were 1,456 individuals in Maine living with HIV.64 The annual incidence of HIV-positive diagnoses in Maine continues to decline, with only 56 new cases reported in 2009.65 Most new cases have occurred in southern Maine, with York, Cumberland, and Androscoggin counties reporting the highest incidence rates. Many whose HIV infection has progressed to AIDS are now treated on an ongoing basis, and mortality rates are extremely low. However, these same southern Maine counties continue to experience hospital admissions for patients with AIDS-related symptoms. The rate of AIDS-related hospital admissions for Maine in 2009 was 5.1 per 100,000. Relatively high admission rates were experienced in Androscoggin (7.5), Cumberland (8.6), Kennebec (7.4), and Oxford (7.1) counties.66 Maine tracks two other sexually transmitted diseases, gonorrhea and chlamydia, with incidence rates of 7.3 and 197 cases per 100,000 respectively. The U.S. CDC estimates that about 2.8 million Americans contract chlamydia each year. The 19% increase in reported cases since 2006 is generally attributed to an increase in the number of individuals being tested. Meanwhile, the rate of new cases of gonorrhea has continued to fall in recent years, to a 2009 rate of 111 cases per 100,000 -- the lowest rate since the CDC started tracking the disease in 1941.67 Figure 35 illustrates that, as with HIV and AIDS, Androscoggin and Cumberland counties have higher rates of these diseases. However, several other counties have high rates of gonorrhea (Aroostook, Hancock, Oxford, and Sagadahoc counties), and high rates of chlamydia (Penobscot and Somerset counties). Influenza Influenza (flu) can be a serious disease, particularly for some groups who are at risk, including older people, young children, people with chronic lung disease, diabetes, heart disease, and some other chronic conditions. Each year, the severity of the coming flu season is unknown, and Maine prepares for it by urging these at-risk groups to get their flu vaccine. Health care workers are also on the priority list for the vaccine. As supplies allow, the remaining populace is encouraged to get vaccinated. The vaccine is now available as a nasal spray, as well as an injectable. In the household survey, 42% of respondents had received either the injection or the nasal mist in the past year. This is consistent with the national estimate of 41.2% for the 2009-2010 flu season.68 Due to the occurrence of the H1N1 flu last year, concern among the general public was higher than usual. Sustaining this level of coverage in 2010-11 may be a challenge. Some variation in coverage was observed, with the lowest rates (34%) in Piscataquis and Washington counties, and the highest rate in Cumberland (49%) as seen in Table 31.

64 65

Maine CDC 2010, Annual Surveillance Report Maine CDC 2010 annual report 66 Extensive data on HIV/AIDS in Maine are available from the Maine CDC at the following URL: http://www.maine.gov/dhhs/boh/ddc/hiv-std/publications.shtml#std 67 USA Today Nov. 23, 2010 Gonorrhea rate at lowest level since 1941 68 USDHHS, CDC online at http://www.cdc.gov/flu/professionals/vaccination/coverage_0910estimates.htm
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OneMaine C Community Health Need Assessme 2010 ds ent Figure 35: Incidence Rates of H 3 e Hepatitis C, G Gonorrhea, a Chlamyd and dia County Dif fferences from State

Central Axis is Maine Rate s e

Source: Maine CDC Division of D Disease Control, 2 2007-2008

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OneMaine Community Health Needs Assessment 2010 Table 31: County Rates of Influenza Vaccination for 2009-2010 flu season. Maine rate = 42% Androscoggin Aroostook Cumberland Franklin Hancock Kennebec Knox Lincoln 40% 37% 49% 35% 40% 39% 44% 38% Oxford Penobscot Piscataquis Sagadahoc Somerset Waldo Washington York 40% 43% 34% 46% 39% 36% 34% 39%

Source: 2010 OneMaine CHNA Household Survey

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OneMaine Community Health Needs Assessment 2010 VII. PRIORITY HEALTH ISSUES Community health needs assessments are designed, in part, to identify issues where changes in the health care delivery system can improve both patient care and preventive services for those at risk for health problems. This section presents a summary of the priority health issues for Maine and its counties. For each identified priority health issue, findings are described followed by a potential list of questions for follow-up. While community health needs assessments can point out underlying causes of good or poor health status, health providers and health related organizationsprimary users of information found in CHNAsare not usually in a position to affect all of the changes required to address a health issue. For example, the ability to reduce poverty, improve educational attainment, or affect employment cannot be achieved by a health system alone. Nor can they affect basic demographics like age or gender distribution patterns. Socio-demographic drivers of health status: Maine as a state has several underlying socio-demographic characteristics that impact many of the health indicators found in this report. For example, Maine has the oldest population in the U.S. i.e., a very high proportion of elderly (65+) compared to the U.S. Aroostook, Knox, Lincoln, Piscataquis, and Washington counties have an even higher proportion of elderly than the state. Part of this is due to the declining population in these counties, especially among younger and working age groups. While being older does not necessarily mean poor health, the reality is that aging populations use more services than younger populations. When older age is combined with other adverse factors, like poverty or unemployment, there is often an association with poor health status. Income is an underlying factor for several health indicators. Maine has a lower median income than the U.S., with high poverty rates in Washington, Somerset, and Franklin counties. The proportion of Maine residents below the Federal poverty level is slightly lower than the U.S., however, the northern and central counties have a greater proportion of residents living below the Federal poverty line than Maine or the U.S. Unemployment is an important demographic predictor of health, and while Maine overall appears to have a lower unemployment rate compared to the US, there are several Maine counties - Franklin, Oxford, Piscataquis, Somerset, and Washington - with high rates of unemployment, many well over 10%. Educational attainment is relatively good in Maine, as measured by the proportion of the population with a high school diploma. However, Washington, Somerset, Aroostook, Androscoggin, and Piscataquis counties all have high proportions of residents without a high school diploma. Access to Health Care: While there is much to commend in Maine regarding access to care, especially in comparison with the rest of the country, it still remains a priority health issue for most if not all - Maine counties and for the state. Maine has a low percentage of uninsured residents (13%), as well as a low percentage of residents without a usual source of care (13%), relative to the U.S. (17% and 24%, respectively). In fact, Maine has already surpassed the Healthy People 2020 goal of reducing the number of people without a usual source of care to 17%. Washington County is the only county in Maine with a greater percentage of uninsured than the U.S., with 22% of Washington County residents reporting no current insurance coverage in the OneMaine household survey. However, access to care remains a priority health issue for Maine due to the pervasive effect that lack of access has on the healthcare system, especially as it relates to high ED use and subsequent effects on cost. Residents in some counties are much more likely to use the Emergency Department.
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OneMaine Community Health Needs Assessment 2010 ED utilization is high in Aroostook, Somerset, and Washington counties. Of these three counties, two (Somerset and Washington) also had high percentages of people without a usual source of care. In Maine and in most counties, the 18-44 year-old population uses the ED at higher rates than other age groups. Among the 65 and older population ED utilization is appears elevated in Hancock, Piscataquis, Somerset, and Washington counties. Every county (with the exception of Washington County) and Maine residents overall named Health care too expensive and Lack of health insurance as the two greatest health problems facing their communities in the OneMaine CHNA 2010 Household Survey.

Suggested Questions for follow-up: What are the barriers for those without a usual source of care? Is it the inability to find a doctor, lack of insurance, geographic access, or something else? Why are the elderly in certain counties using the ED at such high rates? Is there a problem with providers accepting Medicare in these areas? Or is the issue geographic/transportation related (i.e. the ED is closer than a primary care office)? What is driving the very high ED visit rates in certain counties (e.g. Somerset)? Are there simply not enough primary care providers (PCPs)? Are PCPs not willing or financially able to see those who are uninsured or on Medicaid? Is it PCPs hours of operation (e.g., not open after 5pm)? Primary Care Quality and Effectiveness: Access and availability to high quality primary care, especially for those with chronic health conditions, is a continuing challenge in Maine. Access to primary care for chronic conditions appears to be an issue in many counties. This may be due to inadequate availability of providers, lack of health insurance, lack of chronic disease self management and other patient, health system or population issues. Aroostook, Somerset, and Washington counties had higher inpatient and Emergency Department admissions for Ambulatory Care Sensitive (ACS) conditions than the state. Franklin, Knox, and Penobscot counties had higher rates of inpatient ACS admissions, but lower rates of ED admissions. Sagadahoc and Waldo counties had the opposite pattern.

Suggested Questions for follow-up: What is driving the higher use of ED and inpatient utilization for ACS conditions? Is it due to higher disease prevalence, or inadequate access to primary care for chronic health conditions? Is it barriers to chronic disease self management? Are a small number of "frequent flyers" responsible for high user rates in some counties, or are those rates driven by a lot of people utilizing the ED, indicating that system improvement is in order? Is transportation to primary care an issue? Are hours of operation of primary care practices adequate? What is the status chronic disease self-management and community supports for patients diagnosed with chronic health conditions?
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OneMaine Community Health Needs Assessment 2010 Behavioral Risk Factors for Cardiovascular Health: Behavioral health risk factors such as smoking, overweight, and sedentary lifestyles continue to be priority health issues in several, mostly rural, counties, and in the state (overweight, sedentary lifestyle, and smoking). Smoking rates are high in Aroostook, Oxford, Somerset, Washington, and York counties. Prevalence of obesity is 28% in Maine, with Oxford, Penobscot, Piscataquis, and Washington counties elevated above the state. Sedentary lifestyle is prevalent in Aroostook, Oxford, Piscataquis, Somerset, Waldo, and Washington counties.

Suggested Questions for follow-up: What smoking cessation programs are available and accessible to populations in need? Do consumers have adequate knowledge of, and use, the Maine Tobacco Helpline in these counties? Are providers referring smokers to the Helpline? What is the availability and use of tobacco treatment medications? What are the linkages between smoking programs, providers, and patients who smoke? What are the best available behavioral change policies and programs to address weight issues in the general population? Are they available to overweight and obese residents? Are there sufficient state level environmental, nutrition, transportation and related health policies to address this issue in Maine? What community and patient level resources are needed? Are they available? How can the health systems address these issues more effectively in collaboration with community partners, state policy makers, etc.? How can mental health providers assist primary care medical providers in addressing the psychological issues related to weight? What is the availability of all ranges of exercise programs in the communities and at the workplace? What organizations are best situated in the community to promote/administer/partner with healthcare organizations to reach the at-risk populations? Are health systems working with the Maine CDC/DHHS Cardiovascular Health Program on blood pressure and cholesterol detection and control efforts? Can innovative promising practices in diabetes prevention (e.g., the Diabetes Prevention Program) be adapted for those at risk of cardiovascular disease? Can Accountable Care Organizations (ACOs) be designed to address these issues effectively, so that payments for services will support prevention and disease management?

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OneMaine Community Health Needs Assessment 2010 Medical Risk Factors/Access to Treatment for Cardiovascular Health: Levels of medical risk factors are of concern in several counties, as well as high rates of morbidity and mortality in counties without high disease prevalence. This needs to be better understood and addressed. Elevated rates of high blood pressure are seen in Aroostook, Piscataquis, Somerset, and Washington counties. High stroke admission rates are seen in Aroostook, Hancock, Knox, Lincoln, Piscataquis, Somerset, and Washington counties. Elevated rates of hyperlipidemia (high cholesterol) are seen in Androscoggin, Oxford, and Washington counties. High heart attack (AMI) rates are seen in Aroostook, Hancock, Kennebec, Piscataquis, Somerset, Waldo, and Washington counties. Counties with higher prevalence of high blood pressure and high cholesterol are more likely to have higher obesity rates.

Suggested Questions for follow-up: Are there sufficient PCPs and medical specialists available to detect and treat patients with heart disease, especially in these counties? Are there community and employer based programs to detect and manage heart disease and medical risk factors? How effective are they? How can they be improved? What is the status of chronic disease self-management in these counties? What can the health systems provider networks do to increase education (provider and patient), patient self-help resources, and linkages to community resources? Are healthcare systems partnering with Maine CDC/DHHS Cardiovascular Health Program and Partner initiatives such as Maine HeartSafe Communities, In a Heartbeat, and efforts on AMI and sudden cardiac arrest and stroke systems of care? Respiratory Health: Maine overall, as well as several counties, continue to have high prevalence of respiratory risk factors and disease. Smoking rates are high in Aroostook, Oxford, Somerset, Washington, and York counties, despite an older population in most of these counties. Male smoking rates are high, especially in Oxford County. Washington, York, and Androscoggin counties have similar rates of smoking for males and females. Asthma prevalence is 10%, with elevated rates in Androscoggin, Aroostook, Somerset, and Waldo counties. Somerset, Waldo, and Washington counties have elevated COPD rates compared to the state. Washington County has high ED and inpatient admission rates for asthma and bronchitis, despite not having elevated prevalence.

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OneMaine Community Health Needs Assessment 2010 Suggested Questions for follow-up: [See above under behavioral health risks for CVD.] Why do females in these counties have higher smoking rates than in other counties? Is this due to success in lowering male smoking rates in these counties? What can be learned from this? How are programs, providers (especially specialists and PCPs), and patients linked for effective COPD care? How can training and use of spirometry to diagnose and manage COPD patients be spread throughout the state? What is the status of rehabilitation services for COPD patients? What programs are available to improve patient self-management of COPD? What types of mental health programs are there to assist more severe COPD patients (and their families) in coping with this condition? Are the at-risk populations obtaining good primary care to manage asthma? What programs are available to improve self-management of asthma? Diabetes: Diabetes prevalence continues to increase in Maine. Lifestyle and care management continue to be priority health issues. Overall diabetes prevalence in Maine is 10%, but it is elevated in Aroostook, Oxford, Piscataquis, and Washington counties. Diabetes prevalence is associated with high rates of obesity and sedentary lifestyle for most counties. Franklin and Oxford counties have poorer diabetes care management than most other counties. Inpatient admissions and ED visit rates for diabetes appear to correlate with prevalence and risk factors but not with diabetes care management indicators. Aroostook, Franklin, Hancock, Kennebec, Oxford, Somerset, and Washington counties have high diabetes mortality compared to the state.

Suggested Questions for follow-up: [See above behavioral health risk factors for CVD] What accounts for disparities in access to and quality of diabetes care in these counties? What more can be done to reduce ED and inpatient admissions for diabetes? What is the status of patient education and self-management programs to improve diabetes care and health status? What promising practices such as DEPLOY (delivering a group-based diabetes prevention program lifestyle intervention through the YMCA) could be adapted and implemented by healthcare systems in Maine? What accounts for the higher mortality rates for diabetes in these counties? Cancer Health: Maine continues to have high cancer incidence and mortality rates. Mortality due to cancer is largely the result of higher incidence, with several county- and cancer- specific exceptions, suggesting possible treatment disparities in some counties for selected cancers. There are high incidence and mortality rates statewide, and especially for selected counties.
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OneMaine Community Health Needs Assessment 2010 Overall cancer incidence is high in Hancock, Piscataquis, and Washington counties, as well as for three of four leading cancers. Aroostook, Lincoln, Oxford, Piscataquis, and Washington counties have elevated cancer mortality rates. Mortality/incidence ratios in Aroostook, Franklin, Knox, and Oxford counties are high, suggesting possible disparities in access to cancer screening and evidence based treatment. Lung cancer mortality to incidence ratios are highest of all cancer sites.

Suggested Questions for follow-up: What can be done to lower risk factors for cancers in Maine overall and in those counties with very high incidence rates? Are cancer patients from these counties able to access evidence based care? Are there cost, quality or other barriers to care? Are cancer types different and more difficult to treat? What is the availability of state of the art lung cancer treatment in Maine. Are there barriers to care for patients diagnosed with lung cancer in Maine? Mental Health: Mental health is a priority health issue due to the impact of mental health problems on a large portion of Maines population, the fact that mental health problems are frequently co-morbid with physical health issues and co-occurring with substance abuse problems, and issues related to receiving mental health care in appropriate settings. Close to 11% of Maine residents report experiencing 11 or more days (in the past of month) in which their mental health was not good. Five percent of Maines population reported that they had needed mental health treatment in the past year but had not received it, and more than 7.0% are at risk for clinical depression based on their responses to key questions in the OneMaine CHNA household survey. In terms of prevalence, 22% of Maine residents have been diagnosed with depression at some time in their lives, and almost 15% have a current diagnosis of depression. Over 13% have been diagnosed with some other psychiatric disorder in their lives. In terms of service use, Maine residents show high patterns of emergency department utilization for a wide range of mental health issues, including senility and organic mental disorders, major depressive disorders, bipolar disorders, schizophrenia, and anxiety disorders, suggesting potential access issues to mental health services across Maine. Aroostook, Kennebec, Oxford, Penobscot, Somerset, Waldo, and Washington counties have higher combinations of mental health risk factors (i.e., percentage with 11 or more days of poor mental health in last month, percentage needing but not getting mental health treatment in last 12 months, and percentage at risk for clinical depression). Franklin, Kennebec, and York counties have higher rates of mental health problems (i.e., rates of lifetime depression, current depression, lifetime other psychiatric disorders, or developmental delays or learning disabilities). Androscoggin, Kennebec, Knox, Penobscot, and Waldo counties have elevated mental health hospital admission rates for a wide range of conditions. Androscoggin, Penobscot, and Somerset counties have higher emergency department use for mental health issues, including senility and organic mental disorders, major depressive disorders, bipolar disorders, schizophrenia, and anxiety disorders. Maine has elevated suicide mortality. Counties exceeding the state rate include Aroostook, Cumberland, Franklin, Knox, Lincoln, Oxford, Piscataquis, Waldo, and York.
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OneMaine Community Health Needs Assessment 2010 Suggested Questions for follow-up: What are the barriers to accessing care for those needing but not receiving services? What are the reasons for variations in inpatient and emergency department use for mental health problems across Maine counties? What role can primary care providers play in screening for, identifying, treating, and referring routine mental health conditions? What are the reasons for higher rates of suicide mortality in Maine and across Maine counties? What interventions and/or prevention interventions can be implemented to reduce the rates of suicide mortality across Maine counties? Substance Abuse: Substance abuse (SA) is a priority health issue in Maine, due to the high costs associated with SA and the treatment of alcohol and drug conditions. Maines Office of Substance Abuse estimated the total costs of SA to exceed $898 million in 2005. In Maine, alcohol is the most commonly used substance, with more than 58% of adult Maine residents having at least one drink within the past 30 days. Rates of problem drinking behavior such as binge and heavy drinking among Maine residents are comparable to national averages, at 15% and 16% respectively. Close to 5.0% of Maine residents have been diagnosed with a substance abuse problem in their lifetime, and almost 2.0% have a current substance abuse disorder. Over 5.0% of Maine residents have used a street (or illicit) drug within the past 30 days. Non-prescription use of prescription medications is a growing problem that is becoming increasingly recognized in Maine, with 2.0% of the population reporting having misused prescription medications within the last 30 days, and Maine counties showing wide variations in prevalence rates for this problem. Our data suggest potential access barriers to SA treatment services, given the patterns of inpatient admissions and emergency department use for a variety of SA problems. Males in Maine also exhibit higher rates of rates of mortality for alcohol-related issues and alcohol-related motor vehicle accidents than do women. Cumberland, Knox, Lincoln, Oxford, Somerset and Washington counties have higher patterns of substance abuse (SA) prevalence related to alcohol, street, and/or non-prescription drug use. Hospital admission and emergency department use does not correspond with these prevalence rates. Aroostook, Franklin, Lincoln, Oxford, Piscataquis, Somerset, and Washington counties have elevated rates of SA mortality and lower rates of hospital and emergency department admissions for SA problems. Androscoggin, Cumberland, Hancock, Kennebec, Penobscot, Piscataquis, and Washington counties have higher rates of emergency department use for SA related disorders than the state as a whole. Aroostook, Franklin, Lincoln, Oxford, Piscataquis, Somerset, and Washington counties exhibit higher patterns in the rates of SA mortality related to alcohol problems, alcohol liver disease, and alcohol-related motor vehicle accidents. Alcohol and drug abuse are the most commonly cited health problems in Washington County, and the second most commonly cited problems in Aroostook, Kennebec and Knox counties. Maine has higher rates of prescription drug use, with Androscoggin, Cumberland, Hancock, Knox, Penobscot, Piscataquis, Somerset, Washington, and York counties exhibiting higher rates than the state as a whole.
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OneMaine Community Health Needs Assessment 2010 Suggested Questions for follow-up: What is the level of public knowledge related to understanding SA problems in Maine? How knowledgeable are primary care and other medical providers related to the issues of identifying, screening, treating, and referring individuals with SA problems, including prescription drug misuse? What issues related to the SA crisis and treatment service infrastructure impact access and utilization across Maine counties? What contributes to higher rates of SA mortality in select Maine counties, and what can be done to intervene in the causes? What are the factors related to driving under the influence in Maine, and what can be done to reduce rates of driving under the influence? Youth Health: Areas of concern affecting significant numbers of Maine youth are primarily health risk behaviors. Childhood obesity and teenage drinking are risky behaviors that place youth at both immediate and future risk. These concerns suggest a need for prevention interventions involving local organizations and stakeholders. Areas of concern that are not associated with risk behaviors include depression, sometimes leading to suicidal ideation, as well as asthma and bronchitis. High rates of two or more youth risk behaviors were identified in Aroostook, Franklin, Lincoln, Piscataquis, Waldo, and Washington counties. Hospital admissions for depression and suicidal ideation are highest in Androscoggin, Cumberland, Lincoln, Piscataquis, Sagadahoc, and Waldo counties. Hospital admission and emergency department rates are highest for asthma/bronchitis in Androscoggin, Aroostook, Franklin, Kennebec, Knox, Penobscot, Somerset and Washington counties

Suggested Questions for follow-up: What programs are currently in place to address youth risk behaviors, e.g. smoking, drinking, drugs? Are these programs locally initiated? Are they implemented any differently in these high risk counties? Are admission rates for depression related to population need, or are they determined by the availability of services? If need-based, why is the need higher in some counties? Are depression and suicide correlated with youth risk behaviors? Do asthma admission rates correlate with air quality measures? Are they related to housing issues? Do primary care providers have registries for asthma, with disease management protocols? Is disease management related to ED admission rates? Oral Health: Oral health continues to be a high priority for the entire state, with a low ratio of providers to population, especially affecting rural residents and low-income residents. Maine has a very low ratio of practicing, primary care dentists to population, compared to national rates.
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OneMaine Community Health Needs Assessment 2010 Twenty-four percent (24%) of residents report no dental visit in the past two years. This was highest in Aroostook, Oxford, Piscataquis, Somerset and Washington counties. Oral health is the most commonly cited service for which residents report having to travel outside of the service area.

Suggested Questions for follow-up: What innovative or model workforce or training programs aimed at providing oral health in underserved and/or rural states could be applied in Maine? How many Federally Qualified Health Centers (FQHCs) and safety net clinics in Maine have dental clinics, and is there an opportunity to add dental service sites to existing federal grantees or other community health centers entities?

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OneMaine Community Health Needs Assessment 2010 VIII. RECOMMENDATIONS The following recommendations have been developed to address the priority health issues described in the previous section of this report. They are broken out by issue area e.g. primary care. However, several overlap. These recommendations are based on the quantitative information analyzed for the CHNA, and on several decades of experience studying and working with the healthcare delivery systems in Maine and across the U.S. They address Maine as a whole, and as such may not apply to each local health system in the state. Recommendations are typically presented with a specific entity or entities assigned responsibility for further planning and implementation. For instance, a community or local health system could implement some of the recommendations, individual providers could implement others, and still others might require government participation. For many, though, a combination of one or more collaborating entities/sectors will be needed to achieve success. As with any recommendations developed from a comprehensive study that spans many local delivery systems, these will need further discussion and refinement, planning, resource identification, and leadership. In the process of moving from planning to implementation, solutions may also need to be tailored and changed to respond to changes in the healthcare system and/or to allow for adaptations at a local level. Access to Care While Maine has a higher rate of insurance coverage than the U.S., insurance coverage in Maine and nationally69 is still a major issue. According to a recent report by the Urban Institute, implementation of the Affordable Care Act (ACA) in Maine would reduce the number of uninsured by 81,000 people, leaving an estimated 66,000 uninsured - of which 80% would be adults.70 However, there is uncertainty about the implementation of the ACA, both nationally and in Maine71. As of the date of this report there is also uncertainty about retention of existing coverage for many in Maines Medicaid program (MaineCare), as well as in the states insurance program for low income Mainers, DirigoChoice Health Plan. The latter program may be eliminated altogether before the insurance components of ACA are implemented. All of this will likely reduce insurance coverage in Maine in the short term, and have adverse effects on healthcare access, quality and cost. While ACA implementation will likely increase access to care for many, Maine still needs a viable, proven alternative to the current insurance model for small businesses and low-income childless adults (among other populations). Some states are working to expand upon the ACA health insurance reforms, attempting to cover virtually every resident. For example, Vermont has introduced legislation to implement a single payer system for the state that will become effective in 2017.72 Vermonts goal is to provide universal coverage, and the resulting legislation was the result of multi-stakeholder involvement
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The 2010 National Healthcare Quality Report produced by AHRQ indicates improvement on only 40% of the twentytwo measures of access to care, such as the number of people younger than 65 with health insurance. 70 Beuttgens M, Holahan J, and Caitlin C. Health Reform Across The States. The Urban Institute. March 2011. 71 The Patient Protection and Affordable Care Act (ACA) will expand health insurance coverage by about 30 million people reducing the number of uninsured by more than half. The ACA would reduce the number of nonelderly people without health insurance by 28 millionfrom 18.9 to 8.7 percent. Of the 23 million still uninsured, 40 percent would be eligible for, but not enrolled in, Medicaid or the Childrens Health Insurance Program (CHIP). A further 22 percent would be undocumented immigrants. 72 The ACA prohibits a single payer system until 2017. Should this change Vermont will in all likelihood speed up implementation provided the legislation passes.
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OneMaine Community Health Needs Assessment 2010 in system reform. It is recommended that Maine follow suit and develop its own plan for expanded coverage beyond what will be covered under the ACA, should the ACA be implemented. If it is not implemented, having an alternative plan is essential to maintain and improve access. To accomplish this will require outstanding leadership, vision, and objective data and information, and should be based on the known experiences of western democracies in health insurance coverage.73 Access to dental care, while improving in the state, must be expanded and integrated where possible with routine medical care. Oral health is essential for overall physical health and well-being. The lack of dentists, cost issues, cultural issues, and reimbursement policies all combine to severely limit access to dental care in Maine, especially for low-income populations (with or without MaineCare). 74 Local efforts such as the new University of New England College of Dental Medicine will improve the availability of dentists in Maine over time. However, payment for dental care will still be a burden for many and unattainable for others. A consistent set of policy initiatives are required to insure that dental care is incorporated into the benefits of existing health insurance policies and into the fabric of the healthcare delivery system. Recommendations include: Medicaid (MaineCare) reimbursement rates for dental services should be increased.75 Hospitals - particularly critical access hospitals should determine the feasibility of establishing dental offices within the hospital, or at hospital owned primary care practices or clinics. Maines dental hygiene schools at the University of New England Westbrook College of Health Professions (Portland) and at the University of Maine (Bangor) should expand educational experiences with rural clinical experiences. Quality and Effectiveness of Care The 2010 CHNA data provides a disturbing view of high ED and hospital use by patients with symptoms and conditions that could be prevented with care provided in primary care settings. The issue is complex and could be due in part to a maldistribution of primary care providers (PCPs), the inability of patients to be seen on a timely basis or the methods of financing primary care providers. It also reflects the inability of some populations (especially MaineCare participants and the uninsured) to locate or obtain a PCP as their usual source of care. The result is that many patients are receiving their healthcare in the most expensive (and often inappropriate) setting the ED. The ED is far more expensive than an office visit, and does not provide the continuity of care that office based care provides. Maine has many experiments underway attempting to improve the quality, effectiveness and cost efficiency of care.76 They include the Maine Patient Centered Medical Home Project, Pathways to

TR Reid. The Healing of America. Penguin Books, 2009. There are some interesting and innovative dental health experiments in Maine, such as teaching PCPs to screen children for dental health, and the work of Community Dental Health in Portland in setting up dental clinics in many areas of the state particularly some in the service areas of Critical Access Hospitals. 75 Increasing Medicaid funding of pre-natal care was instrumental in reducing expanding access to prenatal care for this population in Maine in the late-1980s. There is no substantive reason this would not happen for dental care.
74

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OneMaine Community Health Needs Assessment 2010 Excellence (Maine Health Management Coalition), the Hancock County Patient Self Management Network, and the Bangor Beacon Community, all previously mentioned. In addition, Maines extensive network of Federally Qualified Health Centers (FQHCs) and cutouts are evidence that comprehensive primary care cost-effectively provided in one location can reduce hospital and ED use. FQHCs have decreased hospital admissions and ED utilization, while sliding fee scales and free or subsidized drug programs bolster the affordability of medical consultations and treatments for low income populations. 77 Many experiments have demonstrated positive results. However, results often reverse when project funding ends. Sustainability of successful models is an issue that has to be addressed. It is recommended that the State play a larger role in establishing, leading and/or funding these efforts though legislation or funding. Community Care of North Carolina, which embeds community health workers in primary care practices, is a good example of a state funded program that provides high quality care while saving millions of dollars in Medicaid funding. Vermonts Blue Print for Health initiative is another state led example (with multi-stakeholder involvement and support), and with its community health teams approach, shows great promise for improving the way in which primary care is delivered. The establishment of an information clearinghouse to review and publish findings from these varied experiments in Maine is recommended. This information is needed to increase understanding of what is working and what isnt. The data provided from a clearinghouse could also help determine how to permanently sustain the successful experiments. Primary Prevention Services There are two at-risk populations in Maine. The first is the population who smoke and/or are overweight/obese but do not yet have serious medical problems. Therefore, they do not frequent medical providers. They tend to be younger, and in the past their addictions have been addressed with education, direct services, and health policy initiatives. For example, there is general consensus that tobacco tax policies have been effective in reducing smoking in the younger, school age population. However, these interventions may be insufficient to maintain a decline in tobacco use among Maines young adults. Obesity remains a major issue across all age and gender groups. To address both smoking and obesity will require much bolder approaches than are currently in place, coupled with additional resources. It is recommended that initiatives to reduce obesity, for example, address both children and adults and focus on the underlying causes of the problem. Approaches should be comprehensive and include use of tax policies. Local resources are needed to enhance access to exercise, nutrition, and treatment modalities including stress management. Approaches should integrate Maines developing local public health infrastructure, community based resources, local providers, patients and families. The second at-risk population is individuals with one or more chronic diseases who continue to smoke and/or are obese. The size of this population varies across the state but represents a real challenge to communities and the healthcare delivery system. Health improvement strategies for this population are best centered where one can reach them - where they obtain medical care, where they are employed, and through community programs to which they have easy access. Strategies for improvement need to be consistent and comprehensive. For example, the need to change smoking behavior should be addressed at
76

Examples are the Maine Patient Centered Medical Home pilot; the new Beacon Community at Eastern Maine Healthcare Systems; the CMS Maine Multi-Payer Advanced Primary Care Practice Demonstration; and a number of developing pilot Accountable Care Organizations. 77 Deprez, RD, Pennell, BE, & Spindler, MA. "The Substitutability of Outpatient Primary Care at Rural Community Health Centers for Inpatient Hospital Care." Health Services Research, 22:2 (June 1987). A follow-up study to this research demonstrated that use of family physicians was the major factor in achieving reduced hospital use.
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OneMaine Community Health Needs Assessment 2010 every available opportunity, and in a way that considers the barriers that many individuals have to quitting. Programs should also recognize that increasing physical activity and improving diet in this population can be a stimulus to reducing smoking, and should encourage and take advantage of community and family support. The challenge is how to motivate current patients to change the behavior(s) that contributed in part to the development of their chronic medical condition. The challenge is considerable, as the data indicates. Policies, programs and services that assist, coach and generally make it easier for patients to engage in weight reduction, better nutrition or smoking cessation activities are critical. The responsibility rests with medical and community-based resources at the local and regional level to work more closely together to ensure consistent reinforcement of behavior change messages. Making exercise, nutrition and counseling services available locally will be a major undertaking. It means re-organizing primary care, making it more patient-centered, improving patient self management resources, and getting payers to be more flexible in funding preventive services that have been shown to be cost effective. (See Care of Chronic Conditions section below for further delineation of this issue.) Recommendations are: Every region of Maine (county, hospital service area or public health district) have in place an online resource guide or tool that is easily accessible to both patients and providers. This guide should map community resources for health and be developed as application for use on cell phones and other widely used electronic devises. It should include a listing of services available locally, how to access them, price of services, and program capacity. 78Additionally, there needs to be an educational component to educate primary care providers and other on how to use the guide. Insurers and employee assistance programs should develop and provide coverage for a range of prevention related benefits and services not currently covered. Care for Chronic Conditions Approximately 90 million Americans are living with at least one chronic disease, and chronic disease contributes to over 70% of deaths in the U.S. each year. The majority of U.S. adults with high cholesterol and about half of adults with high blood pressure do not have their conditions under control. 79 And despite the relatively low cost and proven effectiveness of treatments for these common and preventable but potentially deadly conditions, many Americans are not getting better. The aging demographic in Maine, combined with increased chronic disease morbidity in the 45+ age group, particularly in rural areas, is imposing an increasing burden on the healthcare system, threatening the ability of Maines healthcare system to serve all patients. As chronic illness care takes up an ever larger portion of total healthcare spending, efforts to lessen the impact of projected higher health care costs will drive a fundamental shift in the way care is delivered and paid for. Despite current experiments to improve quality of care in general, and care for chronic disease in particular, the ever increasing cost of
78

Maines current 211 system that is presently being used for this purpose is insufficient. It does not provide enough information on local resources among other shortcomings. 79 Released in February 2011 as a Centers for Disease Control and Prevention Vital Signs report, High Blood Pressure and Cholesterol Out of Control found that two out of three U.S. adults with high cholesterol and about 50 percent of adults with high blood pressure are not being treated effectively and are therefore at increased risk for heart attacks, strokes and other problems. The report calls on health professionals to manage high blood pressure and high cholesterol at every patient visit and to remind patients about follow-up care. Moreover, policy-makers should develop policies that reward effective disease prevention and chronic disease management and develop policies that allow other health care professionals to have a more active role in managing high blood pressure and cholesterol.
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OneMaine Community Health Needs Assessment 2010 care coupled with increases in the number of people in Maine with one or more chronic conditions, and the prospect of reduced insurance coverage, represents a crisis in the state. This crisis comes at a time when there have been significant efforts on several fronts to improve the quality of care through electronic health record systems, disease registries, payment incentives to practice evidence based care, patient self management programs, patient centered medical homes, and community health teams. While evidence based care has been widely implemented in Maine in the past decade, evidence from the CHNA suggests that patient health status, including risk factors that compromise care management and patient adherence, may not be improving. Providing essential prevention and disease management services is a shared community, provider and patient responsibility. Public policy changes and a much higher level of private-public partnering will be needed to improve care and care outcomes (as well as address the cost of care) for these conditions. Reimbursement changes by MaineCare, private insurers and the federal government may be required.80 Payment reform on a national scale is essential. A state and local level initiative is needed to harness the resources required to address this problem, one that builds a true public-private partnership with health care providers, public health entities, employers, patients and the government.81 Recommendations for improving chronic disease care are as follows: Major policy and practice changes should be implemented that improve patient self management. Changes need to address core competencies around how to deliver patient centered care; how to partner with patients, providers and the community; and how to improve medication management and adherence. Use of community care teams that include patients in treatment decisions, and continued quality improvement in evidenced based guidelines coupled with changes in reimbursement policies may be required. Policy initiatives and state level programs and resources to assist practices and communities in achieving these changes will be needed.

Substance Abuse and Mental Health Services Alcohol and drug disorders rank among the most costly of common diseases and conditions in terms of cost to Maine. The Maine Office of Substance Abuse estimated that Maines substance abuse costs totaled $898.4 million in 2005, including societal, personal, and direct treatment costs. The cost of providing substance abuse treatment alone exceeded $25 million. The impact of substance abuse crosses all sectors of our society and has enormous implications for health care, school, and criminal justice systems. It also extracts an inordinate toll on individuals and families. Substance abuse problems commonly co-occur with mental health issues.

Payment reform is a key issue at the federal level as there is agreement that many of the cost and quality problems in health care today are either caused by or exacerbated by the way we pay for healthcare services. Center For Healthcare Quality and Payment Reform (http://www.chqpr.org ) A federal response to this problem is through accountable care organizations that are being promoted in the ACA. There has been growing interest in finding ways to encourage health care providers to take greater accountability for the overall cost as well as the quality of healthcare delivered to patients. An Accountable Care Organization consists of a healthcare provider or group of providers that accepts accountability for the total cost of care received by a population of patients. " Center For Healthcare Quality and Payment Reform (http://www.chqpr.org ) Nationally the Center for Medicare and Medicaid Innovation (CMMI) purpose to develop and test innovative payment and delivery system models designed to encourage coordinated care in Medicare, Medicaid and CHIP.
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OneMaine Community Health Needs Assessment 2010 Two groups of substances stand out as particular problems statewide alcohol and the nonmedical use of prescription medications. Alcohol remains the most commonly used substance both nationally and in Maine. The percentage of adult Maine residents with any past month alcohol use or problem (i.e., binge or heavy) drinking behavior meets or exceeds national rates. The obvious challenge in intervening in alcohol use is that alcohol is a legally obtained and used substance (for those over 21 years of age). This also makes alcohol readily available to those who are not of age. The nonmedical use of prescription medications such as pain relievers, tranquilizers, stimulants, and sedatives is a growing challenge in Maine and mirrors national trends. This is a problem for both adults and adolescents. The problem is likely underreported, as it is often difficult to distinguish between appropriate and inappropriate use. Prescription medications are more easily accessible to adolescents than illicit (i.e., street drugs), creating control issues similar to alcohol. The problems of substance abuse in general, and alcohol and prescription drug misuse in particular, require three levels of intervention prevention, screening and detection. These three opportunities require concerted, collaborative action involving the public health, education, health care, and criminal justice systems at the community level. Community level prevention efforts are a natural area for collaboration between all stakeholders, and provide an opportunity for local Healthy Maine Partnerships and the Public Health District Coordinating Councils to assume a leadership role. Prevention messages need to be carefully targeted to specific age groups and cultural populations - i.e., there is no one size fits all intervention. In the case of children and adolescents, both the target populations and their parents must be considered, as evidence indicates that parental attitudes clearly influence adolescent substance use. Schools and healthcare providers play an important role in reinforcing prevention messages. The criminal justice system can also reinforce these messages, and can create an environment that reduces adolescent access to alcohol by monitoring and reinforcing alcohol distribution laws. Prescription drug monitoring systems and an increased awareness among healthcare providers and pharmacists can help reduce access to prescription medications that can be diverted for nonmedical use. Identification and screening for substance abuse is the second area of intervention that is clearly needed. A growing body of evidence suggests that PCPs are often reluctant to screen for substance abuse issues. This may be due, in part, to lack of knowledge of the problem and/or an unwillingness to screen for problems for which services may not be easily available. The use of the Screening, Brief Intervention, Referral, and Treatment (SBIRT) program tools developed by the Center for Substance Abuse Treatment at SAMHSA should be widely encouraged among primary care and ED providers. The SBIRT program offers a wide variety of clinical and educational tools for providers to use for screening and education. The last area of intervention involves expanding access to substance abuse (SA) treatment services that are easily accessible and appropriately confidential. The rates of ED use for SA related disorders suggest two issues related to access. The first involves the limited availability of substance abuse services in many communities. The second involves the ongoing stigma related to substance use and treatment. PCPs can play an important role in improving access to care, particularly for those with less acute and/or chronic substance abuse problems. For example, screening for problem drinking behaviors and PCP discussions with patients regarding health issues related to such behavior has been shown to reduce rates of binge and heavy drinking. Another example involves the use of suboxone by PCPs in the treatment of patients with opiate use problems. Clearly, PCPs will need training and support to undertake a greater role in substance
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OneMaine Community Health Needs Assessment 2010 abuse treatment. They will also need greater access to drug and substance abuse professionals and addiction specialists for consultative support and easier referral of more complex cases.

Recommendations related to substance abuse are as follows: Implement broad-based, collaborative prevention programs at the community level, using evidence-based strategies targeting specific populations and age groups. These initiatives should involve a full range of community stakeholders including public health, health care provider, schools, the criminal justice system, parents, and adolescents. Provide primary care and ED providers with greater access to in-service education programs related to SA diagnosis and treatment tools and protocols. The highest priority would encourage expanded use of evidence-based screening tools such as SBIRT. Fund the development and implementation of strategies to better coordinate the delivery of SA services at the local level, to provide increased access, and to expand referral and consultative resources for primary care providers. Cancer Health The data presented on cancer care indicates that screening treatment is generally good across all counties, with some exceptions for specific cancers. However, improved education and screening for preventing cancer is recommended, as well as follow-up on treatment access and availability in several counties. 82 A major challenge for Maine is determining the specific contribution of risk factors that contribute to high incidence rates. Behavioral risk factors such as smoking, poor nutrition, and obesity are likely contributors, as are heredity, income, and other social-demographic determinants. We do not currently know enough why Mainer experiences such high rates of cancer incidence, even when age is controlled for. It is recommended that the Maine CDC undertake a major epidemiological and policy study to guide planning and intervention to address cancer incidence rates in Maine. Youth Health Issues An area of concern affecting significant numbers of Maines youth is risky health behaviors. Because many behavior patterns are established early in life, prevention efforts directed at youth are a good investment in the health of the general population. Nutrition and physical activity are the primary determinants of obesity, which can lead to diabetes. Smoking is implicated in many preventable deaths, and most smokers begin smoking in their teens. Similarly, alcohol and illicit drug use behaviors are established early in life, usually before adulthood. We find these risk behaviors in clusters i.e., counties with high rates of one risk behavior often have high rates of others. Because these behavior clusters are somewhat different in different counties, and quite high in a few counties, local involvement must be a key strategy in any prevention initiatives. Recent advances in prevention research have suggested that environmental interventions are needed both for obesity prevention83 and substance abuse prevention.84

82

In October 2010, the Maine Cancer Consortium published the Maine Comprehensive Cancer Control Plan: 2011-2015. This plan is intended to be a roadmap for a collaborative approach to minimizing the impact of cancer in Maine. It highlights opportunities to impact different parts of the cancer continuum, including (1) Primary Prevention; (2) Early Detection; (3) Treatment; (4) Rehabilitation and Survivorship; and (5) Palliation and End-of-Life Care. The county-level data presented in this report can help identify which strategies highlighted in the Maine Comprehensive Cancer Control Plan may be most applicable for select geographic regions.

83

Sallis, J, R Cervero, W Ascher et al. (2006) An ecological approach to creating active living communities. Annual Rev. Public Health 2006. 27:297322.
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Environmental or ecological models of prevention target whole communities rather than individual children, seeking to change the standards of acceptable behavior in a neighborhood, town, or state. As one prevention specialist stated: Holding youth solely responsible for underage drinking is like blaming fish for dying in a polluted stream.85 Environmental interventions involve cooperation and coordination among schools, health care providers, municipal government, law enforcement, businesses, parents, churches and other civic leaders. Although obesity and substance abuse prevention initiatives differ in their details, both require cooperation and coordination at the local level. Maine is fortunate in having an annual survey that communities can use to track health risk behaviors among youth. The Maine Integrated Youth Health Survey is a collaborative effort of the Maine Department of Health and Human Services (Maine Center for Disease Control and the Office of Substance Abuse) and the Maine Department of Education. Its purpose is to quantify the health of Kindergarten - Grade 3 students through parent interviews, and the health-related behaviors and attitudes of 5th through 12th graders by direct student survey. The MIYHS is administered in odd years, with results available online at http://www.maine.gov/youthhealthsurvey. Recommendations include: Health care providers, school officials, and public health district coordinating councils should take the lead in monitoring the MIYHS to identify trends in youth health risk behaviors. Working through the district coordination councils, Maine CDC and Maine Office of Substance Abuse should provide technical assistance to help local coalitions develop environmental prevention initiatives tailored to their communities, their children, and the behavioral issues identified through monitoring the MIYHS. In counties with clusters of very high rates of youth health risk behaviors (identified in this report), Healthy Maine Partnerships and district coordinating councils should place a priority on the development and implementation of prevention initiatives. If programs are currently in place in those counties, they should be evaluated to determine whether they have been implemented according to evidence-based protocols, and to determine their effectiveness.

84

Changing the Larger Environment (1999) Northeast Center for the Application of Prevention Technologies. Available online at http://www.northeastcapt.org/products/critical/envicr/ accessed March 11, 2011. (attributed to Laurie Leiber, Center on Alcohol Awareness, Berkeley, CA).
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OneMaine Community Health Needs Assessment 2010 IX. APPENDICES

APPENDIX 1: STEERING & ADVISORY COMMITTEE MEMBERS

Steering Committee Maine Health Deborah Deatrick, Vice President, Community Health Julie Osgood, Senior Director, Operations Tim Cowan, Director, MaineHealth Index Initiative Eastern Maine Healthcare Systems Jerry Whalen, Vice President, Business Development Jean Mellett, Director of Planning Kathie Sewall, EMHS Planning Analyst MaineGeneral Health Natalie Morse, Prevention Center Director Gail Evans, Senior Vice President of Marketing and Strategy

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OneMaine Community Health Needs Assessment 2010 Advisory Committee State Government: Maine Center for Disease Control and Prevention o Becca Matusovich o Dora Mills Governors Office of Health Policy and Finance o Trish Riley or designee Advisory Council on Health Systems Development o Brian Rines, PhD Diversity Representation Maine Chapter of the NAACP o Rachel Talbot-Ross Maine Tribal Health Wabanaki Center, University of Maine o Gail Dana-Sacco, PhD, Wabanaki Center Public Health: Public Health Statewide Coordinating Council o Shawn Yardley Public Health District Coordinating Councils o Edward (Ted) Trainer Healthy Maine Partnerships o Carol Bell o Kelly Bentley Business Community: Maine Health Management Coalition o Elizabeth Mitchell Foundations: Maine Health Access Foundation o Barbara Leonard Bingham Program o Lisa Miller Maine Development Foundation o Laurie LaChance or designee depending on schedule o Patricia Hart

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APPENDIX 2: MAP OF MAINE COUNTIES

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APPENDIX 3: CIAP PROCESS
Quantitative Assessment-Key Health Indicators on Access, Risk, Quality and Outcomes: General & Functional Health Status Primary Care Access & Utilization Cardiovascular Health Respiratory Health Diabetes Reproductive Health Cancer Mental Health/Substance Abuse Safety/Accidents Oral Health Youth Health Orthopedics Infectious Disease Environmental Health

Primary Data and Community Input

Community Household Survey Health Status Risk Factors Disease Prevalence Utilization Services Preference

Secondary and Comparative Data

Region & State Level Data Hospital Utilization Data Mortality Data ER/Outpatient data Program Specific Data

Identify Priority Health Service Issues/Gaps

Benchmarking National Benchmarks Clinical Standards Best Practice Guidelines

Discussions with Key Stakeholders/Advisory Committee Members

Qualitative Analysis of Services and Delivery System Needs

Model Community Programs and Delivery System Options

Service Needs: Prevention Detection Treatment Sub-acute

Summary Planning Report

Major Findings Service Delivery Issues/Options

Opportunities and Barriers

Dissemination of Results Publications Meetings Website

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APPENDIX 4: HEALTH STATUS PROFILE

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HEALTH STATUS PROFILE

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DEMOGRAPHICS Total Population Median Annual Household Income (to 2008) % of Labor Force Unemployed % Population Not Attaining H.S. Diploma (>25 yr) % Population on Medicaid (all ages) % Population Under the Age of 18 % Population Between Ages 18-44 % Population Between Ages 45-64 % Population Age 65 and Over % Uninsured (18+) % Uninsured Non-Elderly Adults (Ages 18-65) HEALTH STATUS % Health Fair to Poor % 11+ Days Lost due to Poor Mental or Physical Health % 3+ Chronic Conditions Wellness Categories: %Well %At Risk for Future Medical Problems %Some Health Problems %Not Well ACCESS TO CARE % Without Usual Source of Primary Care Males Females % Named a clinic or doctor's office as usual source of care % Named hospital or ER as usual source of care % Not Having a Checkup Within the Past 2 yrs Males Females % Received Flu Shot or Mist past 12 months Males Females % Ever Received Pneumoccal Vaccine (Age 65+) Males Females 12% 18% 5.7% 97% 2.3% 8.7% 12% 5.5% 40% 40% 40% 73% 71% 74% 14% 20% 9.1% 93% 5.7% 11% 16% 5.7% 37% 36% 39% 66% 68% 64% 13% 18% 9.1% 96% 2.6% 8.2% 10% 6.9% 49% 47% 51% 76% 78% 75% 14% 18% 9.2% 99% 0.2% 12% 18% 6.4% 35% 37% 34% 75% 74% 76% 7.3% 24% 41,596 46,337 47,030 29,950 46,089 12,044 7,956 7,731 9,672 33,240 16% 26% 6.6% 95% 2.1% 13% 21% 4.7% 40% 39% 41% 67% 65% 69% 6.4% 23% 49,221 44,856 59,327 35,104 63,177 12,869 6,933 7,625 9,857 35,081 14% 21% 6.9% 97% 1.0% 12% 18% 7.5% 39% 34% 42% 73% 73% 73% 6.7% 22% 54,082 50,188 75,859 36,570 46,513 12,278 7,704 8,855 10,270 30,244 11% 17% 6.1% 98% 1.4% 13% 20% 7.2% 44% 42% 46% 71% 70% 72% 6.5% 17% 50,204 48,594 67,825 34,713 48,922 12,718 7,668 8,734 9,752 29,815 11% 18% 4.7% 97% 2.0% 11% 16% 5.9% 38% 38% 39% 71% 70% 72% 6.3% 20% 46,456 43,191 62,017 30,202 55,556 12,536 6,996 8,410 8,393 31,003 14% 16% 12% 96% 2.7% 11% 17% 6.6% 40% 40% 41% 80% 71% 87% 8.9% 34% 52,871 49,304 71,958 35,606 55,633 12,484 7,110 8,848 10,122 31,433 15% 21% 10% 97% 0.8% 11% 14% 8.4% 43% 43% 44% 72% 69% 75% 8.0% 27% 45,531 40,443 53,318 36,008 50,938 13,357 8,574 8,157 12,306 36,052 15% 22% 8.3% 94% 4.0% 9.8% 18% 1.9% 34% 32% 36% 68% 57% 76% 7.1% 32% 59,780 56,987 73,758 41,807 76,742 13,488 7,876 9,324 9,738 33,171 10% 14% 5.5% 98% 1.0% 9.7% 12% 7.4% 46% 46% 46% 70% 62% 77% 5.4% 21% 36,087 31,382 47,873 26,411 37,123 10,996 6,942 7,973 9,300 27,140 16% 21% 12% 96% 1.9% 11% 17% 5.5% 39% 39% 38% 70% 65% 73% 5.0% 33% 78,252 74,067 104,236 54,410 78,207 13,334 7,736 9,124 10,755 34,795 13% 18% 8.0% 97% 1.1% 11% 15% 7.5% 36% 34% 38% 59% 53% 64% 6.3% 25% 52,106 47,552 66,369 35,765 62,871 12,270 7,830 8,154 9,587 32,885 17% 26% 8.6% 96% 2.1% 11% 18% 5.5% 34% 28% 39% 72% 66% 77% 13% 31% 61,002 61,395 70,968 41,072 77,923 14,280 7,574 8,889 11,222 35,683 10% 13% 7.7% 97% 1.2% 10% 16% 4.9% 39% 35% 43% 76% 78% 75% 6.2% 19% 37,684 35,204 49,981 26,479 37,020 9,824 6,025 6,851 7,805 26,240 13% 18% 8.3% 97% 1.9% 10% 15% 6.4% 42% 40% 43% 73% 71% 74% 6.5% 24% 47,665 44,458 60,516 34,450 49,497 12,076 7,575 8,127 9,832 31,396 24% 17% 7% 15% 30% 9% 35% 26% 18% 10% 15% 28% 10% 37% 26% 11% 7% 12% 39% 7% 35% 19% 15% 8% 12% 38% 7% 34% 22% 15% 8% 12% 35% 6% 38% 22% 15% 7% 15% 31% 10% 35% 24% 11% 8% 11% 37% 7% 37% 18% 14% 6% 13% 29% 6% 45% 19% 23% 11% 17% 32% 7% 32% 29% 17% 9% 14% 32% 8% 36% 24% 20% 7% 14% 31% 8% 36% 25% 14% 7% 13% 36% 6% 39% 18% 17% 11% 15% 29% 9% 34% 28% 15% 10% 13% 36% 7% 33% 23% 26% 11% 16% 22% 8% 40% 30% 15% 6% 13% 35% 8% 36% 21% 15% 8% 13% 34% 8% 36% 23% 15% 107,061 $44,545 8.4% 20% 27% 22% 36% 27% 15% 10% 12% 71,827 $35,999 9.3% 23% 32% 20% 31% 31% 18% 12% 15% 277,512 $55,647 6.5% 9.9% 17% 21% 36% 29% 14% 11% 13% 29,767 $38,865 11% 15% 27% 20% 36% 30% 14% 15% 18% 53,371 121,151 40,917 34,720 56,608 149,268 16,989 36,642 51,220 38,276 $47,507 $46,231 $44,863 $48,232 $38,987 $42,585 $28,250 $54,099 $36,211 $44,144 6.8% 7.3% 7.0% 6.3% 11% 8.0% 12% 6.7% 11% 7.8% 12% 15% 13% 12% 18% 14% 20% 12% 19% 15% 19% 25% 21% 19% 30% 27% 32% 16% 34% 26% 19% 21% 19% 19% 21% 20% 20% 21% 22% 21% 31% 33% 31% 28% 31% 38% 27% 33% 32% 32% 33% 30% 31% 34% 32% 28% 35% 31% 31% 32% 17% 15% 18% 19% 16% 14% 18% 15% 16% 15% 16% 13% 16% 13% 14% 14% 15% 10% 12% 17% 20% 16% 20% 16% 18% 16% 19% 12% 15% 20% 32,490 $34,459 10% 20% 37% 20% 30% 31% 18% 22% 28% 201,872 1,319,691 $54,463 $46,807 7.4% 7.8% 14% 15% 17% 23% 21% 21% 33% 34% 31% 30% 15% 15% 12% 13% 14% 16% 310,659,000 $49,777 9.6% 20% 19% 24% 37% 26% 13% 14% 17%

N/A N/A N/A N/A

35% 31% 38% 61% 59% 62% 6.9% 13% 39000 36000 43000 32000 48000 11,439

4.9% 8.2% 5.2% % Needed Medical Care But Could not Afford it: Past Year 27% 30% 21% % No Dental Visit in Past 2 Years 57,097 68,196 36,351 ED Visits per 100,000 population 55,811 67,503 31,842 Ages <18 74,101 85,389 45,381 Ages 18-44 39,804 50,520 28,723 Ages 45-64 48,645 69,926 35,292 Ages 65+ 12,920 13,764 11,328 Hospitalizations per 100,000 Population 9,952 7,851 7,342 Ages <18 10,068 8,426 7,472 Ages 18-44 10,905 11,033 9,114 Ages 45-64 Ages 65+ 28,349 34,060 31,855 All rates are per 100,000 population (based on US Census estimates 2008) unless otherwise noted

11,439 33,951

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OneMaine Community Health Needs Assessment 2010

HEALTH STATUS PROFILE

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QUALITY/EFFECTIVENESS Ambulatory Care Sensitive Condition (ACSC), Hospital Admission Rate (Overall PQI*) Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+
Ambulatory Care Sensitive Condition (ACSC), ED Visit Rate (Overall PQI*) Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+

1,044 241 319 914 4,329 3,426 2,466 3,618 2,832 5,517 20% 20% 22% 41% 39% 31% 34% 31% 7.3% 306 180 1,757 172 154 866 144 120 734 78 149 245 61%

1,510 212 277 1,071 5,795 4,786 2,796 4,153 3,766 9,819 27% 25% 25% 40% 38% 31% 32% 34% 7.3% 340 95 1,699 431 316 1,772 205 136 871 88 124 268 68%

754 182 167 520 3,618 2,085 1,530 2,114 1,635 3,764 16% 16% 26% 34% 36% 24% 26% 27% 6.4% 251 103 1,557 108 61 637 128 90 690 51 75 201 60%

1,377 332 306 884 6,483 2,226 1,320 2,004 1,734 5,040 20% 18% 30% 31% 38% 31% 28% 27% 3.8% 363 156 2,176 213 89 1,222 146 128 710 72 128 233 62%

922 243 271 620 3,473 3,359 1,943 2,832 2,246 8,095 19% 20% 31% 36% 38% 22% 30% 31% 6.6% 348 158 1,725 325 207 1,487 183 99 854 76 76 272 66% 59% 76% 66 55 277 64 6 362 246 115 1,221

927 143 253 720 3,921 3,358 2,359 3,761 2,626 5,328 24% 20% 25% 31% 34% 31% 27% 31% 5.6% 247 113 1,389 272 204 1,337 147 114 712 66 102 213 62% 65% 62% 50 24 275 54 10 331 200 85 1,117

1,163 265 250 792 4,279 2,782 2,150 2,561 2,096 4,998 18% 19% 29% 33% 38% 25% 28% 32% 5.5% 301 105 1,438 227 182 905 180 113 772 66 89 200 59% 60% 68% 58 23 271 50 5 262 213 78 1,003

1,069 157 218 553 4,064 2,789 1,730 2,484 1,853 5,881 19% 20% 24% 33% 34% 25% 29% 30% 7.7% 302 112 1,345 158 120 584 170 103 650 81 86 259 65% 61% 71% 36 17 158 69 17 325 240 114 1,010

915 107 190 652 3,922 3,227 2,043 2,890 2,411 7,101 25% 24% 27% 36% 36% 33% 35% 31% 6.9% 255 108 1,379 135 97 631 141 88 692 68 110 194 66% 67% 72% 36 18 188 55 15 310 203 92 1,052

1,241 257 291 1,123 5,401 2,907 1,680 2,309 2,516 7,015 23% 23% 25% 36% 34% 35% 31% 31% 7.0% 308 165 1,806 223 199 1,135 148 117 771 72 102 281 62% 62% 73% 52 45 271 50 14 321 223 137 1,273

415 131 142 279 1,400 5,356 2,392 3,491 3,666 14,697 21% 26% 26% 36% 38% 33% 32% 35% 6.9% 256 127 1,156 359 236 1,530 197 127 814 77 59 277 65% 70% 63% 112 101 401 77 6 391 281 130 1,280

374 51 104 342 1,507 2,129 1,376 2,261 1,609 4,021 20% 20% 23% 32% 39% 23% 28% 29% 3.5% 203 88 1,174 128 131 573 130 123 601 50 114 83 52% 62% 66% 39 20 222 80 18 499 164 85 906

990 231 311 782 3,840 6,960 3,637 6,279 5,586 15,705 26% 26% 27% 35% 40% 28% 32% 35% 6.4% 361 140 2,023 258 232 1,130 165 121 793 67 99 219 62% 66% 72% 60 40 296 53 19 296 223 125 1,141

472 82 191 386 1,788 3,941 2,202 3,281 2,831 10,111 21% 25% 25% 32% 36% 27% 25% 32% 3.8% 280 162 1,501 281 179 1,380 146 110 712 57 110 139 62% 60% 55% 44 32 220 54 14 324 223 116 1,221

1,479 319 336 944 5,536 5,462 3,198 3,816 3,431 14,091 31% 25% 29% 37% 39% 33% 33% 40% 5.1% 379 232 1,664 477 297 2,057 199 109 886 74 94 226 62% 62% 73% 92 30 452 58 10 290 291 122 1,349

916 157 207 570 4,339 2,144 1,633 2,347 1,579 3,606 25% 20% 29% 33% 37% 23% 28% 28% 5.9% 254 105 1,491 180 134 909 137 98 699 37 51 139 64% 64% 74% 33 23 168 37 9 227 175 82 987

967 191 234 707 4,166 3,073 1,994 2,868 2,374 6,375 22% 21% 26% 35% 37% 28% 29% 30% 6.3% 283 127 1,588 211 157 1,037 149 107 736 62 92 212 62% 63% 72% 45 30 232 49 11 294 202 99 1,101 18% 24% 51% 36% 27% 29% 4.3%

CARDIOVASCULAR HEALTH % Current Smokers (Age 18+) Risk Factors % Sedentary Lifestyle (measured by no physical activity) % Physical Activity (5 times a week at 30 min,) % Use aspirin daily (Age 35+) % Overweight (Ages 18+) % Obesity (Ages 18+) % High Cholesterol (ever told) % High Blood Pressure (ever told) % Heart Disease Congestive Heart Failure, Hospital Admissions Ages 45-64 Ages 65+ AMI, Hospital Admission Rate Ages 45-64 Ages 65+ Management Cerebrovascular Disease (stroke), Hospital Admission Rate Ages 45-64 Ages 65+ CABG, Hospital Admission Rate Ages 45-64 Ages 65+ % Advised to cut down on salt by doctor (ever)

Disease Prevela

192 258 914

% Having Cholesterol Checked within the past year (Ages 68% 65% 63% 57% 21+) % Smokers advised to quit smoking in the past yr. 71% 79% 78% 58% 40 77 25 73 AMI, Mortality Rate 35 44 17 41 Ages 45-64 202 345 142 411 Ages 65+ 45 62 39 49 Cerebrovascular Disease (stroke), Mortality Rate 14 15 8 22 Ages 45-64 279 312 256 287 Ages 65+ 203 262 161 223 Heart Disease, Mortality Rate 128 113 74 96 Ages 45-64 Ages 65+ 1,126 1,240 976 1,288 All rates are per 100,000 population (based on US Census estimates 2008) unless otherwise noted Overall PQI = methodology based on AHRQ Prevention Quality Indicators using 13 identified conditions Quality/Effectiveness

45 306 204

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OneMaine Community Health Needs Assessment 2010

HEALTH STATUS PROFILE

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RESPIRATORY HEALTH % Current Smokers Male Female % Former Smokers % Current Asthma (Ages 18+) % Ever Asthma (Ages 0-17) % COPD Lung and Broncus Cancer, Males, Incidence Rate Lung and Broncus Cancer, Females, Incidence Rate % Received Flu Shot or Mist past 12 months Males Females % Ever Received Pneumoccal Vaccine (Ages 65+) Males Females Bronchitis and Asthma, Hospital Admission Rate Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+ Bronchitis and Asthma, ED Visit Rate Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+ COPD, Hospital Admission Rate Ages 45-64 Ages 65+ COPD, ED Visit Rate Ages 45-64 Ages 65+ Pneumonia, Hospital Admission Rate Ages 45-64 Ages 65+ Pneumonia, ED Visit Rate Ages 18-44 Ages 45-64 Ages 65+ Emphysema, Hospital Admission Rate Ages 45-64 Ages 65+ 20% 20% 20% 32% 12% 10% 4.3% 101 86 40% 40% 40% 73% 71% 74% 127 311 90 47 84 1,064 1,291 1,507 619 435 307 383 1,255 1,264 1,298 1,870 299 206 1,255 506 407 406 747 12 10 35 27% 31% 23% 30% 13% 6.6% 5.8% 163 80 37% 36% 39% 66% 68% 64% 120 171 32 111 230 1,292 1,606 1,695 872 970 455 465 1,622 2,638 2,476 4,445 459 258 1,753 608 329 443 1,431 27 32 73 16% 19% 13% 31% 9.6% 2.4% 2.6% 87 71 49% 47% 51% 76% 78% 75% 74 188 23 42 99 860 987 1,119 614 502 194 190 965 407 511 911 204 140 942 284 220 233 497 20 17 75 20% 20% 19% 36% 9.4% 3.0% 2.5% 95 72 35% 37% 34% 75% 74% 76% 94 307 42 39 47 544 894 698 289 221 502 511 2,339 754 756 1,769 349 189 1,653 232 174 189 500 24 22 105 58% 42% 21% 19% 19% 18% 30% 7.3% 11% 4.0% 141 118 40% 39% 41% 67% 65% 69% 91 218 45 48 117 1,371 1,194 1,886 1,041 1,265 261 226 1,032 536 487 1,359 386 198 1,609 527 295 325 1,515 41 48 133 76% 43% 20% 24% 26% 22% 33% 11% 8.5% 5.5% 103 82 39% 34% 42% 73% 73% 73% 65 149 32 30 90 931 1,084 1,379 579 431 208 240 829 1,167 1,250 1,801 302 205 1,236 683 674 482 917 12 14 33 62% 55% 20% 18% 19% 18% 30% 7.5% 5.0% 2.0% 109 92 44% 42% 46% 71% 70% 72% 86 151 44 39 166 872 1,564 1,028 497 526 280 299 978 1,151 982 1,817 348 182 1,264 316 238 214 552 33 23 113 67% 53% 14% 19% 21% 17% 43% 11% 5.7% 3.7% 86 101 38% 38% 39% 71% 70% 72% 52 135 21 30 52 763 974 1,097 489 554 276 189 1,071 822 721 1,633 350 184 1,167 477 431 309 828 33 26 118 71% 45% 20% 25% 29% 20% 30% 11% 6.9% 6.7% 123 91 40% 40% 41% 80% 71% 87% 87 161 72 47 100 987 1,285 1,430 574 559 401 389 1,662 1,306 1,262 2,531 465 260 2,105 531 323 356 1,235 26 25 100 72% 61% 22% 23% 25% 22% 29% 11% 8.0% 4.9% 108 99 43% 43% 44% 72% 69% 75% 117 267 59 65 163 935 1,055 1,144 681 707 381 451 1,697 1,175 1,290 2,413 426 355 1,858 422 254 354 1,028 31 37 104 73% 48% 18% 21% 21% 20% 38% 9.2% 6.0% 4.4% 131 105 34% 32% 36% 68% 57% 76% 74 233 44 25 33 1,636 1,546 2,517 1,140 1,383 318 253 1,253 1,316 1,284 3,418 509 270 1,855 1,042 646 752 2,799 38 25 98 63% 49% 20% 20% 22% 18% 35% 9.2% 6.1% 5.6% 93 66 46% 46% 46% 70% 62% 77% 68 96 37 61 111 656 627 953 438 499 281 250 1,285 479 460 878 247 145 1,165 349 233 285 638 26 22 102 66% 67% 13% 26% 28% 23% 32% 13% 6.2% 7.9% 133 111 39% 39% 38% 70% 65% 73% 103 240 65 38 119 1,495 1,625 2,187 989 899 337 334 1,411 1,915 2,101 4,153 450 258 1,892 1,688 1,314 1,275 3,928 26 29 94 72% 48% 21% 21% 24% 19% 28% 12% 3.0% 6.6% 105 89 36% 34% 38% 59% 53% 64% 74 114 53 45 130 879 1,035 1,217 585 573 252 215 1,146 1,244 1,251 2,734 455 260 2,248 796 505 605 2,005 35 20 156 54% 48% 11% 31% 30% 31% 30% 11% 9.1% 6.0% 188 110 34% 28% 39% 72% 66% 77% 102 235 51 59 109 1,556 2,028 1,900 1,009 1,397 439 331 1,739 1,360 1,177 2,919 563 356 2,066 860 346 425 2,651 48 44 151 73% 53% 13% 25% 25% 26% 31% 7.6% 5.5% 2.9% 82 79 39% 35% 43% 76% 78% 75% 70 150 42 29 101 921 975 1,403 567 496 218 182 1,067 652 614 1,010 239 146 1,049 370 310 267 556 14 12 40 74% 61% 18% 22% 23% 20% 31% 10% 6.1% 4.2% 105 86 42% 40% 43% 73% 71% 74% 87 196 45 46 114 988 1,145 1,346 654 632 284 285 1,236 998 1,019 1,914 326 209 1,402 505 366 376 1,053 23 22 79 72% 54% 19% 18% 20% 17% 26% 8.8%
Risk Factors

Disease Prevelance

35% 31% 38% 61% 59% 62% 126.0

Management

796

414

352 283 1610

71% 78% 78% % Current Smokers advised to quit smoking in the past year % Current smokers tried to quit in past year 52% 62% 54% % Current smokers ever used Maine Tobacco Quitline 21% 26% 19% All rates are per 100,000 population (based on US Census estimates 2008) unless otherwise noted

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OneMaine Community Health Needs Assessment 2010

HEALTH STATUS PROFILE

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RESPIRATORY HEALTH Cont. Lung Cancer, Mortality Rate Males Quality/Effectiveness Females COPD, Mortality Rate Ages 45-64 Ages 65+ Pneumonia, Mortality Rate Ages 45-64 Ages 65+ Smoking-Related Neoplasms, Mortality Rate Males Females % Current Smokers (Age 18+) % Sedentary Lifestyle % Former smokers (Age 18+) % Overweight (Age 18+) % Obesity (Age 18+) % Diagnosed Cancer (Age 18+) All Cancers, Incidence Rate Bladder, Incident Rate Female Breast Cancer, Incidence Rate Female Cervix Uteri, Incidence Rate Colorectal, Incidence Rate Lung and Bronchus Cancer, Incidence Rate Melanoma, Incidence Rate Male Prostate, Incidence Rate % Reported Mammogram past year (40+) % Stage Female Breast, Local % Stage Female Breast, Distant % Reported Pap Smear past 2 years % Stage Cervix Uteri Female, Local % Stage Cervix Uteri Female, Distant Management / Patient Care % Reported Blood Stool Test Past Year (Age 50+) % Reported Having Sigmoid/Colonoscopy Past 5 Yrs (Age 50+) % Stage Colorectal, Local % Stage Colorectal, Distant % Stage Lung and Brunchus Male, Local % Stage Lung and Brunchus Male, Distant % Stage Lung and Brunchus Female, Local % Stage Lung and Brunchus Female, Distant

66 73 59

91 117 67

59 67 52

86 104 69

74 71 76

69 76 62

64 82 47

76 85 68

80 88 73

77 84 69

69 95 43

72 65 79

72 86 57

67 71 63

101 114 88

60 67 52

69 78 61

72 32 436 13 6 79 165 191 141 20% 20% 32% 39% 31% 5.8% 585 35 141 7.9 57 93 25 169 69% 68% 4.3% 67% 46% 15% 23% 67% 47% 18% 17% 55% 20% 50%

67 29 320 24 5 125 215 258 175 27% 25% 30% 38% 31% 8.2% 669 32 151 4.5 84 121 13 149 73% 62% 3.6% 72% 20% 0% 15% 57% 52% 14% 20% 48% 20% 46%

47 15 301 19 4 124 154 179 130 16% 16% 31% 36% 24% 6.1% 580 34 159 7.5 52 79 32 179 69% 67% 2.9% 70% 59% 3% 17% 69% 43% 19% 14% 51% 18% 42%

74 37 435 20 15 109 204 243 167 20% 18% 36% 38% 31% 8.0% 609 41 156 8.7 72 83 15 176 74% 71% 9.7% 72% 25% 25% 25% 59% 41% 14% 15% 51% 30% 52% 60% 57% 74% 1.3%

49 8 274 18 4 96 189 211 167 19% 20% 30% 38% 22% 9.4% 744 37 198 8.6 66 129 27 231 68% 67% 3.7% 72% 43% 29% 25% 56% 48% 13% 30% 40% 28% 37% 64% 71% 79% 5.5%

61 34 331 20 8 116 180 206 155 24% 20% 33% 34% 31% 8.4% 609 29 166 8.0 55 92 22 193 72% 65% 2.6% 77% 33% 27% 20% 68% 46% 19% 13% 48% 18% 54% 77% 67% 75% 6.2%

59 28 262 19 8 89 180 234 127 18% 19% 30% 38% 25% 9.6% 690 31 196 6.4 59 100 39 190 66% 66% 5.7% 69% 50% 25% 23% 60% 50% 17% 12% 53% 23% 47% 68% 63% 81% 4.3%

72 34 310 22 3 103 204 230 178 19% 20% 43% 34% 25% 9.9% 715 45 203 3.8 60 94 31 228 71% 65% 2.8% 72% 50% 0% 20% 63% 41% 22% 5.0% 57% 11% 50% 65% 75% 77% 3.4%

73 24 406 16 7 89 208 254 163 25% 24% 30% 36% 33% 9.3% 684 40 178 3.5 69 107 24 184 70% 67% 3.2% 68% 100% 0% 27% 61% 28% 36% 16% 51% 18% 58% 72% 66% 84% 1.3%

50 29 298 17 3 110 176 197 156 23% 23% 29% 34% 35% 6.2% 638 35 145 7.0 69 104 19 175 67% 63% 2.4% 68% 56% 19% 22% 59% 51% 18% 22% 48% 22% 44% 62% 63% 68% 3.4%

77 23 369 12 0 65 232 267 197 21% 26% 38% 38% 33% 8.0% 779 45 232 3.9 77 118 16 243 69% 72% 5.0% 75% 100% 0% 23% 58% 42% 20% 21% 42% 19% 52% 63% 65% 61% 4.9%

67 20 413 15 0 105 157 169 146 20% 20% 35% 39% 23% 8.1% 582 25 145 3.6 54 79 38 212 65% 67% 7.4% 72% 50% 50% 19% 67% 41% 15% 8% 50% 24% 43% 69% 69% 78% 4.4%

83 51 429 26 6 150 198 222 175 26% 26% 32% 40% 28% 9.8% 629 34 161 7.7 64 122 15 178 60% 63% 3.2% 64% 0% 17% 21% 51% 45% 15% 17% 48% 26% 43% 55% 53% 78% 3.7%

57 32 307 15 0 98 182 202 162 21% 25% 28% 36% 27% 8.8% 661 24 171 20.5 70 97 25 199 68% 64% 6.0% 73% 42% 17% 20% 56% 41% 22% 24% 32% 19% 50% 68% 68% 85% 2.7%

87 30 418 19 13 84 230 285 178 31% 25% 30% 39% 33% 8.4% 787 43 142 8.0 95 148 18 261 68% 69% 4.2% 69% 100% 0% 22% 58% 54% 15% 12% 54% 20% 49% 65% 65% 77% 4.0%

49 17 295 11 2 73 161 187 137 25% 20% 31% 37% 23% 7.4% 605 38 163 6.8 58 80 29 191 68% 63% 4.7% 70% 71% 9.5% 18% 66% 45% 16% 9% 58% 21% 49% 75% 69% 79% 3.0%

58 25 332 17 5 103 177 205 150 22% 21% 31% 37% 28% 7.5% 629 35 162 7.3 62 95 26 187 69% 66% 3.8% 70% 52% 14% 20% 63% 47% 17% 16% 50% 21% 47% 69% 68% 76% 3.8% 80% 4.2% 38 19 15% 54% 18% 51% 18% 24% 26% 36% 27% 6.1% 476 22 132 8.5 52 70 18 142 76% 61% 4.8% 85% 48% 11% 21%

CANCER HEALTH Risk Factors

% Reported Prostate Exam (PSA test) past 2 yrs (males 65% 68% 75% Age 50+) % Reported Digital Rectal Exam past 2 years (males Age 71% 65% 73% 50+) % Stage Prostate, Local 84% 78% 73% % Stage Prostate, Distant 4.5% 3.8% 3.6% All rates are per 100,000 population (based on US Census estimates 2008) unless otherwise noted

Disease Prevelance

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OneMaine Community Health Needs Assessment 2010

HEALTH STATUS PROFILE

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CANCER HEALTH Cont. All Cancers, Mortality Rate Bladder, Mortality Rate Female Breast Cancer, Mortality Rate Female Cervix Uteri, Mortality Rate Colorectal, Mortality Rate Lung, Mortality Rate Melanoma, Mortality Rate Male Prostate, Mortality Rate 216 10 24 2.4 17 66 4.0 20
20%

285 6.0 40 2.7 30 91 2.8 18

25%

205 6.7 26 2.3 18 59 2.9 22

16%

251 1.1 20 2.2 26 86 1.1 25

18%

256 10 31 1.2 19 74 8.1 38

20%

244 6.9 33 3.2 22 69 5.0 28

20%

244 9.8 35 1.6 19 64 4.1 33

19%

267 12 21 1.9 27 76 5.8 29

20%

277 9.4 38 2.3 24 80 1.8 17

24%

227 6.7 26 3.5 20 77 2.5 21

23%

296 14 23 0.0 27 69 3.9 24

26%

209 5.5 30 0.0 16 72 2.7 28

20%

251 5.2 24 8.9 27 72 0.7 21

26%

243 3.5 27 5.1 21 67 4.4 23

25%

307 8.2 34 4.0 16 101 3.1 32

25%

217 8.3 27 0.6 19 60 4.8 19

20%

234 7.5 28 2.5 21 69 3.6 23

21%

190 4.4 28 2.6 19 54 2.7 20

36%

Disease Prevelance Risk Factors

DIABETES HEALTH % Sedentary Lifestyle (measured by no pysical activity) % Adults consume fruits and vegetables 5 or more times/day % Overweight (Age 18+) % Obesity (Age 18+) % Diagnosed Diabetes Ages 18-44 Ages 45-64 Ages 65+ % Reported hemoglobin A1c measurement (at least once) in past year (Age 18+) % Reported pupil dilation eye exam in past yr (age 18+) % Reported foot examination in past yr (Age 18+) % Reported ever taken diabetes self management course (Age 18+) Diabetes, Hospital Admission Rate Ages 18-44 Ages 45-64 Ages 65+ Diabetes Short-term Complications, ACSC ED Visit Rate Diabetes Long-term Complications, ACSC ED Visit Rate Diabetes Uncontrolled, ACSC ED Visit Rate Diabetes, Mortality Rate Ages 45-64 Ages 65+

Quality/Effectiveness

27% 39% 31% 11% 2.8% 16% 23% 77% 78% 77% 59% 84 57 137 129 7 171 11 25 21 120

20% 38% 31% 13% 4.1% 17% 20% 82% 70% 74% 56% 93 104 86 169 22 168 17 33 23 133

33% 36% 24% 9.4% 2.2% 12% 21% 97% 79% 83% 51% 64 62 57 121 3 83 7 20 19 103

27% 38% 31% 9.7% 2.8% 14% 16% 81% 65% 60% 35% 77 127 33 128 13 181 12 49 44 233

30% 38% 22% 8.3% 0.9% 8% 23% 93% 80% 75% 65% 82 66 79 128 11 91 31 33 15 166

26% 34% 31% 12% 9.0% 18% 24% 93% 79% 78% 70% 70 63 75 112 4 86 13 31 20 147

33% 38% 25% 9.2% 2.1% 11% 17% 91% 78% 67% 63% 73 32 89 160 6 134 9 19 13 71

32% 34% 25% 10% 6.3% 10% 15% 84% 76% 86% 47% 72 57 60 133 13 92 7 23 9 103

26% 36% 33% 12% 5.4% 12% 26% 78% 84% 67% 56% 84 92 52 172 17 125 11 34 22 162

25% 34% 35% 10% 3.3% 14% 21% 92% 79% 80% 54% 102 90 99 201 11 109 6 26 24 128

26% 38% 33% 13% 7.9% 14% 20% 89% 65% 71% 51% 150 219 110 293 15 209 15 29 34 98

30% 39% 23% 10% 0.0% 12% 28% 84% 70% 75% 58% 74 54 75 185 3 101 1 13 3 74

25% 40% 28% 11% 4.2% 12% 22% 91% 70% 81% 36% 82 120 70 119 25 170 20 33 17 175

29% 36% 27% 11% 3.2% 14% 18% 85% 70% 74% 60% 84 102 57 182 27 132 16 28 22 133

27% 39% 33% 13% 5.9% 14% 21% 72% 78% 73% 29% 103 92 84 226 23 232 46 61 36 251

30% 37% 23% 9.2% 3.3% 9.6% 21% 92% 73% 85% 53% 71 64 61 151 3 56 4 20 17 96

28% 37% 28% 10% 2.9% 13% 21% 89% 76% 78% 54% 79 75 75 150 9 111 11 26 20 126

27% 36% 27% 8.3%

72% 70%

Management

Quality/ Effectiv

77

All rates are per 100,000 population (based on US Census estimates 2008) unless otherwise noted

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OneMaine Community Health Needs Assessment 2010

HEALTH STATUS PROFILE

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MENTAL HEALTH

% 11+ Days Mental Health Not Good Ages 18-44 Ages 45-64 Ages 65+ % needed, but did not get, mental health treatment in past 12 months % receiving outpatient mental health treatment in past 12 mos % At Risk for Clinical Depression Based on MHI5 (18+) % Diagnosed Depression (ever, 18+) % Current Depression (18+) % Diagnosed Other Psychiatric Disorder (ever, 18+) % Developmental Delay/Learning Disability (Ages 0-17) Psychoses Hospital Admission Rate Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+ Senility and Organic Mental Disorders, Hospital Admission Rate Ages 65+ Major Depressive Disorder, Hospital Admission Rate Ages 0-17 Ages 18-64 Ages 65+ Bipolar Disorder, Hospital Admission Rate Ages 0-17 Ages 18-64 Ages 65+ Schizophrenia, Hospital Admission Rate Ages 18-64 Ages 65+ Anxiety, Hospital Admission Rate Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+ Senility and Organic Mental Disorders, ED Rate Major Depressive Disorder, ED Rate Bipolar Disorder, ED Rate Schizophrenia, ED Rate Anxiety Disorder, ED Rate

Risk Factors

10% 10% 12% 6.9% 5.0% 12% 6.3% 22% 15% 12% 4.1% 911 980 1,184 756 409 7.0

12% 15% 12% 4.7% 6.6% 9.5% 8.9% 20% 13% 14% 4.5% 486 455 699 477 176 6.3

10% 12% 9.6% 6.3% 3.5% 12% 5.0% 22% 12% 14% 3.3% 536 365 685 588 302 9.9

8.5% 11% 8.5% 2.9% 3.9% 11% 9.2% 21% 15% 15% 6.0% 376 213 646 295 105 6.7 47 133 0 191 47 188 170 222 58 47 64 0 185 128 579 213 17 12 72 106 74 1,465 16 25 6.5

9.3% 14% 6.4% 4.5% 3.5% 11% 5.6% 21% 14% 10% 9.0% 373 297 548 345 189 18 94 98 35 127 61 170 173 198 55 79 93 50 246 89 694 387 134 40 63 121 43 1291 13 22 4.9

11% 9.4% 15% 5.1% 6.5% 14% 6.8% 24% 17% 14% 2.7% 703 527 988 734 256 7.0 44 151 51 202 74 329 439 352 82 194 273 74 411 220 1,139 522 71 38 111 137 55 1,729 12 20 4.3

10% 11% 12% 5.8% 4.6% 11% 7.7% 19% 12% 11% 3.4% 689 372 1,195 606 319 7.3 40 302 82 424 120 230 277 247 120 142 202 67 356 246 1,066 448 76 15 93 122 37 1,281 19 30 8.1

11% 14% 11% 5.7% 4.0% 9.8% 5.9% 21% 14% 13% 4.4% 448 427 816 322 163 4.3 15 143 120 174 66 240 292 280 66 40 49 22 251 255 622 367 60 24 69 154 36 1,224 18 35 1.9

14% 15% 17% 5.2% 6.0% 13% 11.9% 22% 16% 12% 4.7% 572 503 802 558 255 5.3 33 145 70 188 78 306 395 330 89 84 121 11 189 198 404 227 54 37 72 145 75 1,763 14 20 6.9

10% 9.8% 12% 6.9% 5.2% 8.5% 8.1% 20% 15% 11% 3.6% 785 692 989 843 262 14 78 154 65 200 73 366 525 376 92 216 293 61 365 244 949 523 89 27 80 265 112 1,956 14 25 3.9

13% 19% 12% 5.1% 3.0% 9.0% 6.6% 21% 14% 13% 9.1% 509 379 755 583 146 15 81 171 0 257 65 215 306 238 33 91 129 16 200 88 525 292 88 41 71 165 53 1,607 24 36 12

9.9% 11% 9.9% 6.8% 3.8% 17% 6.8% 23% 16% 13% 3.3% 474 467 579 504 185 6.8 37 121 96 139 83 266 320 297 55 59 64 37 228 243 563 186 77 16 116 79 40 1,174 9.1 19 0.0

14% 16% 14% 8.7% 5.5% 9.9% 9.5% 23% 15% 12% 3.9% 545 543 815 471 144 7.8 44 146 85 186 75 305 432 321 62 76 105 19 329 223 868 356 53 39 127 189 18 1,854 13 23 3.8

12% 13% 12% 7.6% 2.7% 9.2% 8.7% 21% 17% 13% 4.6% 610 776 802 471 269 6.5 26 193 101 246 95 278 618 203 130 106 146 8.7 310 303 732 404 57 24 140 182 64 1,429 18 32 5.1

12% 14% 12% 6.3% 4.2% 12% 10% 20% 16% 14% 12.8% 420 289 601 410 284 9.2 50 160 23 211 142 169 190 191 75 68 83 17 335 68 798 646 144 15 117 111 38 1,590 7.2 11 4.0

9.6% 9.6% 11% 6.7% 5.5% 12% 7.3% 24% 18% 13% 5.5% 399 290 597 372 170 5.4 30 135 80 168 72 178 197 197 69 65 91 20 199 181 447 249 48 19 61 118 52 1,426 15 23 7.1

11% 12% 12% 6.1% 4.8% 11% 7.2% 22% 15% 13% 4.5% 578 484 801 559 246 8.6 50 157 85 196 93 280 353 302 88 114 155 39 269 213 662 342 70 28 109 166 70 1,618 14 23 5.4 143

Disease Prevalence

563

42 35 66 210 134 160 132 89 120 256 165 179 126 81 133 599 207 234 804 267 212 613 238 273 222 35 86 81 111 118 112 147 160 19 31 55 247 230 229 369 222 183 523 458 537 176 338 296 42 109 68 34 32 27 129 79 179 277 122 169 70 57 101 2,132 1,671 1,511 13 18 13 Suicide, Mortality Rate 21 32 20 Males Females 5.5 3.6 6.6 All rates are per 100,000 population (based on US Census estimates 2008) unless otherwise noted Management Quality

117

108 61

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OneMaine Community Health Needs Assessment 2010

HEALTH STATUS PROFILE

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SUBSTANCE ABUSE % Chronic Heavy Drinking - Past Month Ages 18-64 Ages 65+ % Binge Drinking -Past Month Ages 18-44 Ages 45-64 Ages 65+ % Ever diagnosed with Substance Abuse Problem % Current Substance Abuse Problem % Overdose Past 12 mos (Households) % have used any street drugs in past 30 days % have used any prescription drugs for non-prescribed purpose in past 30 days Substance Abuse, Hospital Admission Rate Ages 18-64 Ages 65+ Acute Alcohol-Related Mental Disorders, Hospital Admission Rate Ages 18-64 Ages 65+ Alcohol-Related Psychoses, Hospital Admission Rate Ages 18-64 Ages 65+ Acute Drug-Related Mental Disorders, Hospital Admission Rate Ages 18-64 Ages 65+ Drug-Related Psychoses, Hospital Admission Rate Ages 18-64 Ages 65+ Acute Alcohol-Related Mental Disorders, ED Rate Alcohol-Related Psychoses, ED Rate Acute Drug-Related Mental Disorders, ED Rate Drug-Related Psychoses, ED Rate 5.5% 12% 0.8% 15% 24% 12% 3.0% 4.2% 0.7% 1.0% 7.9% 1.8% 673 1,021 138 17.3 27 0 368 566 74 27 5.5% 12% 3% 15% 21% 13% 1..2% 4.9% 1.8% 0.5% 1.8% 0.8% 161 221 123 36.2 53 19 52 75 31 30 7.9% 17% 5.2% 18% 20% 8.1% 3.0% 5.9% 2.9% 1.1% 4.5% 1.8% 544 787 220 32 46 15 326 480 106 28 4.0% 9.6% 2.4% 15% 27% 14% 2.9% 3.8% 0.7% 0.0% 4.3% 1.0% 227 321 93 29 41 12 86 122 35 18 26 0 94 133 47 86 6.7 254 44 204 243 167 18 23 13 15 21 32 11 5.3% 10% 6.1% 15% 19% 15% 4.0% 4.4% 0.9% 0.7% 5.5% 2.2% 208 274 172 91 124 67 53 73 39 27 35 17 37 42 50 138 67 156 82 189 211 167 15 24 6.1 11 16 25 7.4 6.1% 12% 5.7% 14% 24% 11% 4.8% 3.8% 0.1% 0.5% 4.9% 1.4% 419 628 98 91 136 16 142 214 33 67 101 5.5 120 177 44 73 18 331 75 180 206 155 15 18 12 12 16 20 12 7.3% 15% 6.4% 16% 21% 10% 3.1% 7.3% 1.3% 0.5% 4.5% 2.8% 363 530 160 98 151 20 108 165 27 62 98 0 95 116 113 100 8.6 221 50 180 234 127 12 16 8.1 8.1 17 26 8.1 6.7% 11% 9.4% 14% 24% 14% 2.8% 8.7% 2.2% 1.9% 4.7% 0.9% 288 421 140 46 70 15 115 179 30 40 61 7.4 86 110 89 122 30 184 49 204 230 178 21 22 21 15 30 47 13 7.8% 17% 5.1% 16% 25% 9.4% 3.1% 4.1% 0.9% 1.5% 7.2% 0.9% 359 539 116 22 30 22 168 261 28 18 24 0 152 224 66 135 26 250 40 208 254 163 21 25 16 18 17 23 12 4.6% 9.6% 3.7% 14% 22% 14% 2.1% 4.2% 1.2% 0.4% 5.5% 2.2% 286 391 180 86 124 28 79 112 35 67 95 9.5 54 59 104 218 39 411 76 176 197 156 15 21 9.2 12 14 21 6.6 5.6% 13% 2.0% 19% 20% 11% 3.8% 5.9% 0.8% 0.5% 3.2% 3.5% 153 200 146 41 62 16 32 43 33 38 62 0 41 33 98 109 15 224 100 232 267 197 16 24 7.7 14 16 32 0.0 5.8% 12% 5.1% 13% 26% 20% 2.0% 4.4% 3.0% 0.6% 4.8% 0.2% 263 382 111 20 30 9.2 119 171 65 20 26 9.2 104 156 28 101 27 244 50 157 169 146 10 13 7.1 6.4 11 15 7.1 7.0% 16% 0.5% 18% 18% 12% 4.7% 5.6% 1.3% 1.0% 6.0% 2.5% 303 441 137 53 81 12 65 97 25 72 109 0 112 153 100 97 25 322 61 198 222 175 19 25 13 15 23 33 13 4.6% 9.2% 4.8% 16% 30% 10% 0.5% 4.3% 1.1% 1.4% 3.9% 1.4% 201 289 95 65 98 17 63 92 26 31 45 8.7 42 55 43 110 18 206 39 182 202 162 13 18 9 8 16 27 5.1 7.8% 17% 2.9% 18% 25% 11% 1.1% 5.9% 2.8% 0.4% 7.6% 2.9% 291 421 159 112 168 50 40 58 25 95 143 33 43 53 50 97 20 217 80 230 285 178 15 23 8 11 23 42 4.0 7.3% 16% 4.6% 17% 29% 12% 2.7% 3.0% 1.2% 1.3% 5.6% 1.9% 320 469 113 28 42 10 155 232 44 22 28 6.7 115 167 52 78 16 279 40 161 187 137 12 14 9 9 12 16 8.4 6.4% 14% 4.5% 15% 26% 14% 3.6% 4.7% 1.5% 0.9% 5.2% 1.8% 379 553 149 50 73 19 174 260 52 39 56 6.5 117 164 72 131 28 297 57 177 205 150 14 19 10 11 14 21 8.0 5.1% 3.0% 16%

Prevelance

3.2%

36 42 41 0 11.5 3.9 261 43 157 393 51 220 64 61 95 140 88 180 18 31 39 443 232 291 48 74 50 165.3 215 154 Smoking-Related Neoplasms, Mortality Rate 191 258 179 Males 141 175 130 Females 15 19 12 Alcohol-Related Mortality Rate 17 24 15 Males 13 15 8.2 Females 12 17 7.9 Alcohol Liver Disease, Mortality Rate 10 19 10 Motor Vehicle Accidents, Mortality Rate 14 29 15 Males Females 6.1 11 5.9 All rates are per 100,000 population (based on US Census estimates 2008) unless otherwise noted Quality / Effectiveness

Management

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OneMaine Community Health Needs Assessment 2010

HEALTH STATUS PROFILE

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REPRODUCTIVE HEALTH % Binge Drinking Females (past month) 2 or more sex partners in past yr (ages 18-34) % used condom last time had sex (ages 18-34) Teen Birth Rate (10-17yrs) Per 1,000 Females High Risk Pregancy, Hospital Admission Rate (10-44 year old females) C-Section Rate per 100 births % Adequate Prenatal Care (of live births) % Inadequate Prenatal Care (of live births) % Low Birthweight (<2500 grams) % Prematurity (< 37 weeks) Infant Mortality Rate (deaths to infants from birth through 364 days of age) per 1,000 live births Neonatal Mortality Rate (deaths to infants under 28 days) per 1,000 live births Post-Neonatal Mortality Rate (deaths to infants 28 through 364 days of age) per 1,000 live births CHILD/YOUTH HEALTH % Sad/Hopeless (two weeks in a row, stopped usu. activities) % Seriously Considered Suicide % Current Smoker (Past Month) (Grade 9-12) % Current Smokeless Tobacco User % Alcohol Use (Past Month) (Grade 9-12) % Binge Drink (5+ in a row) Past Month) (Grade 9-12) % Marijuana Use (Past Month) (Grade 9-12) % Sniffed Glue or Other Inhalant (Past Month) (Grade 9-12) % Used Rx Drug w/out Rx (Past Month) (Grade 9-12) % Regular Physical Activity (at least 60 min on 5 of last 7 dys) % Consume fruits and vegetables 5 or more times/day % Drank sugar sweetened beverage in past week Teen Birth Rate (10-17yrs) Per 1,000 Female Population % Ever Been Diagnosed with Asthma (0-17) parental report % Overweight/Obesity Problem (0-17) parental report % Overweight (Grade 9-12) % Obese (Grade 9-12) % with developmental delay or learning disability (0-17) parental report 25% 14% 18% 10% 31% 19% 23% 11% 12% 37% 15% 32% 6.9 10% 1.7% 15% 14% 4.1% 24% 14% 21% 6% 34% 20% 17% 7% 7% 41% 13% 35% 4.2 6.6% 4.0% 17% 14% 5.4% 22% 13% 17% 9% 35% 21% 24% 9% 11% 41% 16% 25% 3.4 2.4% 1.8% 11% 10% 3.3% 24% 11% 17% 9% 40% 24% 28% 6% 11% 50% 17% 29% 6.1 3.0% 2.3% 16% 13% 6.0% 26% 15% 22% 11% 33% 21% 25% 12% 13% 42% 15% 32% 4.0 11% 1.5% 13% 12% 9.0% 24% 13% 19% 11% 32% 21% 24% 10% 12% 38% 15% 30% 4.2 8.5% 2.0% 13% 12% 2.7% NA NA NA NA NA NA NA NA NA NA NA NA 5.1 5.0% 1.7% NA NA 3.4% 27% 18% 29% 14% 42% 25% 29% 14% 17% 32% 15% 29% 2.2 5.7% 0.7% 15% 17% 4.4% 24% 15% 19% 11% 34% 22% 25% 10% 12% 34% 14% 30% 3.3 6.9% 3.7% 17% 16% 4.7% 24% 12% 20% 9% 33% 19% 22% 8% 11% 37% 12% 30% 3.3 8.0% 2.6% 14% 14% 3.6% 26% 17% 26% 13% 39% 26% 25% 14% 16% 38% 16% 35% 6.2 6.0% 3.9% 14% 12% 9.1% 26% 16% 18% 7% 34% 19% 21% 7% 9% 41% 17% 27% 2.7 6.1% 1.6% 14% 14% 3.3% 25% 13% 22% 11% 35% 22% 22% 8% 9% 39% 14% 29% 6.2 6.2% 2.4% 16% 14% 3.9% 26% 15% 22% 13% 44% 28% 28% 12% 13% 37% 15% 31% 6.7 3.0% 1.3% 14% 18% 4.6% 26% 15% 27% 12% 41% 31% 24% 11% 12% 39% 14% 37% 5.3 9.1% 3.1% 18% 11% 12.8% 25% 15% 20% 8.5% 35% 21% 25% 9% 13% 38% 17% 29% 2.8 5.5% 1.2% 14% 11% 5.5% 24% 14% 20% 9.5% 35% 21% 24% 9% 11% 39% 15% 29% 4.1 6.1% 2.0% 14% 13% 4.5% 18% 22% 20% 8.9% 42% 24% Management 11% 21% 25% 6.9 499 33 93% 1.9% 6.4% 8.3% 6.2 3.6 2.6 10% 7.2% 22% 4.2 423 32 91% 2.1% 5.6% 7.1% 4.2 2.3 * 13% 14% 35% 3.4 349 30 89% 2.1% 6.4% 8.9% 5.7 3.8 2.0 7.8% 8.1% 34% 6.1 383 32 89% 2.5% 7.0% 8.8% * * * 11% 22% 41% 4.0 325 27 91% 3.1% 6.0% 7.3% 4.0 * * 11% 13% 27% 4.2 377 29 90% 1.7% 6.2% 8.2% 6.1 5.0 * 8.1% 12% 35% 5.1 238 30 94% 1.9% 4.9% 7.0% 5.9 4.2 * 7.6% 19% 34% 2.2 264 29 92% 2.5% 7.5% 9.7% 6.6 * * 12% 19% 39% 3.3 477 30 92% 2.5% 6.1% 8.2% 4.2 3.0 * 9.2% 18% 42% 3.3 294 30 91% 4.0% 6.8% 10% 5.2 4.4 * 8% 1.8% 25% 6.2 500 26 86% 3.5% 7.5% 9.4% * * * 12% 5.1% 36% 2.7 431 28 94% 1.5% 5.8% 8.0% 4.3 * * 11% 14% 29% 6.2 501 33 84% 3.9% 8.6% 10% 8.3 3.8 4.5 4.9% 8.7% 42% 6.7 343 33 90% 3.2% 7.8% 8.5% 5.8 5.8 * 14% 25% 34% 5.3 373 31 87% 4.4% 5.9% 7.7% * * * 13% 18% 40% 2.8 275 29 92% 2.4% 6.3% 9.3% 5.8 4.6 1.2 11% 16% 35% 4.1 360 30 91% 2.5% 6.4% 8.7% 5.5 3.9 1.7 32 11%

8.9

8.2% 13% 6.7 4.5 2.2

Prevalance

12%

All rates are per 100,000 population (based on US Census estimates 2008) unless otherwise noted * Rates based on less than 5 occurrences omitted

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OneMaine Community Health Needs Assessment 2010

HEALTH STATUS PROFILE

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CHILD/YOUTH HEALTH Cont. ACSC, ED Rate - Overall PQI (Ages 0-17) ACSC, Hospital Admission Rate - Overall PQI 0-17) Asthma and Bronchitis, Hospital Admission Rate 0-17) Pneumonia, Hospital Admission Rate (Ages 0-17) Psychoses Hospital Admission Rate (Ages 0-17) (Ages (Ages 2,466 241 311 193 980 132 804 1,291 634 31% 13% 40% 61% 94 473 64 180 7.5 91 9.4 307 15% 2.8% 2,796 212 171 171 455 89 267 1,606 543 32% 16% 38% 65% 94 418 53 161 5.6 55 8.4 89 10% 1.0% 1,530 182 188 79 365 120 212 987 322 29% 10% 37% 56% 93 483 68 238 8.6 89 15 234 9% 1.0% 1,320 332 307 187 213 0 170 894 204 30% 10% 40% 53% 92 500 60 233 1.7 47 6.7 161 11% 0% 1,943 243 218 104 297 35 173 1,194 382 32% 15% 35% 56% 114 499 66 200 0.9 69 9.4 169 11% 1.6% 2,359 143 149 163 527 51 439 1,084 820 32% 16% 37% 66% 105 527 55 199 7.4 40 4.1 198 11% 1.4% 2,150 265 151 164 372 82 277 1,564 385 36% 15% 36% 65% 101 393 76 200 0 54 0 194 16% 0.8% 1,730 157 135 165 427 120 292 974 479 34% 13% 39% 55% 108 473 53 148 2.9 38 0 104 14% 0.9% 2,043 107 161 128 503 70 395 1,285 564 35% 16% 44% 62% 120 493 72 210 7.1 78 11 155 15% 1.2% 1,680 257 267 149 692 65 525 1,055 406 29% 12% 38% 63% 81 404 51 139 2.0 35 2.7 219 14% 1.4% 2,392 131 233 263 379 0 306 1,546 496 42% 29% 45% 61% 112 505 41 146 5.9 42 0 100 14% 0.4% 1,376 51 96 58 467 96 320 627 422 32% 18% 35% 59% 83 388 50 194 1.4 38 8.3 217 9.9% 0.7% 3,637 231 240 205 543 85 432 1,625 1,211 31% 13% 40% 63% 106 525 50 94 5.9 51 1.9 220 9% 0.2% 2,202 82 114 38 776 101 618 1,035 662 37% 20% 44% 62% 94 469 44 104 0 50 0 149 14% 0.7% 3,198 319 235 213 289 23 190 2,028 668 35% 12% 44% 60% 114 443 49 125 1.5 56 6.2 111 18% 1.4% 1,633 157 150 103 290 80 197 975 483 31% 12% 39% 56% 70 363 47 156 4.0 55 5.9 137 9.7% 1.2% 1,994 191 196 132 484 85 353 1,145 516 32% 13% 39% 59% 93 452 57 180 5.1 62 7.3 197 12% 1.2% 112 401 26%

Major Depressive Disorder, Hospital Admission Rate (Ages 0-17) Bipolar Disorder, Hospital Admission Rate (Ages 0-17) Asthma and Bronchitis, ED Rate (Ages 0-17) Pneumonia, ED Rate (Ages 0-17) ORTHOPEDICS % Diagnosed Arthritis Ages 18-44 Ages 45-64 Ages 65+ Hip Procedures, Hospital Admission Rate Ages 65+ Head Brain Injury, Hospital Admission Rate Ages 65+ INFECTIOUS DISEASE HIV/AIDS, Hospital Admissions Rate Hepatitis C, Incidence Rate Sexually Transmitted Disease Incidence Rate: Gonorrhea Chlamydia INTIMATE PARTNER VIOLENCE % Ever physically hurt by Intimate Partner % Past yr physical violence or unwanted sex from Intimate Partner

Management

54%

All rates are per 100,000 population (based on US Census estimates 2008) unless otherwise noted Please note that not all percentages have % sign in data point, use indicator name until fixed

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OneMaine Community Health Needs Assessment 2010

APPENDIX 5: ANNOTATED SURVEY INSTRUMENT

147

OneMaine Health Maine Community Health Needs Assessment Survey

Annotated Survey
December 10, 2010
Brian Robertson, Ph.D. Market Decisions Kira Rodriguez, MHS UNE-CCPH

Table of Contents
Page
Survey Introduction ...................................................................................................................................... 1 Introductory Demographic Items Needed for Survey Questions ............................................................. 5 Health Services Access and Utilization ....................................................................................................... 7 Health Status and Chronic Conditions ....................................................................................................... 9 Chronic Disease Management Questions .................................................................................................... 17 Youth .............................................................................................................................................................. 27 Exercise .......................................................................................................................................................... 31 Primary Care ................................................................................................................................................. 33 Height and Weight ........................................................................................................................................ 41 Dental Care .................................................................................................................................................... 42 Mental Health ................................................................................................................................................ 43 Risk Factors ................................................................................................................................................... 48 Intimate Partner Violence ............................................................................................................................ 53 Health Insurance ........................................................................................................................................... 54 Health Care Barriers .................................................................................................................................... 55 Community Health Needs ............................................................................................................................ 56 Wellness Activities and Programs ............................................................................................................... 62 Alternative Therapies ................................................................................................................................... 65 End of Life Care ............................................................................................................................................ 67 Demographics ................................................................................................................................................ 68 Computed Variables ..................................................................................................................................... 76

Survey Introduction
QUESTION: LEAD This is ____________ calling for the Center for Health Policy at the University of New England. We're doing a study of health needs in your area to assist in the planning of health care services in the future. First, have I reached you at your home telephone? IF ASKED: WE ARE VERY INTERESTED IN HEARING WHAT YOU THINK ABOUT HEALTH CARE. YOUR PHONE NUMBER HAS BEEN CHOOSEN AT RANDOM TO BE INCLUDED IN THIS STUDY. THE SURVEY SHOULD TAKE ABOUT 15-20 MINUTES DEPENDING ON YOUR ANSWERS 11 13 15 17 19 21 23 25 27 29 31 33 88 99 YES NO NOT NOW, CALL BACK [Wait - Schedule Time] OTHER CONTACT ONLY BUSINESS LANGUAGE INFIRM GROUP QUARTERS, INSTITUTION (DORMS) WRONG NUMBER HANG UP RESPONDENT NOT AVAILABLE DURING DATA COLLECTION PERIOD HOUSEHOLD REFUSAL NEED MORE INFORMATION - OR TO PROVIDE MORE INFORMATION

QUESTION: INFOQ INFORMATION: GENERAL RELUCTANCE We are doing a study of health needs in your area to assist in the planning of health care services in the future. We are very interested in hearing what you think about health care. Your participation is important because you will be helping to represent your entire community. STUDY LENGTH The study will take between 15 and 20 minutes, depending on your answers HOW WAS I SELECTED Your phone number has been chosen at random to be included in this study. Because we can't interview everyone in your community, we are randomly choosing a smaller group of people to speak on behalf of all residents. Will you help us? For specific information about this study, please ask for Dr. Brian Robertson of Market Decisions at our Toll Free Number 1-800-293-1538 ext. 102.

QUESTION: RES Is this a... 1 Residence in Maine County where SOMEONE lives at least 6 months a year 2 Vacation residence or vacation rental? 3 An institutional residence? 4 A group home? 8 DK 9 REFUSED

QUESTION: SELC To start with, I need to know how many of the people living at this phone number are age 18 or above. ENTER NUMBER OF INDIVIDUALS. ENTER 30 FOR 30 or MORE 31 FOR DK OR 32 FOR REF IF ASKED: IT IS IMPORTANT THAT WE INCLUDE ALL MAINE RESIDENTS IN THIS STUDY. WE USE THIS QUESTION SO THAT ALL ADULTS IN THE HOUSEHOLD HAVE THE OPPORTUNITY TO PARTICIPATE. THIS QUESTION ALLOWS US TO IDENTIFY A RANDOM ADULT IN YOUR HOUSEHOLD 0 1 2-30 31 DK 32 REF QUESTION: SEL1 Of these adults, may I please speak to the person who had the most recent birthday? IF ASKED: IT IS IMPORTANT THAT WE INCLUDE ALL MAINE RESIDENTS IN THIS STUDY. WE USE THIS QUESTION SO THAT ALL ADULTS IN THE HOUSEHOLD HAVE THE OPPORTUNITY TO PARTICIPATE. THIS QUESTION ALLOWS US TO IDENTIFY A RANDOM ADULT IN YOUR HOUSEHOLD 1 SPEAKING 2 SOMEONE ELSE 8 DK 9 REF

QUESTION: ANMACH INTS: LEAVE MESSAGE ON IDENTFIED RESIDENTIAL ANSWERING MACHINES ON THE 1st, 3rd, and 7th ATTEMPTS! This is ____________ calling for the Center for Health Policy at the University of New England. We're doing a study of health needs in your area to assist in the planning of health care services in the future. Another interviewer will be contacting your household in the next few days to participate in this important study. If you have any questions about the survey or need to verify it as legitimate, please feel free to call: Dr. Brian Robertson at 1-800-293-1538, extension 102. Thank you and goodbye. INTS CODING FOR ANSWERING MACHINES 1 IDENTIFIED RESIDENTIAL ANSWERING MACHINE 2 UNKNOWN IF RESIDENTIAL ANSWERING MACHINE

Introductory Demographic Items Needed for Survey Questions

QUESTION: Q00 First, a few questions about you and your household

QUESTION: AGE What was your age on your last birthday? ASK IF DK OR REF TO AGE QUESTION: B1a In order to ask you appropriate health related questions, can you tell me which of the following age categories you belong?
Total Respondents Count 18-44 45-64 65+ Total 1,772 3,106 2,221 7,099 Respondents % 41% 39% 20% 100% Weighted Count 431,124 409,034 205,617 1,045,775 Weighted % 41% 39% 20% 100%

QUESTION: E1c Including yourself, how many people in your household are: Under 18 years old?
Total Respondents Count 5,500 739 596 187 57 12 4 2 2 7,099 Respondents % 77% 10% 8% 3% 1% 0% 0% 0% 0% 100% Weighted Count 698,978 152,481 135,566 45,188 10,230 2,223 653 332 124 1,045,775 Weighted % 67% 15% 13% 4% 1% 0% 0% 0% 0% 100%

.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 Total

Health Services Access and Utilization

QUESTION: A1 These next questions are about you use of health care services. Do you have one person you think of as your personal doctor or health care provider? IF NO, ASK: Is there more than one, or is there no person who you think of as your personal doctor or health care provider?
Total Count 871,483 35,161 137,877 1,044,521 % 83% 3% 13% 100%

Yes, only one More than one No Total

ASK IF NO TO QUESTION A1 QUESTION: A2 If you or someone in your family were ill and required medical care, where would you go?
Total Count 13,320 21,522 16,291 64,740 7,044 8,600 131,516 % 10% 16% 12% 49% 5% 7% 100%

DOCTOR A CLINIC OR HEALTH CENTER HOSPITAL OUTPATIENT CLINIC HOSPITAL EMERGENCY ROOM WALK-IN URGENT CARE CENTER OTHER Total

ASK IF YES TO QUESTION A1 QUESTION: A3 What kind of place do you usually go...?
Total Count 734,152 140,493 14,116 3,331 3,401 8,784 904,277 % 81% 16% 2% 0% 0% 1% 100%

A doctor's office or HMO A clinic or health center A hospital outpatient department A hospital emergency room A walk-in or urgent care center Some other kind of place Total

QUESTION: A7 During the past 12 months, how many times have you sought care at an emergency room?
Total Count 747,524 180,745 87,579 28,129 1,043,977 % 72% 17% 8% 2% 100%

NONE 1 2-3 times 4+ times Total

Health Status and Chronic Conditions

QUESTION: B2 Next, a few questions about your health. In general, would you say your health is...?
Total Count 219,911 377,258 288,425 121,571 37,148 1,044,313 % 21% 36% 28% 12% 4% 100%

Excellent Very Good Good Fair Poor Total

QUESTION: B5 During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
Total

Count 0 days 1-2 days 3-5 days 6-10 days 11-20 days 20+ days Total 815,797 66,806 44,399 25,920 26,594 55,306 1,034,822

% 79% 6% 4% 3% 3% 5% 100%

QUESTION: C1 For each of the following conditions I'd like to know whether a doctor, nurse or other health professional ever told you that you had this condition. Has a doctor, nurse, or other health professional ever told you that you have...? High blood pressure or Hypertension
Total

YES NO YES, BUT FEMALE TOLD ONLY DURING PREGNANCY TOLD BORDERLINE HIGH OR PRE-HYPERTENSIVE Total

Count 315,777 717,364 4,966 5,430 1,043,537

% 30% 69% 0% 1% 100%

QUESTION: C2 High Cholesterol (Has a doctor, nurse, or other health professional ever told you that you have...?)
Total

YES NO Total

Count 303,519 737,071 1,040,591

% 29% 71% 100%

QUESTION: C3 Diabetes or high blood sugar PROMPT: IF YES AND FEMALE, ASK: Were you told only during pregnancy? (Has a doctor, nurse, or other health professional ever told you that you have...?)
Total Count 108,595 922,581 3,569 9,920 1,044,666 % 10% 88% 0% 1% 100%

YES NO YES, BUT FEMALE TOLD ONLY DURING PREGNANCY TOLD BORDERLINE HIGH OR PRE-DIABETES Total

QUESTION: C5 Angina or coronary artery disease (Has a doctor, nurse, or other health professional ever told you that you have...?)
Total Count 65,246 977,002 1,042,248 % 6% 94% 100%

YES NO Total

QUESTION: C8 Cancer (Has a doctor, nurse, or other health professional ever told you that you have...?)
Total Count 78,301 965,766 1,044,067 % 7% 93% 100%

YES NO Total

QUESTION: C9 Chronic Obstructive Pulmonary Disease PROMPT: (COPD), including emphysema, or chronic bronchitis (Has a doctor, nurse, or other health professional ever told you that you have...?)
Total Count 44,145 999,342 1,043,487 % 4% 96% 100%

YES NO Total

QUESTION: C10 Asthma (Has a doctor, nurse, or other health professional ever told you that you have...?)
Total Count 129,720 913,684 1,043,403 % 12% 88% 100%

YES NO Total

ASK IF YES TO C10 QUESTION: C10a Do you still have asthma?

Total Count 104,470 23,928 128,398 % 81% 19% 100%

YES NO Total

QUESTION: K3 Has a doctor or other healthcare provider EVER told you that you have... Depression PROMPT: IF UNSURE: This includes depression, major depression, dysthymia, or minor depression
Total Count 230,424 812,989 1,043,413 % 22% 78% 100%

YES NO Total

ASK IF YES TO K3 QUESTION: K3a Do you still have depression?

Total Count 155,445 73,479 228,925 % 68% 32% 100%

YES NO Total

QUESTION: K4 A psychiatric condition other than Depression, such as Anxiety, Bipolar Disorder, Schizophrenia, Anxiety Disorder, or an Eating Disorder like Anorexia or Bulimia (Has a doctor or other healthcare provider EVER told you that you have any of the following conditions...?)
Total Count 136,298 905,012 1,041,310 % 13% 87% 100%

YES NO Total

QUESTION: C20 Have you ever been told by a doctor, nurse or other health professional you had a substance abuse problem with alcohol or drugs?
Total Count 49,435 995,542 1,044,977 % 5% 95% 100%

YES NO Total

ASK IF YES TO C20 QUESTION: C20a Do you still have a substance abuse problem with alcohol or drugs?
Total Count 16,043 33,325 49,368 % 32% 68% 100%

YES NO Total

Chronic Disease Management Questions

ASK OF RESPONDENTS > 34 YEARS OLD QUESTION: D1a Do you take aspirin daily or every other day?
Total Count 270,547 507,594 778,141 % 35% 65% 100%

YES NO Total

ASK OF THOSE INDICATING YES TO D1a QUESTION: D1D Do you take aspirin to reduce the chance of...?
Total Count 205,444 150,146 9,389 6,187 2,485 3,151 8,718 1,467 3,525 6,333 5,588 1,234 4,863 918 825 79 1,333 546 347 2,336 458 3,376 261,803 % 78% 57% 4% 2% 1% 1% 3% 1% 1% 2% 2% 0% 2% 0% 0% 0% 1% 0% 0% 1% 0% 1% 100%

A heart attack A stroke Blood thinner Arthritis Muscle aches, pains Blood clot Doctor told me to Back aches, pains Blood pressure Headaches, migraines Pain in general Diabetes Overall health, good for you Colon problems Knee pain, surgery Back pain, injury Cholesterol Leg pain Due to age Heart issues Cancer Other Total

ASK OF THOSE WITH DIABETES (YES TO C3) QUESTION: D2a Next, I'd like to ask you a few questions about your diabetes. How old were you when you were told you have diabetes?
Total Count 0 1 3 4 5 7 8 9 10 11 12 13 14 15 16 17 18 and older Total 306 269 86 79 171 1,135 141 97 214 125 81 743 696 371 188 148 100,318 105,169 % 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 1% 1% 0% 0% 0% 97% 100%

ASK OF THOSE WITH DIABETES QUESTION: D2b Are you now taking insulin?
Total Count 25,970 81,095 107,065 % 24% 76% 100%

YES NO Total

ASK OF THOSE WITH DIABETES QUESTION: D2e A test for "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for "A one C"?
Total Count 4,992 17,000 32,493 13,677 28,381 555 1,519 874 54 882 62 52 170 189 118 75 227 101,320 % 5% 17% 32% 13% 28% 1% 1% 1% 0% 1% 0% 0% 0% 0% 0% 0% 0% 100%

0 1 2 3 4 5 6 8 11 12 18 20 24 36 52 72 76 OR MORE TIMES Total

ASK OF THOSE WITH DIABETES QUESTION: D2f About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
Total Count 20,848 23,602 21,969 8,181 21,705 1,061 3,290 847 130 81 1,667 114 183 366 113 54 958 302 326 136 105,934 % 20% 22% 21% 8% 20% 1% 3% 1% 0% 0% 2% 0% 0% 0% 0% 0% 1% 0% 0% 0% 100%

0 1 2 3 4 5 6 8 9 10 12 15 20 24 25 26 27 52 77 97 OR MORE TIMES Total

ASK OF THOSE WITH DIABETES QUESTION: D2g When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.
Total Count 30,543 52,311 10,431 9,104 4,426 106,815 % 29% 49% 10% 9% 4% 100%

Within the past month Within the past year Within the past 2 years 2 or more years ago NEVER Total

ASK OF THOSE WITH DIABETES QUESTION: D2i Have you ever taken a course or class in how to manage your diabetes yourself?
Total Count 58,862 49,232 108,094 % 54% 46% 100%

YES NO Total

WHY ARE THE DENOMINATORS ALL DIFFERENT?

ASK OF THOSE WITH HIGH BLOOD PRESSURE QUESTION: D3a Next, I'd like to ask you a few questions about your high blood pressure. About how long has it been since you last had your blood pressure taken by a doctor, nurse, or other health professional?
Total Count 290,972 16,623 6,714 570 674 179 315,731 % 92% 5% 2% 0% 0% 0% 100%

Within the past 6 months Within the past year Within the past 2 years Within the past 5 years 5 or more years ago NEVER Total

ASK OF THOSE WITH HIGH BLOOD PRESSURE QUESTION: D3g Has a doctor or other health professional ever advised you to do any of the following to help lower or control your high blood pressure? Cut down on salt?
Total Count 194,851 118,257 313,109 % 62% 38% 100%

YES NO Total

QUESTION: D3h Exercise? (Dr ever advised you to ________ to help lower your high blood pressure?)
Total Count 256,029 58,856 314,885 % 81% 19% 100%

YES NO Total

QUESTION: D3i Take medication? (Dr ever advised you to _______ to help lower your high blood pressure?)
Total Count 268,774 46,627 315,401 % 85% 15% 100%

YES NO Total

ASK IF YES TO D3g QUESTION: D3c Are you now cutting down on salt to help lower or control your high blood pressure?
Total Count 178,319 16,232 194,551 % 92% 8% 100%

YES NO Total

ASK IF YES TO D3h QUESTION: D3d Are you now exercising to help lower or control your high blood pressure?
Total Count 178,319 16,232 194,551 % 92% 8% 100%

YES NO Total

ASK IF YES TO D3i QUESTION: D3e Are you now taking medication to help lower or control your high blood pressure?
Total Count 253,010 15,610 268,620 % 94% 6% 100%

YES NO Total

QUESTION: D4a Next, I'd like to ask you a few questions about your COPD. Have you ever received any kind of pulmonary rehabilitation? This is sometimes called "rehab."
Total Count 12,838 29,539 42,378 % 30% 70% 100%

YES NO Total

QUESTION: D4b Have you received a lung function test to measure airflow, also called spirometry, in the past 12 months?
Total Count 22,469 20,484 42,954 % 52% 48% 100%

YES NO Total

Youth
ASK OF THOSE WITH CHILDREN < 18 QUESTION: EINTO These next questions are about the children living in your household ASK OF THOSE WITH CHILDREN < 18 Counts and percentages based on total population of children under age 18 in Maine QUESTION: E2a Now I am going to read you a list of health problems that children and adolescents often experience. I'd like to know whether a medical doctor has ever told you that anyone in your household under the age of 18 had each problem. Have any children in your household under the age of 18 ever been diagnosed with...? Asthma
Total Count 16,628 255,490 272,118 % 6% 94% 100%

Yes No Total

ASK OF THOSE WITH CHILDREN < 18 Counts and percentages based on total population of children under age 18 in Maine QUESTION: E3a Diabetes (Have any children in your household under the age of 18 ever been diagnosed with...?)
Total Count Yes No Total 781 271,510 272,291 % 0% 100% 100%

ASK OF THOSE WITH CHILDREN < 18 Counts and percentages based on total population of children under age 18 in Maine E4a A problem with overweight or obesity (Have any children in your household under the age of 18 ever been diagnosed with...?)
Total Count 5,546 266,693 272,249 % 2% 98% 100%

Yes No Total

ASK OF THOSE WITH CHILDREN < 18 Counts and percentages based on total population of children under age 18 in Maine QUESTION: E11 Autism, Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD), or any other developmental delay (Have any children in your household under the age of 18 ever been diagnosed with...?)
Total Count 12,297 259,823 272,120 % 5% 95% 100%

Yes No Total

ASK OF THOSE WITH CHILDREN < 18 SELECT CHILD AT RANDOM All household with one or more children were asked this question. In cases where there was more than one child in the household, one child was chosen at random and the question asked of this child. QUESTION: E10 This question is about FILL CHILD. At your FILL CHILDs last well-child visit, did a doctor, nurse, or anyone else in your child's doctors office talk to you about?
Total Count 83,847 79,349 63,009 64,391 793 33,896 129,855 % 65% 61% 49% 50% 1% 26% 100%

Nutrition Physical activity or exercise Television viewing or other screen time, Sugar-sweetened drinks NO WELL CHILD VISITS AT ALL NONE OF THESE Total

ASK OF THOSE WITH CHILDREN < 18 QUESTION: E8b Was there a time in the past 12 months when any of the children living in your household needed to see a dentist but could not because of cost?
Total Count 7,736 264,213 271,949 % 3% 97% 100%

Yes No Total

ASK OF THOSE WITH CHILDREN < 18 QUESTION: E12 Do your children receive oral health services, specifically exams and fluoride varnish at
Total Count 203,084 6,056 14,390 34,454 257,985 % 79% 2% 6% 13% 100%

A dental office You child's doctor's office Both Neither, no dental care Total

Exercise
QUESTION: F2 Now I'm going to ask you about exercise. During the past month, did you participate in any physical activities such as running, calisthenics, golf, tennis, or walking for exercise?
Total Count 830,383 214,817 1,045,201 % 79% 21% 100%

YES NO Total

Variables F3a, F3b, F4 are used to compute variable exerreg: Does person exercise 5+ times a week for 30+ minutes each time? Variable exerreg is found in the computed variable section on page 85.

ASK OF THOSE INDICATING YES TO F2 QUESTION: F3a How many times per week or per month did you take part in this activity during the past month? 1 ENTER # OF TIMES PER WEEK 2 ENTER # OF TIMES PER MONTH 8 DK 9 REF

ASK OF THOSE INDICATING YES TO F2 QUESTION: F3b How many times per week or per month do you take part in this activity? 0-96 ENTER # OF TIMES PER WEEK: 97 MORE THAN 97 TIMES 98 DK 99 REF

ASK OF THOSE INDICATING YES TO F2 QUESTION: F4 And when you took part in this activity, for how many minutes did you usually keep at it? (RECORD RESPONSE IN MINUTES) 0-996 ENTER # OF MINUTES: 997 MORE THAN 997 MINUTES 998 DK 999 REF

Primary Care
QUESTION: H1 INTERVIEWER: RESPONDENT SEX BY OBSERVATION (DO NOT READ)
Total Respondents Count 3,169 3,930 7,099 Respondents % 45% 55% 100% Weighted Count 504,176 541,599 1,045,775 Weighted % 48% 52% 100%

MALE FEMALE Total

QUESTION: H2 About how long has it been since you last visited a doctor for a routine checkup or physical examination? PROMPT: A ROUTINE CHECKUP IS A GENERAL PHYSICAL EXAM, NOT AN EXAM FOR A SPECIFIC INJURY, ILLNESS OR CONDITION.
Total Count 822,702 110,231 50,061 54,529 3,485 1,041,008 % 79% 11% 5% 5% 0% 100%

Within the past year Within the past 2 years Within the past 5 years More than 5 years ago Never Total

QUESTION: H3 Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
Total Count 889,820 121,581 1,011,401 % 88% 12% 100%

YES NO Total

ASK OF THOSE INDICATING YES TO H3 QUESTION: H3a About how long has it been since you last had your blood cholesterol checked?
Total Count 662,968 112,570 66,008 34,259 875,805 % 76% 13% 8% 4% 100%

Within the past year Within the past 2 years Within the past 5 years More than 5 years ago Total

ASK OF MALES QUESTION: H7 A digital rectal exam PROMPT: This is an exam in which a doctor, nurse, or other health professional places a gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland. (How long has it been since you last had any of the following tests or examinations?)
Total Count 158,841 45,237 39,921 29,674 210,441 484,114 % 33% 9% 8% 6% 43% 100%

Within the past year Within the past 2 years Within the past 5 years More than 5 years ago Never Total

ASK OF MALES QUESTION: H8 A Prostate Specific Antigen test, also called a PSA test, to check your prostate gland (How long has it been since you last had any of the following tests or examinations?)
Total Count 148,123 31,852 20,946 11,333 255,034 467,288 % 32% 7% 4% 2% 55% 100%

Within the past year Within the past 2 years Within the past 5 years More than 5 years ago Never Total

ASK OF FEMALES QUESTION: H10 A mammogram is an x-ray of the breast to look for cancer. Have you ever had a mammogram?

Total Count 371,754 168,779 540,533 % 69% 31% 100%

YES NO Total

ASK OF THOSE INDICATING YES TO H10 QUESTION: H10a How long has it been since you had your last mammogram?
Total Count 270,919 57,260 14,702 11,075 16,032 369,989 % 73% 15% 4% 3% 4% 100%

WITHIN THE PAST YEAR WITHIN THE PAST 2 YEARS WITHIN THE PAST 3 YEARS WITHIN THE PAST 5 YEARS 5 OR MORE YEARS AGO Total

ASK OF FEMALES QUESTION: H11 A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?
Total Count 509,163 31,173 540,336 % 94% 6% 100%

YES NO Total

ASK OF THOSE INDICATING YES TO H11 QUESTION: H11a How long has it been since you had your last Pap smear?
Total Count 294,935 85,733 28,193 24,075 72,471 505,407 % 58% 17% 6% 5% 14% 100%

WITHIN THE PAST YEAR WITHIN THE PAST 2 YEARS WITHIN THE PAST 3 YEARS WITHIN THE PAST 5 YEARS 5 OR MORE YEARS AGO Total

QUESTION: H13 Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. Have you ever had either of these?
Total Count 454,709 588,510 1,043,219 % 44% 56% 100%

YES NO Total

QUESTION: H13a How long has it been since you had your last sigmoidoscopy or colonoscopy?
Total Count 112,280 93,916 167,527 79,429 453,152 % 25% 21% 37% 18% 100%

Within the past year Within the past 2 years Within the past 5 years More than 5 years ago Total

QUESTION: H14 During the past 12 months, have you had a Flu shot or a flu vaccine that was sprayed in your nose? PROMPT: The flu vaccine sprayed in the nose is called FluMistTM
Total Count 434,540 608,109 1,042,649 % 42% 58% 100%

YES NO Total

ASK OF THOSE AGE 50+ QUESTION: H15 A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia vaccination?
Total Count 219,990 258,302 478,291 % 46% 54% 100%

YES NO Total

QUESTION: H15a During the past 12 months, have you had a pneumonia vaccination?
Total Count 81,927 131,730 213,657 % 38% 62% 100%

YES NO Total

QUESTION: H30 In the last 12 months, how often did your doctor give you easy to understand instructions about what to do to take care of an illness or health condition?
Total Count 544,355 146,330 76,825 95,075 862,585 % 63% 17% 9% 11% 100%

Always Usually Sometimes Never Total

QUESTION: H31 In the last 12 months, how often did your doctor ask you to describe how you were going to follow these instructions?
Total Count 281,700 131,898 122,912 195,152 731,662 % 39% 18% 17% 27% 100%

Always Usually Sometimes Never Total

Height and Weight

Height and weight are used to calculate BMI. Variable BMICAT is found in the computed variable section on page 85. QUESTION: H16 How tall are you with your shoes off? (RECORD IN FEET AND INCHES; E.G. 6'1"=601) 401-800 ENTER # OF FEET/INCHES: 400 998 999 4 FEET OR LESS DK REF

QUESTION: H17 What is your weight with your shoes off? (ROUND FRACTIONS UP) 0 - 996 ENTER # OF POUNDS: 997 MORE THAN 997 POUNDS 998 DK 999 REF

QUESTION: H21 Which of the following are you trying to do about your weight?
Total Count 508,551 34,803 258,996 238,304 1,040,655 % 49% 3% 25% 23% 100%

Lose weight Gain weight Stay the same weight I am not trying to do anything about my weight Total

Dental Care
QUESTION: J1 Now I'd like to change the subject and ask about dental care. How long has it been since you last visited the dentist or dental clinic? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as hygienists.
Total Count 692,968 98,202 82,082 160,491 7,103 1,040,846 % 67% 9% 8% 15% 1% 100%

WITHIN THE PAST YEAR WITHIN THE PAST 2 YEARS WITHIN THE PAST 5 YEARS 5 OR MORE YEARS AGO NEVER Total

QUESTION: J2 What is the main reason you have not visited a dentist in the last year?
Total Count 17,575 132,356 8,079 3,001 115,068 18,140 10,837 19,432 17,885 394 1,887 1,253 2,573 1,194 345,558 % 5% 38% 2% 1% 33% 5% 3% 6% 5% 0% 1% 0% 1% 0% 100%

Fear, apprehension, nervousness, pain, dislike going Cost Do not have, know a dentist Cannot get to the office, clinic No reason to go Other priorities Have not thought of it Dentures, False teeth, No teeth No dental insurance Not accepting new patients Do not accept MaineCare, My insurance Distance Health issues Other Total

Mental Health
QUESTION: K5 Now, I would like to ask you a few questions about mental health. These next questions are about treatment and counseling for problems with emotions, nerves or mental health. Please do not include treatment for alcohol or drug use. During the past 12 months, did you receive any outpatient treatment or counseling for any problem you were having with your emotions, nerves, or mental health? PROMPT: Please do not include treatment for alcohol or drug use.
Total Count 118,859 924,419 1,043,278 % 11% 89% 100%

YES NO Total

QUESTION: K6 During the past 12 months, was there any time when you needed mental health treatment or counseling for yourself but didn't get it?
Total Count 50,325 991,129 1,041,454 % 5% 95% 100%

YES NO Total

QUESTION: K7 Was this because you couldn't afford mental health treatment or counseling, or was there some other reason you didn't get the care you needed?
Total Count 21,561 1,017 3,180 2,167 2,827 1,790 5,291 912 2,348 927 1,887 703 626 1,291 279 236 2,155 47,999 % 45% 2% 7% 5% 6% 4% 11% 2% 5% 2% 4% 1% 1% 3% 1% 0% 4% 100%

Could not afford it Did not know where to go Took too much time Embarrassed or fearful others would find out Too far to travel, takes too long to get there Did not think it would help Cannot get appointment Not taking new patients Could not find doctor, specialist Did not go, Did not make appointment No insurance, Insurance would not cover it Had other priorities Unable find care that was right for me Could not help me Wanted to handle it myself Illness got in the way of my helping myself Childcare issues, unable to free myself up to go Other Total

QUESTION: K20 These next questions are about how you feel and how things have been with you during the past month. How much of the time during the past month... Have you felt very nervous?
Total Count 14,291 29,068 34,818 145,217 318,837 498,044 1,040,275 % 1% 3% 3% 14% 31% 48% 100%

All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time Total

QUESTION: K21 Have you felt calm and peaceful? (How much of the time during the past month...)
Total Count 138,881 552,613 120,824 136,242 62,177 26,330 1,037,067 % 13% 53% 12% 13% 6% 3% 100%

All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time Total

QUESTION: K22 Have you felt downhearted and blue? (How much of the time during the past month...)
Total Count 13,103 26,088 27,062 137,256 313,619 519,552 1,036,679 % 1% 3% 3% 13% 30% 50% 100%

All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time Total

QUESTION: K23 Have you felt happy? (How much of the time during the past month...)
Total Count 135,879 577,877 141,967 126,892 42,400 12,633 1,037,648 % 13% 56% 14% 12% 4% 1% 100%

All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time Total

QUESTION: QK24 Have you felt so down in the dumps that nothing could cheer you up? (How much of the time during the past month...)
Total Count 5,020 9,905 9,277 44,122 109,565 859,239 1,037,129 % 0% 1% 1% 4% 11% 83% 100%

All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time Total

Risk Factors
QUESTION: L1 Now, I would like to ask you about your use of tobacco products. Have you smoked at least 100 cigarettes in your entire life?
Total Count 553,911 488,289 1,042,200 % 53% 47% 100%

YES NO Total

ASK OF THOSE INDICATING YES TO L1 QUESTION: L2 Do you now smoke cigarettes everyday, some days or not at all?
Total Count 185,874 40,678 327,210 553,763 % 34% 7% 59% 100%

Everyday Some days Not at all Total

ASK OF THOSE INDICATING EVERY DAY OR SOME DAYS TO L2 QUESTION: L6 In the past 12 months, has a doctor, nurse, or other health professional advised you to quit smoking?
Total Count 162,719 63,549 226,268 % 72% 28% 100%

YES NO Total

ASK OF THOSE INDICATING EVERY DAY OR SOME DAYS TO L2 QUESTION: L7 During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
Total Count 122,945 103,229 226,175 % 54% 46% 100%

YES NO Total

ASK OF THOSE INDICATING EVERY DAY OR SOME DAYS TO L2 QUESTION: L8 Have you ever called the Maine Tobacco helpline?
Total Count 43,284 182,853 226,137 % 19% 81% 100%

YES NO Total

ASK OF THOSE 18-34 QUESTION: L20 These next few questions are about your personal behavior, and I want to remind you that your answers are confidential. During the past 12 months, with how many people have you had sexual intercourse?
Total Count 41,256 178,380 17,469 10,765 5,211 2,418 1,448 134 1,025 1,086 407 117 259 67 146 260,188 % 16% 69% 7% 4% 2% 1% 1% 0% 0% 0% 0% 0% 0% 0% 0% 100%

NONE 1 2 3 4 5 6 8 9 10 12 13 20 24 40 Total

ASK OF THOSE 18-34 QUESTION: L21 Was a condom used the last time you had sexual intercourse?
Total Count 83,091 156,076 239,167 % 35% 65% 100%

YES NO Total

QUESTION: L30 During the past 30 days have you used any street drugs including: marijuana, cocaine, crack, heroin, hallucinogens, or inhalants? PROMPT: Street Drugs include marijuana or hashish. Cocaine or crack, and hallucinogens such as LSD, PCP, Mescaline, or Ecstasy
Total Count 54,375 989,384 1,043,759 % 5% 95% 100%

YES NO Total

QUESTION: L31 Within the last 30 days, on how many days did you use prescription drugs not as directed or used someone else's prescription not prescribed for you?
Total Count 1,025,507 3,569 7,003 525 168 1,493 556 93 381 1,821 144 196 290 2,200 1,043,945 % 98% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 100%

NONE 1 2 3 4 5 7 8 9 10 14 15 20 30 Total

QUESTION: L40 During the past 12 months were you or anyone in your family experience an overdose/ poisoning from taking too many pills, mixing pills and or alcohol
Total Count 9,444 1,035,017 1,044,461 % 1% 99% 100%

YES NO Total

ASK IF YES TO L40 QUESTION: L41 When this occurred was 911 called or did you seek medical attention from a doctor or hospital?
Total Count 6,319 2,811 9,130 % 69% 31% 100%

YES NO Total

Intimate Partner Violence

QUESTION: IPV02 The next questions are about violence in relationships with an intimate partner. By an intimate partner, I mean any current or former spouse, boyfriend, or girlfriend. Someone you dated would also be considered an intimate partner. Has an intimate partner EVER hit, slapped, pushed, kicked, or physically hurt you in any way?
Total Count 120,548 914,807 1,035,355 % 12% 88% 100%

YES NO Total

QUESTION: IPV04 In the past 12 months, have you experienced any physical violence or had unwanted sex with current or former intimate partner? Physical violence includes being hit, kicked, punched, choked or otherwise physically hurt.
Total Count 12,456 1,020,172 1,032,628 % 1% 99% 100%

YES NO Total

Health Insurance
QUESTION: N1 Do you currently have health insurance that would cover at least part of the bill if you had to stay in the hospital overnight? PROMPT: include any kind of coverage, including health insurance, prepaid plans (HMOs), government plans such as Medicare.
Total Count 906,453 131,874 1,038,327 % 87% 13% 100%

Yes No Total

ASK OF THOSE INDICATING YES TO N1 QUESTION: N2 What is that coverage? Is it...

Total Count 172,653 216,053 56,616 509,571 128,080 4,608 900,744 % 19% 24% 6% 57% 14% 1% 100%

Medicaid or MaineCare Medicare Champus or any other government program Insurance that you get through an employer Insurance that you buy on your own Other Total

Health Care Barriers

QUESTION: HC01 During the past 12 months, was there any time when you needed any of the following but didn't get it because you could not afford it? QUESTION: HCB02 Medical care from a doctor or surgery?
Total Count 68,118 976,393 1,044,510 % 7% 93% 100%

YES NO Total

QUESTION: HCB03 Prescription medicines?

Total Count 68,562 976,173 1,044,735 % 7% 93% 100%

YES NO Total

QUESTION: HCB05c During the past 12 months, was there any time that you skipped doses or took smaller amounts of your prescription drugs to make them last longer?
Total Count 90,646 954,136 1,044,782 % 9% 91% 100%

YES NO Total

Community Health Needs

QUESTION: O1 These next questions are about health concerns and health care services in your community. What do you think is the biggest health problem facing your community?
Total Count 69,610 104,062 41,966 25,723 135,638 134,639 4,022 4,299 17,157 2,804 10,473 1,192 19,444 117,089 7,322 50,752 446 908 16,237 6,991 14,325 2,240 11,868 7,863 2,757 7,447 5,299 5,436 793 12,613 % 8% 12% 5% 3% 15% 15% 0% 0% 2% 0% 1% 0% 2% 13% 1% 6% 0% 0% 2% 1% 2% 0% 1% 1% 0% 1% 1% 1% 0% 1%

Ability to pay for care Alcohol, drug abuse Cancer Elderly care Health care too expensive Lack of health insurance Lack of transportation to care Poor oral health Prescription medication too expensive Teen pregnancy Travel times to services are too long Violence Inadequate healthcare, Incompetent doctors, hospitals Obesity Abuse of the system Access to healthcare, doctors, Need more doctors Arthritis Asthma, COPD Smoking Insurance does not cover care, Insurance not accepted Lack of dental care Depression Diabetes Economy, lack of jobs Emergency services Lack of exercise Government involvement, interference Heart disease High blood pressure Poor nutrition

QUESTION: O1 What do you think is the biggest health problem facing your community? (continued)
Total Count 3,663 19,739 4,658 7,816 4,046 4,378 1,224 4,073 4,137 5,369 1,129 540 23,986 27,109 887,511 % 0% 2% 1% 1% 0% 0% 0% 0% 0% 1% 0% 0% 3% 3% 100%

Welfare Mental health Obamas plan People not taking care of themselves Poverty, Homelessness People using ER when should see Doctor Too many people on MaineCare Those who need coverage do not get it, those not working do get it Care for children Education Insurance companies, industry Need single payer system, universal care for all Other None Total

QUESTION: BA13 Are there any medical or health related services that you or family members need but that you have to travel outside this area to receive?
Total Count 3,940 3,523 24,140 29,210 4,993 42,592 9,885 8,858 8,829 6,934 14,990 3,161 1,466 3,301 12,303 3,606 6,240 16,117 19,614 7,265 3,982 21,268 1,275 2,941 3,308 1,941 8,400 25,078 8,957 18,034 3,094 12,913 3,792 11,623 % 0% 0% 2% 3% 0% 4% 1% 1% 1% 1% 1% 0% 0% 0% 1% 0% 1% 2% 2% 1% 0% 2% 0% 0% 0% 0% 1% 2% 1% 2% 0% 1% 0% 1%

Allergy Angiogram Cancer treatment, services Cardiological services, surgery Chiropractic, back Dental, Orthodontic, surgery Dermatology Diabetes Diagnostic Tests, MRI, X-Ray Ear, nose, throat Eye Care Feet problems, podiatrist Hearing Hematology Infant, pediatric services Knee surgery, replacement Lung, Pulmonary services Mental health Neurological services Oncology Ophthalmology, Eye care Orthopedic, Bone disease, Arthritis Outpatient Care, Day Surgery Pain Management Physical therapy Rehabilitation Services Stomach, bowel, gastrointestinal Surgery Womens health, mammogram, birth All, any medical services Nephrology, kidney, dialysis Doctor, PCP, general care ER, Emergency services Specialist

QUESTION: BA13 Are there any medical or health related services that you or family members need but that you have to travel outside this area to receive? (continued)
Total Count 2,241 1,915 634 5,855 2,662 626 1,082 530 1,408 456 766 3,490 1,288 251 260 7,185 797,246 1,034,733 % 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 77% 100%

Endocrinology Hospital Clinic VA, Togus Lyme disease, infectious disease Immune system Naturopathy, Holistic, Alt. Med. Therapies Radiation Rheumatology Sleep apnea Drug, alcohol abuse, counseling Urology Prescriptions Spinal, MS Geriatric, Elder care, Alzheimers Other None Total

QUESTION: BA14 Are there any medical or health related services that you would travel outside of this area to receive because you feel there are no qualified physicians or specialists?
Total Count 3,745 1,403 86,623 66,594 4,275 19,905 9,146 4,829 4,427 7,931 12,308 3,832 2,099 3,003 8,483 4,769 4,759 13,064 30,265 19,479 3,033 26,837 1,826 1,951 2,163 1,822 8,939 57,172 9,774 19,100 1,904 7,680 3,428 13,719 % 0% 0% 9% 7% 0% 2% 1% 0% 0% 1% 1% 0% 0% 0% 1% 0% 0% 1% 3% 2% 0% 3% 0% 0% 0% 0% 1% 6% 1% 2% 0% 1% 0% 1%

Allergy Angiogram Cancer treatment, services Cardiological services, surgery Chiropractic, back Dental, Orthodontic, surgery Dermatology Diabetes Diagnostic Tests, MRI, X-Ray Ear, nose, throat Eye Care Feet problems, podiatrist Hearing Hematology Infant, pediatric services Knee surgery, replacement Lung, Pulmonary services Mental health Neurological services Oncology Ophthalmology, Eye care Orthopedic, Bone disease, Arthritis Outpatient Care, Day Surgery Pain Management Physical therapy Rehabilitation Services Stomach, bowel, gastrointestinal Surgery Womens health, mammogram, birth All, any medical services Nephrology, kidney, dialysis Doctor, PCP, general care ER, Emergency services Specialist

QUESTION: BA14 Are there any medical or health related services that you would travel outside of this area to receive because you feel there are no qualified physicians or specialists? (continued)
Total Count Endocrinology Hospital Clinic VA, Togus Lyme disease, infectious disease Immune system Radiation Rheumatology Sleep apnea Drug, alcohol abuse, counseling Urology Prescriptions Alternative care Serious, major illness Burn care Disease If needed, If referred by doctor Brain, surgery To get a second opinion Depends on the issue Geriatric, Elder care, Alzheimers Other None Total 668 1,853 204 1,460 2,586 79 260 1,037 356 1,061 2,724 1,548 1,252 10,243 653 2,263 1,809 779 3,387 1,300 25 10,403 677,219 1,003,923 % 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 1% 67% 100%

Wellness Activities and Programs

QUESTION: Well1 Does your employer or your community currently offer any wellness activities or programs? IF YES ASK: Is that your employer, your community, or both? PROMPT: This would include programs such as exercise, nutrition, or tobacco cessation.
Total Count 137,431 311,697 117,744 314,774 881,647 % 16% 35% 13% 36% 100%

EMPLOYER COMMUNITY BOTH NEITHER, EMPLOYER AND COMMUNITY DO NOT OFFER Total

QUESTION: Well2 In the past year, have you participated in any wellness activities or programs?
Total Count 9,422 4,457 154,508 47,718 46,892 3,732 8,256 6,506 1,277 16,646 1,323 2,501 2,442 2,349 3,617 8,946 2,580 6,364 1,341 1,678 7,586 1,701 5,022 4,306 1,719 859 1,361 2,508 1,351 386 548 10,439 777,192 1,031,269 % 1% 0% 15% 5% 5% 0% 1% 1% 0% 2% 0% 0% 0% 0% 0% 1% 0% 1% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 75% 100%

CPR and First Aid Depression management program Exercise program Health screenings Nutrition program Parenting program Smoking cessation program Stress management program Time management program Yoga, Meditation Cardiac therapy, rehab Diabetes program Physical therapy Swimming, pool therapy Weight loss program Wellness program Zumba classes, dancing YMCA, Gym, Personal exercise Cancer support, meetings Elder wellness Walking, Running, Biking, Hiking Eating healthy Intramurals, Sports Lectures, Workshops, Seminars Follow up phone call inquiring about health Heart health program Survey for insurance, employer, Online See, talk to a counselor Mental health Gardening AA, NA meetings, support groups for addiction, affected by Other Have not participated in wellness program Total

QUESTION: WELL3 What barriers are there to your participating in wellness activities or programs?
Total Count 118,517 12,778 3,243 43,493 4,538 3,685 14,949 2,260 28,643 16,387 10,763 18,776 23,806 15,847 12,705 8,166 12,137 2,560 3,385 10,898 1,806 183 4,096 735 5,207 1,257 722 781 3,872 696 590 1,222 607 340 6,343 617,892 1,013,888 % 12% 1% 0% 4% 0% 0% 1% 0% 3% 2% 1% 2% 2% 2% 1% 1% 1% 0% 0% 1% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 61% 100%

Time, too busy Kids, family commitments Age Availability of programs, Did not know they were available Back problems Knee problems Transportation, lack of, Cannot drive Child care Cost Distance, travel time No reason to, Do not need them Do not want to, Not interested Work, job constraints Motivation, Laziness Health problems, Injury, Illness in general Anxiety, Antisocial, Do not like people, Panic attacks Physical limitations, Limited mobility, balance Disabled Foot, ankle, leg problems Do it myself, Do it on my own Arthritis Arm, wrist, shoulder problems COPD, Asthma, Breathing problems Blind, Poor eyesight Other commitments, priorities Fibromyalgia, Muscle pain Hip problems Weather Mental health, Depression Cancer Pain MS Obesity Smoking Other No barriers Total

Alternative Therapies
QUESTION: ALT1 According to recent studies, a large number of Americans now use one or more alternative or complementary medical therapies or practices. Over the past 3 years, have you tried any alternative medical therapies or practices?
Total Count 290,846 752,471 1,043,318 % 28% 72% 100%

YES NO Total

ASK IF YES TO ALT1 QUESTION: ALT2 What specific treatments or practitioners did you use?
Total Count 143,898 99,114 44,601 48,010 20,768 8,158 1,196 676 965 1,841 848 1,597 1,669 1,323 5,535 2,777 7,458 6,527 1,168 6,961 1,334 784 5,992 6,261 604 806 784 627 1,652 565 7,318 290,135 % 50% 34% 15% 17% 7% 3% 0% 0% 0% 1% 0% 1% 1% 0% 2% 1% 3% 2% 0% 2% 0% 0% 2% 2% 0% 0% 0% 0% 1% 0% 3% 100%

Chiropractic Massage Therapy Acupuncture Herbal Therapy Homeopathy Naturopathy Aromatherapy Bio feedback Chinese Cranial therapy; Cranio, sacral therapy Dietary Exercise Holistic Hypnosis Meditation Nutritional Osteopathic, DO, Manipulation, OMMT Physical therapy Reflexology Reiki, Spiritual, palm healing Tai Chi Therapy in general Vitamins, Supplements Yoga Marijuana Prayer Acupressure Relaxation, Mind & body Aquatic Therapy; pool, swimming Ayurvedic Therapies Other Total

End of Life Care

QUESTION: EOLC6

Advance directives allow people to make their health care choices known in advance of an incapacitating illness or death. Has your healthcare provider discussed "Advanced Directives" with you?
Total Count 290,713 735,918 1,026,632 % 28% 72% 100%

YES NO Total

QUESTION: EOLC1 Advance directives allow people to make their health care choices known in advance of an incapacitating illness or death. Have you completed A Health Care Power of Attorney (HCPA) in which you name someone to make decisions about your health care in the event you become incapacitated A living will in which you state the kind of health care you want or dont want under certain circumstances
Total Count 330,943 369,886 630,566 1,038,407 % 32% 36% 61% 100%

Health Care Power of Attorney Living Will NEITHER Total

Demographics
EMP01 This next series of questions is about jobs and employment. PROMPT: Answers to these questions are important because they help us understand about health care issues. Also, I want to emphasize that the information you provide will be kept confidential and will only be used in combined form. [PRESS 1 TO CONTINUE]

Variables EMP02 and EMP03 are used to calculate the working. The variable working is found in the computed variable section on page 84. EMP02 Are you working, keeping house, going to school, or something else? IF ON VACATION ASK: Does this person generally work? IF SOMETHING ELSE ASK: Are/Is FILL NAME PRIMARILY unemployed, not at your/his/her job temporarily, retired, disabled, unable to work, or something else?
Total Count 591,060 83,184 45,367 3,788 37,594 200,569 72,666 7,144 517 620 1,042,508 % 57% 8% 4% 0% 4% 19% 7% 1% 0% 0% 100%

Working Keeping house Going to school With a job, but not at work temporarily Unemployed, laid off, looking for work Retired Disabled Unable to work Volunteering Other Total

ASK OF THOSE 18 AND OLDER AND GOING TO SCHOOL, KEEPING HOUSE, RETIRED, OTHER, DK, OR REF TO EMP02 EMP03 Do you typically work for pay? 1 YES 2 NO 8 DK 9 REF

ASK OF THOSE WORKING EMP04a Now thinking about the job you work the most hours. Is this a permanent, temporary job, or seasonal job?

Total Count 557,092 47,250 51,674 656,017 % 85% 7% 8% 100%

Permanent Temporary Seasonal Total

ASK OF THOSE WORKING EMP05 For the job you work the most hours, what is the total number of hours you usually works per week?
Total Count 397,403 129,765 282,092 209,650 1,035,135 % 37% 11% 26% 18% 100%

<10 hours 10 to 31 hours 32-40 hours Over 40 hours

Total

QUESTION: Z1 These last few questions are for classification purposes only. What is the highest grade or year of school you completed?
Total Count Never attended school or only attended kindergarten Grades 1 through 8 Grades 9 through 11 Grade 12 or GED College 1 year to 3 years College 4 years or more Graduate/Professional Degree Total 141 16,164 56,930 342,627 314,008 189,615 123,073 1,042,558 % 0% 2% 5% 33% 30% 18% 12% 100%

QUESTION: Z2 Are you now...?

Total Count 609,855 120,535 72,839 15,755 162,490 54,962 1,036,437 % 59% 12% 7% 2% 16% 5% 100%

Married Divorced Widowed Separated Never been married Part of an unmarried couple living in the same household Total

QUESTION: Z5 Are you Hispanic, Latino, or Spanish?

Total Count 11,555 1,034,220 1,045,775 % 1% 99% 100%

YES NO Total

QUESTION: Z6 Which one or more of the following would you say is your race? QUESTION: Z7 Which one of these groups would you say best represents your race?
Total Count 1,014,679 8,798 2,251 3,062 16,568 417 1,045,775 % 97% 1% 0% 0% 2% 0% 100%

White Black or African American Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other Total

QUESTION: INC01 The next questions are about income that your FAMILY received during 2009 PROMPT: This information helps explain whether people can afford the health insurance and health care they need. Your information is strictly confidential and will be kept private. INTS: IF THEY ASK WHY PEOPLE ARE CLASSIFIED AS SEPARATE FAMILIES: The government considers the people included in a family unit based upon their age, marital status, whether they have children, and whether they are a full time student.

QUESTION: INC02 During the entire year of 2009, what was the total income for THIS FAMILY before taxes, including money from jobs, investments, social security, retirement income, child support, unemployment payments, public assistance, and so on. PROBE FOR MILD RESISTANCE: Answers to questions on earnings are important because they help explain whether people can afford the health care they need. Also, the information you provide will be kept confidential and will only be used in summary reports. PROBE FOR DK OR HESITATION: If you do not know exactly, your best estimate would be fine.

Total Count 32,161 9,399 44,569 25,312 13,540 72,845 64,417 57,620 59,748 55,799 105,639 82,271 121,514 300,942 1,045,775 % 3% 1% 4% 2% 1% 7% 6% 6% 6% 5% 10% 8% 12% 29% 100%

Less than $5,000 $5,000 to $7,499 $7,500 to $9,999 $10,000 to $12,499 $12,500 to $14,999 $15,000 to $19,999 $20,000 to $24,999 $25,000 to $29,999 $30,000 to $34,999 $35,000 to $39,999 $40,000 to $49,999 $50,000 to $59,999 $60,000 to $74,999 $75,000 or more Total

QUESTION: Z8 Altogether, how many years have you lived in Maine?

Total Count 52,912 77,819 123,715 289,414 206,171 289,606 1,039,637 % 5% 7% 12% 30% 17% 24% 100%

0-5 years 6-10 years 11-20 years 20-35 years 36-49 years 50+ years Total

Computed Variables
Computed Variable: WORKING Does person work for pay?
Total Count 659,983 385,792 1,045,775 % 63% 37% 100%

Working Not Working Total

Computed Variable: CNTY County of Residence

Total Respondents Count ANDROSCOGGIN AROOSTOOK CUMBERLAND FRANKLIN HANCOCK KENNEBEC KNOX LINCOLN OXFORD PENOBSCOT PISCATAQUIS SAGADAHOC SOMERSET WALDO WASHINGTON YORK Total 426 415 433 422 425 431 421 421 423 735 425 426 424 419 425 428 7,099 Respondents % 6% 6% 6% 6% 6% 6% 6% 6% 6% 10% 6% 6% 6% 6% 6% 6% 100% Weighted Count 82,964 57,185 220,168 23,655 43,447 95,870 33,120 28,094 44,465 118,616 13,489 28,869 40,105 30,376 25,702 159,650 1,045,775 Weighted % 8% 5% 21% 2% 4% 9% 3% 3% 4% 11% 1% 3% 4% 3% 2% 15% 100%

Computed Variable: BMICAT BMI Categories

Total Count 11,698 348,080 374,217 283,153 1,017,148 % 1% 34% 37% 28% 100%

Underweight Normal Overweight Obese Total

Computed Variable: CHRONC Number of Chronic Conditions

Total Count 460,597 274,055 171,029 85,228 37,503 13,388 3,331 644 1,045,775 % 44% 26% 16% 8% 4% 1% 0% 0% 100%

.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 Total

Computed Variable: EXRREG Does person exercise 5+ times a week for 30+ minutes each time?

Total Count 268,174 777,601 1,045,775 % 26% 74% 100%

Yes No Total

Computed Variable: WELLNESS Wellness Categories

Total Count 409,740 104,834 372,269 158,216 1,045,059 % 39% 10% 36% 15% 100%

Well Behavioral Risk Symptomatic Not Well Total

Computed Variable: SMOKSTAT Current Smoking Status

Total Count 226,553 327,210 488,289 1,042,052 % 22% 31% 47% 100%

Current Smoker Former Smoker Non-smoker Total

OneMaine Community Health Needs Assessment 2010

APPENDIX 6: SURVEY METHODS TECHNICAL

Stage 1 Sampling (Stratified RDD Sample) A set of 16 independent Random Digit Dialing (RDD) samples were generated based on Maines 16 counties. These sampling strata are defined in Table 6-1. Table 6-1: Geographic Sampling Strata Used During Stage 1 Strata # Geographic Area 1 Androscoggin County 2 Aroostook County 3 Cumberland County 4 Franklin County 5 Hancock County 6 Kennebec County 7 Knox County 8 Lincoln County 9 Oxford County 10 Penobscot County 11 Piscataquis County 12 Sagadahoc County 13 Somerset County 14 Waldo County 15 Washington County 16 York County Market Decisions, LLC, generated the RDD samples in-house to derive the equal probability sample of telephone numbers. Within the data collection period, sample records were entered in replicates to meet callback and refusal conversion goals. Development of RDD Telephone Samples for this Research and Sample Generation The model for Stage 1 relied on RDD samples as the sampling strategy. Any RDD sample used for this research must be designed to insure equal and known probability of selection (within each of the sampling stages). Market Decisions, LLC, currently uses in-house software for generation of residential samples. The software is provided by Marketing Systems Group. The GENESYS sampling software is the first and only commercially available in-house sampling system with fully configured RDD design and generation capabilities. GENESYS supports RDD telephone sampling for any geographic area down to the census tract level. This includes state, county, metropolitan statistical area (MSA), ZIP Code, time zone, etc. The GENESYS system also contains telephone exchange-level estimates for over 48 demographic variables (e.g., age and income distributions) that can be used in conjunction with geographic definitions to produce truly unique geo-demographic sampling capabilities. The standard GENESYS RDD methodology produces a strict single stage, epsem sample of residential telephone numbers. In other words, a GENESYS RDD sample ensures an equal and known probability of selection for every residential telephone number in the sample frame.

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OneMaine Community Health Needs Assessment 2010 Sample Generation The sample files for the 16 strata were generated in-house using GENESYS sampling software. Each of the four strata samples was generated in proportion to the distribution of population of exchanges and telephone numbers throughout each sampling stratum. Thus, a higher percentage of sample telephone numbers were generated in those areas with higher residential populations. The sample thus reflected the distribution of the population throughout each Maine county. In each of these 16 sampling strata, all residential telephone numbers in Maine were included within the sampling frame. In all, a total of 70,200 random telephone numbers were generated. Sample Cleaning Any methodology that generates sample for RDD surveying produces non-household numbers. This is a simple fact that researcher must anticipate when the goal is to generate equal probability samples. Market Decisions used the GENESYS ID Plus System to help remove non-productive numbers. Following cleaning through GENESYS ID-Plus, a total of 42,128 telephone numbers were retained in the sample. Sample Entry/Replicates It is counter-productive to enter the entire potential sample at once. It is not possible to contact every potential respondent within the first few days of the study, given the large sample size. In addition, if efforts prove more efficient than anticipated it may result in the need for less sample than originally thought. Entering all sample at the beginning would then adversely affect response rates as numbers would not be resolved. Market Decisions entered sample as a set of replicates throughout the data collection process. The entry of each replicate was timed so that numbers in prior replicates had been sufficiently resolved and that later replicates were entered in order to provide adequate time to meet callback requirements. In all, the sample was entered in 14 replicates throughout the data collection period. That is, the original file that was generated for the general population was divided into replicates. A sample replicate was entered and calls made to these cases. As numbers were resolved, an additional sample replicate was then entered. Spacing between entries of the replicates was generally four days. This allowed adequate callback attempts before new cases were entered. Call attempts were still made on all replicates of the sample throughout the data collection process based upon data collection protocols (that is, attempts werent halted when a new replicate was entered). Respondent Selection Once a household was identified and determined to be eligible, the number of adults aged 18 and older was determined. If there was more than one adult within the household, the respondent was chosen at random from all adults. Only this randomly chosen adult was considered eligible to participate. That is, if this respondent refused or did not complete the survey for any other reason, they were not replaced with another member of the household.

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OneMaine Community Health Needs Assessment 2010 Identification of Cell Phones Contained in RDD Sample Given number portability, a larger percentage of cell phone numbers are now found outside of exchanges that are solely dedicated to cell phone service. Thus, generated RDD samples now include a sizeable percentage of cell phone numbers. To factor this into the overall sampling design, screening questions were asked of all respondents contained in the RDD to determine if they had been reached on a cellular telephone. In cases where the respondent was contacted on a cellular telephone they were classified as eligible or ineligible based on whether their household also had a land line telephone: In cases where the respondent indicated that their household also had a land-line telephone they were considered ineligible and not interviewed. In cases where the respondent indicated that their household did not have a land-line telephone they were considered eligible and interviewed.

Among the total of 471 interviews conducted among those with only a cell phone, 99 came from RDD samples. Stage 2 Sampling Cell Phone Sample The use of a cell phone sample represents a strategy to include the growing number of households and residents that no longer have access to a land-line telephone. For this study, Market Decisions relied on Marketing Systems Group to provide random cell phone samples for use in the study. There are some limitations associated with cell phone samples. Unlike the land line samples in which telephone exchanges are linked to a range of geographic variables, cell phone samples are not explicitly linked to any geography. Cell phone only samples can currently be designed to target a state or telephone area code and not smaller geographic units within a state. Given this constraint, the study relied on a random sample of cell phone telephone numbers within the 207 area code or a statewide sampling frame. Marketing Systems Group provided a total of 6000 randomly selected cell phone numbers within the 207 area code. Among this pool of telephone numbers 2,632 were entered into the CATI system to be contacted. Each telephone number within the sample was contacted. An initial screening questions was asked to determine in the person was a resident of the state of Maine. In cases where the person was not a resident of the state of Maine, they were considered ineligible for participation. In order to maintain the independence of all sample strata in this study, screening criteria were used to identify households that have no land line telephone (as these households were included in stage 1 RDD sample generated for each county. For this cell phone only component, screening questions were added to determine if the cell phone represents the only telephone for the household. If the household also has a landline, the case was coded as ineligible and no survey was conducted with the cell phone owner. Respondent Selection Given that cell phones are most often associated with individuals rather than households (as is the case with traditional land-lines). The respondent for the cell phone was considered the person who owned or most frequently used the cell phone. During the survey, information about other users of the cell phone was gathered to allow appropriate probabilistic weighting adjustments in the data set. Stage 3 Sampling Strata (18-34 Over Sample)
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OneMaine Community Health Needs Assessment 2010 One of the concerns in conducting survey research is that those aged 18-34 tend to be under-represented among those completing surveys. The inclusion of a cell phone only sampling stage was incorporated into the study to reach those aged 18 to 34 (and who proportionally are the most likely to only have a cellular telephone). In reviewing the data during the course of data collection, it was determined that even with a cell phone only sample supplement that this age group would still be significantly underrepresented. To help offset this lack of response for those age 18-34, it was decided to incorporate a over sample of residents aged 18-34 into the overall sampling methodology. The over sample of residents aged 18-34 relied on a two separate sampling protocols: A statewide RDD sample A statewide cell phone only sample

Both the RDD sample and cell phone samples were generate using the sample protocols described above in sampling stages 1 and 2. The only difference is that once a household was contacted, a screening questions was asked to determine if any member of the household was aged 18 to 34 (for the RDD sample) or if the person who owned the cell phone was aged 18-34 (cell phone only sample). Among households with more than one resident aged 18-34, the respondent was selected at random. Both sample files used for the 18-34 over sample were crosschecked against the corresponding RDD and cell phone samples used in stage 1 and stage 2 to insure that there was no duplication of telephone numbers across sample files. In all a total of 9,179 RDD and 5,838 cell phone numbers were used in conducting the over sample interviews with residents aged 18-34 Sample Representation One important source of bias in telephone surveys is that households without telephones are artificially eliminated from selection as are those who experience an interruption in telephone service. Thus, a component of the population is not able to participate. In telephone surveys, Market Decisions typically relies on households that have experienced an interruption in telephone service to represent this component of the population and also to adjust for the probability of selecting a home that may experience telephone service interruption: Market Decisions relied on two questions to measure service interruption: 1. Was there anytime in the last 12 months that you did not have a working telephone for two weeks or more? 2. IF YES: For how many months of the past 12 months did you not have a working telephone for one week or more? Households with an interruption in telephone service were then weighted to represent households without telephone service and to make appropriate weighting adjustments for households that experience service interruptions.

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OneMaine Community Health Needs Assessment 2010 One other biasing factor is the fact that households may have more than one telephone. A household with more than one phone has a greater probability of selection (in proportion to the number of telephones in the household) than a household with only one telephone. To correct for this bias, respondents were asked a set of questions about the number of telephones in the household: The number of telephones in the household The number of telephones that are used exclusively for business Whether the contacted telephone is a business telephone exclusively

During the non-response weighting phase, data was weighted in proportion to the number of residential telephones in the household to balance out the greater probability of selection among those with more than one telephone. For the purposes of data collection, cellular phones are not included in the weighting adjustment, which are based on landline phones for RDD samples. This adjustment was not applied to those completing the survey via cellular phones since in this case households that only had a cellular telephone and no land-line telephone were included. Eliciting Cooperation Given the goal of achieving a high response rate for the Maine Community Health Needs Assessment Survey, special attention was paid to survey elements designed to elicit cooperation. A number of design elements incorporated into the surveys helped maximize response rates. These elements included: Clear lead in and introductory statements that explained the nature of the research. Informing contacts who caller is. Providing the name of the client. Persuader statements that explained why the research is important and why it is important for them personally to participate. A toll free telephone number and the name of the primary investigator (Dr. Robertson) so a potential respondent could verify that the research was legitimate or ask any questions about the research. A toll free telephone number and the name of the primary contact at UNE-CCPH, so a potential respondent could verify that the research was legitimate or ask any questions about the research. A statement of implied consent that indicated the research is confidential and their name will in no way be associated with results; the results are reported in aggregate form only. The statement also indicated that the call may be monitored. Finally, it also indicated that if they do not wish to answer a question that is fine. Coded help screens that contained information about the research and selection process that interviewers provided to potential respondents.

Data Imputation Given the nature of the survey data collected, it was decided that missing values would be imputed on certain key values, particularly weighting variables. Data imputation is a procedure that determines the likely value of a given variable based upon other known characteristics of the respondent. Imputation relies on answers to other questions to derive the most likely value for the missing value. Market Decisions used data imputation on several of the variables in this research. In those cases where a variable was imputed, the final data set contains a copy of the variable with imputed values, a copy of the
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OneMaine Community Health Needs Assessment 2010 original variable with missing values retained, and a flag variable which identifies which values were imputed and the method used. The research staff used three primary methods of data imputation: Logical Imputation This step involved an assessment of answers to other questions (within the case) to determine if it were possible to deduce the answer to a question with a missing value. In some cases, this was done by evaluating a question that was very similar in nature and content. In other cases, it involved assessing a number of related questions to derive the most likely value. The initial survey design anticipated this approach, somewhat. There were a number of consistency checks programmed throughout the survey on certain key variables. These consistency checks were used during the course of imputation to impute missing values to certain key variables. Donor Substitution Imputation Hot Deck Imputation Hot deck imputation relies on the fact that individuals with similarities on a number of variables are likely to be similar on those variables with missing values. The process involves identifying an individual with similar values on other variables and substituting this persons response for the missing value. In each of these cases, a number of variables were used to identify those respondents that were similar to a respondent with a missing value for a specific variable. The types of variables that were used to define characteristics that are similar varied depending on the nature of the variable to be imputed. These included key demographic characteristics and variables with a high correlation to the variable imputed. Once defined, the process of imputing the missing value relied on replacement. Base upon defined characteristics, the file was sorted in serpentine fashion (alternating ascending and descending sorts on variables). The value from the nearest neighbor was then used to replace that of the missing value. Regression Based Imputation For certain variables, such as income, the use of regression-based imputation was the most suitable method. This process relied on regression analysis to predict the value of the variable. The process relied on the use of analytical software that is designed to conduct missing values analysis. As with hot deck imputation, the number and type of variables used during regression analysis varied by the variable that was imputed but this also relied on key demographic variables and those correlated with the variable containing missing data. The primary variables that were imputed were those used in weighting the survey data (gender, race and ethnicity). In addition, income was also imputed. This was important since missing values would cause problems with the post stratification weighting of the data. Those cases with missing values would not have appropriate adjustments made and this would lead to an increase in variance since their weights would differ from those cases with complete demographic data. The data imputation process estimated any missing values in those variables used in post stratification weighting to minimize their impact on data quality. The method of imputation used for these variables is outlined in Table 6-2.

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OneMaine Community Health Needs Assessment 2010 Table 6-2: Imputed Variables and Method of Imputation Gender Age Ethnicity Race Income Logical Imputation Logical Imputation Logical and Hot Deck Imputation Logical and Hot Deck Imputation Regression Based Imputation

Data Weighting The data has been weighted to adjust for non-response and also to match state and county profiles based upon sex and age and statewide by race and ethnicity. Weighting also adjusted for households with multiple phone lines and interruptions in phone service. The weighting also factored in whether a survey was completed using RDD land-line samples or the cell phone only sampling components. The weighting procedures involved primary phases: Non-response weighting adjustments and post stratification weighting adjustments. Weighting was handled sequentially by calculating initial probabilistic weights, applying non-response weighting adjustments, and then applying post stratification adjustments. The first two weighting steps (probabilistic and non-response) were handled independently for each of the independent sampling strata (the 16 county based RDD samples, the RDD 18-34 over sample, and the two cell phone only samples). Post-stratification weighting adjustments were applied across all cases once the final non-response adjusted weights were calculated for each case in the data set. An initial sample weight was assigned to each record in the sample file. This base weight was equal to the inverse of the probability of selecting a number within each of the sampling strata. Initial Classification of Case Records The non-response weighting adjustments relied on weighting sample records based upon the eligibility status assigned to the telephone number. The eligibility status tracked the resolution of each sampled telephone number in terms of identification of eligible households and completing interviews with these households. The eligibility status of a sample record ranged from undetermined (no information had been obtained that would help determine if this was even a residence) through interview completion. Table 6-3 below provides a summary of the eligibility status codes and Table 6-4 describes how these eligibility status codes match up to case disposition codes.

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OneMaine Community Health Needs Assessment 2010 Table 6-3: Eligibility Classes Used in Non-response Weighting Eligibility Class Code (ELIGRESP) Eligibility Class Description 1 Completed Interview 3 Partially Completed Interview 4 Eligible Household, Non-interview, 5 Working Residential Number Ineligible 6 Working Residential Number Undetermined Eligibility Ineligible Business, Institution/Non-working Number/Not a 7 Cell Phone Only Residence (call phone samples) 8 Undetermined

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OneMaine Community Health Needs Assessment 2010 Table 6-4: Final Disposition Codes and Eligibility Status Eligibility Class Code Final Disposition Code (ELIGRESP) Complete 1 Complete With Exclusions 2 Partially Complete - Terminated Interview 3 Partially Complete (Unresolved Callback) 3 No One 18 or Older 5 Not a Maine Residence 5 Vacation Residence 5 DQ Not a Cell Phone Only Residence (Cell Phone Samples Only) 5 DQ Not Aged 18-34 (18-34 over sample) 5 Business 7 Disconnected Phone 7 Fast Busy 7 Fax/Modem 7 Group Quarters/Institution 7 No Ring 7 Number not in Service 7 Pager 7 Telephone Number changed 7 Temp Out of Service 7 Call Intercept 7 Answering Machine VARIES Busy VARIES Contact only VARIES Hard Refusal VARIES Hang-up VARIES Infirm VARIES Language Barrier VARIES Not Available in Time Frame VARIES No Answer VARIES Scheduled Callback VARIES Soft Refusal VARIES In the initial sample file, all sample records were assigned an eligibility status code of 8. As additional information was gained about the case, the eligibility status was changed to reflect this information. It is important to note that eligibility status is determined by evaluating all call attempts to the telephone number and not simply the last attempt. The eligibility status is determined by the call dispositions assigned to the sample record. A table of potential disposition codes for this research is presented below along with their assigned
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OneMaine Community Health Needs Assessment 2010 eligibility status. The eligibility status of 11 of these dispositions can vary depending on the overall call history. For example, the last disposition of a case may have been a hang-up (which would have an assigned eligibility of 8), but if earlier calls had determined that this was a residential telephone number, its eligibility status would be 6. The sample file recorded both the disposition codes and eligibility status to allow assignment of these particular cases to their actual eligibility status. Non-response weighting adjustments were then made at each determined level of eligibility (the eligibility status). For example, the first non-response weighting adjustment distributed the component of the probability of selection for the undetermined cases (cases where no information about the eligibility of the telephone number) among those cases with an eligibility status of one through seven. When completed, the non-response weighting adjustments allocated the probabilities of selection from all sample records into the final set of completed cases. The steps of the non-response weighting process are outlined below: Working Residential Status Non-response Adjustment Factor Following this step, all telephone numbers where residential status is unknown (ELIGRESP=8) will have adjusted weights of zero. Note that this adjustment assumes that the same proportion of residences that were identified in the known residential categories (ELIGRESP=1-7) occurs in the unknown residential category (ELIGRESP=8). Eligible Residence Non-response Adjustment Factor The second step in data collection was to identify whether or not the residence was eligible for an interview. A residence may be considered ineligible if: The residence is not located in Maine The residence is a vacation home For the cell phone samples, the number contacted was not a cell phone or the resident also had a land-line For the over sample of those aged 18-34 that there were no residents in this age range

The eligible residence non-response adjustment adjusts the sampling weights of records for which eligibility was determined to account for those sampled cases for which eligibility could not be determined. Following this step, all residences with unknown eligibility (ELIGRESP=6) and all numbers for which residential status is unknown (ELIGRESP=8) will have adjusted weights of zero. Those with sample records that are business/non-working (ELIGRESP=7), will retain their step 2 weights. Note that this adjustment assumes that the same proportion of eligible residences that were identified in the eligible residence categories (ELIGRESP=1-5) occurs in the unknown residential category (ELIGRESP=6). Weighting Adjustment for Households with Multiple Telephone Numbers This adjustment converts the sample of telephone numbers to a sample of households. The adjustment factor accounts for the fact that households with more than one residential telephone number had a greater chance of selection than those that did not. Households with multiple phone numbers are given lower weights, since these households had multiple chances of being selected. Weighting Adjustment for Telephone Interruption
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OneMaine Community Health Needs Assessment 2010 This adjustment factor attempts to adjust for under-coverage due to an inability to capture households with no telephones in the sample. Households with substantial recent interruptions in telephone service receive higher weights because they are conjectured to represent a class of households with a lower chance of selection than households with no interruption. In addition, these households are assumed to resemble the chronic non-telephone households more closely than do households with no service interruptions. Survey Initiation Non-response Adjustment Factor This non-response adjustment factor accounts for non-response prior to the initial survey questions, that is, did the respondent begin the survey. This would account cases where the household and a respondent were identified as eligible to participate but then did not begin the survey. This might include individuals that refused to participate, respondents that scheduled a callback but were then never reached, and so on. Thus, non-response at this stage indicates that a household is eligible to participate but did not answer any survey questions. Following this stage, all record with ELIGRESP equal to 4,6, or 8 have adjusted weights of zero, those with ELIGRESP = 5 retain their step 4 weight and those with ELIGRESP = 7 retain their step 2 weight. Respondent Selection Adjustment Factor For this study, a random adult was selected to participate in the study in cases where the survey was completed via a landline telephone. Since the results of the study are generalized to the adult population, a weighting adjustment is required to account for the probability of selecting the respondent from among all adults in the household. This weighting adjustment factors in the size of the household in terms of the number of adults within the household. The weighting adjustment is simply multiplying the step 5 adjusted weight by the number of adults in the household for survey completing via landline. The adjustment is equal to one for surveys completed via cell phone. In order to avoid excessive differential in weighting, the weighting adjustment was limited to a maximum of 3 (i.e 3 or more adults). Questionnaire Completion Non-response Adjustment Factor The last step in non-response adjusted weights is to adjust for non-response to the questionnaire. That is, did the respondent begin but not complete the entire survey. Following this stage, all records with ELIGRESP equal to 3,4,6, or 8 have adjusted weights of zero, those with ELIGRESP = 5 retain their step 4 weight and those with ELIGRESP = 7 retain their step 2 weight. Post Stratification Weighting NOTE: Post stratification adjustments were made relying on 2009 population estimates as the basis for the actual population counts. After the final set of post stratification adjustments to the data, the data reflected the actual population of Maine residents based on age, gender, area, race, ethnicity. The purpose of post stratification weighting is to standardize the weights so they sum to the actual population within Maine as well as summing to the population by area, age, gender, race, and ethnicity.
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OneMaine Community Health Needs Assessment 2010 Post stratification weighting adjustments were made by age and gender within county. Post stratification weighting adjustments for ethnic origin and race were made at the state level. Prior to making demographic post stratification adjustments, an initial adjustment was made based on whether the household had a land-line telephone, a cell phone only, or both a land-line or cell phone. The weighting adjustment was based on the proportion of all records within these three categories. This provided a final non-response adjusted weight that factored in the prevalence of: Land-line only homes Homes with both a land-line and cell phone Homes with only a cell phone.

Demographic data on population counts was developed from the 2009 population estimates, from the US Census Bureau. The final weighting numbers were based on this estimate of the 2009 population in Maine. An initial review of survey and census data was conducted to determine the appropriate steps in the weighting process. The general guideline in post stratification weighting is that no cell should have fewer than 20 cases. The post-stratification process relied on three steps. This included weighting adjustments of: Age by gender by county Race by age (statewide) Ethnic origin by age (statewide)

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OneMaine Community Health Needs Assessment 2010 Table 6-5: Variables and Categories Used in Post-stratification Weighting County Androscoggin County Aroostook County Cumberland County Franklin County Hancock County Kennebec County Knox County Lincoln County Oxford County Penobscot County Piscataquis County Sagadahoc County Somerset County Waldo County Washington County York County Age 18-34 35-49 50-64 65+ Female Male Hispanic Non-Hispanic White Other Race

Gender

Ethnic Origin

Race (based on primary race)

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OneMaine Community Health Needs Assessment 2010 The initial post stratification weighting applied to the data set was age within gender within county. This initial post stratification weight adjusted the survey data to match the population counts by age cohort and gender within each Maine county. An adjustment factor was calculated within each county by age by gender cell: Adj(AS) = AS(county census actual)/AS(county survey) Where: Adj(AS) was the age cohort by gender weighting adjustment within each county AS (area actual) was the actual Maine population within a specific county by age cohort by gender cell AS (area survey) was the weighted survey counts within a specific county by age cohort by gender cell (weighted by final family weight)

Adjustments were made to this initial weight to adjust for the actual number of Mainers by race and ethnic origin within age group (two separate weighting adjustments). Since the application of any weighting adjustment to the initial weight may cause the age/gender/county survey counts to vary, a process called raking was utilized. That is, once the ethnic origin and race weighting adjustments were applied, the survey counts of age by gender by county did not match the actual population counts. The raking process alternates making weighting adjustments by variables for which there are only marginal counts (for example weighting by age/gender/county and then by ethnicity/age) by making alternating adjustments. Thus, the initial person level weight was adjusted by ethnic origin and in a separate adjustment by race. Then, this new weight was adjusted by age/gender/county so it again matched the demographic profile of Maine by these characteristics. This weight was then adjusted to match the ethnic origin/age counts for the state and then the counts by race/age for the state. The post stratification weighting process was repeated until the weighting adjustments converged and the weighted counts matched the state demographic profile by age/gender/county, ethnic origin/age, and race/age. Data Collection The data collection phase of the Maine Community Health Needs Assessment Survey was begun on June 17, 2010 and data collection was completed by September 16, 2010. A total of 7,099 Maine residents were interviewed during this period. In order to insure data accuracy for this study, a rigorous data collection strategy was used in conducting this survey. This included the following: Rotation of call attempts across all seven days at different times of the day according to industry standards for acceptability and legality in telemarketing. A minimum of 20 call back attempts per telephone number at the screener level (before number was identified as a qualified residential number). 4 attempts to convert refusals (the exception were those households that made it clear they were not to be contacted again). A minimum of 10 callback attempts for no answer or answering machine only telephone noncontacts and for inappropriate contacts (contact only, no most knowledgeable adult home), and scheduled callback appointments.
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OneMaine Community Health Needs Assessment 2010 A brief message with a toll free number was delivered to answering machine only attempts to encourage participation (messages were left on the first, third and seventh answering machine dispositions).

Per industry standards, interviews were only conducted during the hours from 9 AM to 9 PM and seven days a week. The only exceptions were specific, scheduled appointments outside this range. Responding to Maine Residents Inquiries about the Survey One strategy that was used in order to increase response rates was providing reluctant residents with the name and telephone number of the primary investigator (Dr. Robertson) as well as that of a contact at UNE-CCPH was provided when requested by respondents. Over the course of data collection, both parties received a number of calls from potential survey respondents. Dr. Robertson responded to calls from 24 respondents. In most cases, the resident called either to simply verify the legitimacy of the survey, get more information about what the survey asked, or to respond to a message left on their answering machine. A few calls were made to have the respondents telephone number removed from the sample. Depending on the timing of the call, the resident was called back according to the callback protocol or the survey was completed at that time. Nearly all of those who contacted Dr. Robertson ended up completing the survey. Scheduling Callback Appointments The CATI system used by Market Decisions during the course of this survey is designed to allow interviewers to set callback appointments for a specific date and time. It is also designed to allow a respondent who has begun the survey and cannot complete it to complete it at a later time. This is done so that the respondent can complete the survey at a time that is most convenient for him or her. The interviewer enters the date and time the respondent provides and the respondent is then contacted at that time. Over the course of the data collection phase, 5,060 scheduled appointments were made. Approximately 24% of interviews that were completed were done so with respondents that had scheduled these specific appointments. Survey Length The Maine Community Health Needs Assessment Survey required respondents to provide a great deal of information about themselves on a range of health topics. The goal was to obtain accurate information about all household members while limiting the time commitment required of the respondent. On average, the 7,099 interviews required 16.8 minutes. There was no significant difference between those complete the survey via a land-line telephone or a cell phone. Sixty-five percent of the interviews were completed in 16 minutes or less. The shortest amount of time required was 10 minutes while the longest survey required 34 minutes. Sampling Error In order to accurately report sampling error, it is important to incorporate the overall design effect into sampling error calculations. The standard formula for calculating sampling error is derived by assigning a confidence level to the standard error (for a proportion), typically 95%. At 95%, the sampling error is considered to be the standard error multiplied by 1.96: Sampling Error (95% confidence) = +1.96*((p*(1-p))/n)

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OneMaine Community Health Needs Assessment 2010 Where p is the observed proportion in the sample and n is the number of completed surveys. In calculating sampling error, p is always set to 50%, which results in the most conservative measure of sampling error. In the case of the Maine Community Health Needs Assessment Survey, the sampling error calculations were adjusted by the design effect: Sampling Error (95% confidence) = +1.96*[((p*(1-p))/n)*deff]

Where deff is the product of the design effect due to stratification, the design effect due to intracluster correlation, and the design effect of the oversample.

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APPENDIX 7: DATA SOURCES AND YEARS DATA TYPE SOURCE
U.S. Census Bureau estimates for Maine. Maine State Planning Office Projections U.S. Census Bureau, Maine Census State Data Center Maine Office of Data Research and Vital Statistics, Maine CDC Maine Office of Data Research and Vital Statistics, Maine CDC Maine Health Data Organization 2008 2008, 2018, 2028 Most recent inter-censal estimates 2007, 2008, 2009 2007, 2008, 2009 Q4 2007 -Q3 2009

DATA YEAR(s)

Population Estimates Population Projections Demographics - Income and Education Births Mortality Hospital Inpatient Hospital Emergency Cancer Incidence and Staging Infectious Disease:
Hepatitis C Chlamydia/Gonorrhea HIV/AIDS

Maine Health Data Organization Maine Cancer Registry, Maine CDC Maine CDC Division of Disease Control

2007, 2008

2005, 2006, 2007

2007, 2008

Maine Behavioral Risk Factor Surveillance System

(BRFSS)

Maine CDC US CDC - National Center for Chronic Disease Prevention & Health Promotion Maine CDC Maine Department of Labor UNE/Muskie/Market Decisions

2006, 2007, 2008, 2009

National BRFSS Maine Integrated Youth Health Survey (MIYHS) Employment, Unemployment 2010 OneMaine CHNA Household Survey

2009

2009 2010 2010

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APPENDIX 8: SELECTED DEFINITIONS OF INDICATORS

Population Estimates and Demographics Population data for each county by age was accessed from the US Census website using the census estimates for 2008. 2008 Census estimates were also used for all rates (e.g. hospitalization rates) that included population based denominators. Since inter-censal population estimates do not include education, income and employment breakdowns, 2000 Census data was used for the education indicator, Median household income was obtained through the Maine State Planning Office data center for 2010, and Maine Department of Labor data for 2010 was used to look at unemployment by county. The 2004 HRSA Area Resource File was used to estimate Medicaid participation by county86. Annual Household Income = The reported annual household income for the state is the average household income in that region. The reported annual household income for the U.S. is the median household income of the U.S. (Source: U.S. Census Bureau). Births and Mortality The Office of Data Research and Vital Statistics at the Maine CDC provided the birth and mortality datasets for 2007, 2008 and 2009. Selected Definitions Infant Deaths = Deaths to a live born infant less than 1 year old Neonatal Deaths = Deaths to a live born infant less than 27 days old Premature Delivery = Delivery following a pregnancy of a gestational period less than 37 weeks. Kessner Index = The Kessner Index is a measure of the adequacy of prenatal care (PNC) being provided in a community. The Index is based upon the month PNC began, the number of visits, and the gestational age at birth. The classification of prenatal care as adequate, intermediate or inadequate is derived from the Institute of Medicines Three-Factor Prenatal Care Index. The classes of care are in accordance with recommendations for prenatal care set by the American College of Obstetricians and Gynecologists and the World Health Organization. This classification scheme accounts for length of gestation by requiring fewer prenatal visits for pregnancies with short gestation time. Records with missing information (i.e., last normal menstrual period, gestation weeks, number of visits, or month prenatal care began) are assigned to the inadequate prenatal care category. The gestation weeks are calculated by subtracting the last menstrual date from the childs birth date. If the last menstrual date is missing from the birth record, the doctors (or other medical professionals) estimate of gestation is used. The accuracy of the level of prenatal care is as reliable as the information provided by the mother and her caregiver.

86

Maine Department of Labor: http://www.maine.gov/labor/labor_stats/index.html Maine State Planning Office: http://www.state.me.us/spo/economics/ HRSA County Comparison: http://arf.hrsa.gov/arfwebtool/index.htm
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The table below shows the Institute of Medicines Three-Factor Prenatal Care Index.
Gestation (Weeks) 13 or less 14 17 18 21 22 25 26 29 30 31 32 33 34 35 36 or more Number of Prenatal Visits 1 or more or not stated 2 or more 3 or more 4 or more 5 or more 6 or more 7 or more 8 or more 9 or more

Prenatal Care ADEQUATE (Includes women who started their first prenatal visits within the first three months of pregnancy)

INADEQUATE (Includes women who started care within the third trimester)

14 21 22 29 30 31 32 33 34 or more

0 or unstated 1 or less or unstated 2 or less or unstated 3 or less or unstated 4 or less or unstated Unstated

INTERMEDIATE

All combinations not stated above

Formulae:

Total Deaths Average Mortality Rate = ------------------------------------ 100,000 Total Population

Infant Deaths (or Neonatal Deaths) Infant (or Neonatal) Mortality Rate = ---------------------------------------------- 1,000 Total Births

Total Births (Age 10-17) Teen Birth Rate = ----------------------------------------------------- 1,000 Female Population (Age 10-17)

Total Births of <37 Weeks Gestation % Prematurity = ----------------------------------------------------- 100 Total Births

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OneMaine Community Health Needs Assessment 2010 Hospital Inpatient & Emergency Utilization Datasets were obtained from the Maine Health Data Organization for inpatient and emergency room admissions. The full list of ICD-9 and DRG codes used in these analyses can be found in Appendix 9.
ACS = Ambulatory Care Sensitive The hospital admission rate for ACS conditions is used as a measure of access to and need of primary medical care in a community. The metrics calculated in this report are based on methodology developed by the Agency for Health Resources and Quality (AHRQ)87. ACS conditions are those that are less likely to result in hospitalization when treated on an outpatient basis with high quality primary medical care and good patient compliance. Therefore, higher rates of hospitalizations for ACS conditions may be an indication of poorer access to and/or quality of primary care in an area. The 13 conditions considered to be ambulatory care sensitive for adults are:

Adult Asthma Angina without Procedure Bacterial Pneumonia Congestive Heart Failure Chronic Obstructive Pulmonary Disease (COPD) Dehydration Diabetes Short-term Complications

Diabetes Long-term Complications Hypertension Lower-extremity Amputation among Diabetics Perforated Appendix Admission Rate Urinary Tract Infection Uncontrolled Diabetes

AMI = Acute Myocardial Infarction, commonly referred to as a heart attack CABG = Coronary Artery Bypass Graft

Formulae:

Admissions Hospital Admission Rate = --------------------------------- 100,000 Population

Cancer Incidence and Staging

Cancer Stages = Refers to how much cancer has spread Local = Cancer has not spread beyond its primary site Distant = Cancer has spread beyond its primary site

Incidence Rate = the number of new cases of a particular disease or condition that develop in a population of individuals during a specified period of time

Cancer Incidence
87

SOURCE: http://www.qualityindicators.ahrq.gov/pqi_overview.htm (Note: three of the sixteen indicators not included because they are pediatric ACSC measures)
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Cancer Incidence Rate = --------------------------------------- 100,000 Total Population Mortality to Incidence Ratio = Mortality Rate / Incidence Rate

Infectious Disease:
HIV/AIDS = Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Incidence Rate = the number of new cases of a particular disease or condition that develop in a population of individuals during a specified period of time

Maine Behavioral Risk Factor Surveillance System (BRFSS) Maines Behavioral Risk Factor Surveillance System (BRFSS) is a population based survey conducted throughout the year with robust sampling for State level estimates. However, for many county-level estimates, more than one year of data must be combined in order to get an adequate sample size at this geographic level. Since BRFSS questionnaires are revised annually, and many questions are not asked every year, the two most recent years of data collection were identified for all of the BRFSS indicators needed and combined for the estimates. The specific two years used for each BRFSS variable is included in the right-hand column of the Health Status Profile in Appendix 4.
Binge Drinking = Five or more drinks of alcohol (men) or four or more drinks of alcohol (women) consumed over a period of two hours Chronic Heavy Drinking = More than two drinks of alcohol every day (men) or more than one drink of alcohol every day (women) over the past 30 days.

Maine Integrated Youth Health Survey (MIYHS)

Youth Overweight = High school students (Grades 9-12) who reported a BMI at or above the 85th percentile but below the 95th percentile, by age and sex) Youth Obesity = High school students (Grades 9-12) who reported a BMI at or above the 95th percentile for body mass index, by age and sex Youth Current Smoker = High school students (Grades 9-12) who have reported smoking at least once in the past 30 days

OneMaine CHNA Household Survey The sampling strategy, questionnaire design and response rates for the OneMaine Household Survey conducted from June through August, 2010, is described in detail in the Methodology section of this report. All responses to this survey, as with most population based surveys including BRFSS, are considered self-reported in that there is not independent validation of reported diagnosis or health behavior information.
Percentage 11+ Days Lost due to Poor Mental or Physical Health = The % of respondents who indicated that within the past 30 days, they had at least 11 days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation

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Body Mass Index (BMI) = A key index for relating a person's body weight to their height. The body mass index (BMI) is a person's weight in kilograms (kg) divided by their height in meters (m) squared Adult Overweight = Adults (18+) who have a body mass index (BMI) between 25 and 29.9 Adult Obesity = Adults (18+) who have a BMI greater than 30.0 COPD = Chronic Obstructive Pulmonary Disease; includes chronic bronchitis and emphysema Adult Current Smoker = Respondents (18+) who have smoked at least 100 cigarettes in lifetime, and reported smoking currently. Adult Former Smoker = Respondents (18+) who have smoked 100 cigarettes in lifetime but currently do not smoke. Percentage Advised to Quit Smoking in the Past Year = Asked of adults (18+) smokers Heart Disease= Any disorder that affects the heart. Among the many types of heart disease, see, for example: Angina; Arrhythmia; Congenital heart disease; Coronary artery disease (CAD); Dilated cardiomyopathy; Heart attack (myocardial infarction); Heart failure; Hypertrophic cardiomyopathy; Mitral regurgitation; Mitral valve prolapse; and Pulmonary stenosis. HIV/AIDS = Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Incidence Rate = the number of new cases of a particular disease or condition that develop in a population of individuals during a specified period of time Physical Activity = No Physical Activity = Survey respondents who reported no physical activity for exercise in the past month. Vigorous Physical Activity = Survey respondents who reported engaging in physical activity for exercise for 30 minutes or more at least 5 times a week. Prevalence Rate = the proportion of individuals in a population who have a particular disease or condition at a specific point in time Street Drugs = marijuana, cocaine, crack, heroin, LSD, PCP, mescaline, or ecstasy 3+ Chronic Diseases = The diseases included in this measure are angina, diabetes, chronic obstructive pulmonary disease, hypertension, hyper-cholesterol, cancer, arthritis, asthma, depression, substance abuse, and psychiatric conditions other than depression.

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Wellness Categories = Well = Survey respondents that had never been diagnosed with any of the following long-standing conditions (Hypertension, High Cholesterol, Diabetes, Angina/CAD, COPD, Current Asthma, Current Depression), that reported their health as excellent, very good, or good, had good functional health, and, if over 35 years old, did not smoke and were not obese based on their body mass index. At Risk for Future Medical Problems = Survey respondents never diagnosed with any of the following long-standing conditions (Hypertension, High Cholesterol, Diabetes, Angina/CAD, COPD, Current Asthma, Current Depression), but were 35 years of age or older and smoked cigarettes regularly or were obese based on their body mass index. Some Health Problems = Survey respondents who reported their health as fair or poor, had reduced functional health, or had been diagnosed with Hypertension, High Cholesterol, Diabetes, Angina/CAD, COPD, Current Asthma, Current Depression. Not Well = Survey respondents that have been diagnosed with three of the following long-standing conditions (Hypertension, High Cholesterol, Diabetes, Angina/CAD, COPD, Current Asthma, Current Depression), or had been diagnosed with at least one chronic disease and reported their health as either fair or poor or experienced significant functional health problems.

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APPENDIX 9: DETAILED DATA SOURCES AND HOSPITAL DISCHARGE CODES

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Detailed Data Sources for HEALTH STATUS PROFILE

Maine Counties Source US Source Defining Code

DEMOGRAPHICS Total Population Median Annual Household Income (to 2008) % of Labor Force Unemployed % Population Not Attaining H.S. Diploma (>25 yr) % Population on Medicaid (all ages) % Population Under the Age of 18 % Population Between Ages 18-44 % Population Between Ages 45-64 % Population Age 65 and Over % Uninsured (18+) % Uninsured Non-Elderly Adults (Ages 18-65) HEALTH STATUS % Health Fair to Poor % 11+ Days Lost due to Poor Mental or Physical Health % 3+ Chronic Conditions Wellness Categories: %Well %At Risk for Future Medical Problems %Some Health Problems %Not Well ACCESS TO CARE % Without Usual Source of Primary Care Males Females % Named a clinic or doctor's office as usual source of care % Named hospital or ER as usual source of care % Not Having a Checkup Within the Past 2 yrs Males Females % Received Flu Shot or Mist past 12 months Males Females % Ever Received Pneumoccal Vaccine (Age 65+) Males Females % Needed Medical Care But Could not Afford it: Past Year % No Dental Visit in Past 2 Years ED Visits per 100,000 population Ages <18 Ages 18-44 Ages 45-64 Ages 65+ Hospitalizations per 100,000 Population Ages <18 Ages 18-44 Ages 45-64 Ages 65+ QUALITY/EFFECTIVENESS Ambulatory Care Sensitive Condition (ACSC), Hospital Admission Rate (Overall PQI*) Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+ Household Survey 2007 AHRQ (HP 2020) Household Survey Household Survey Household Survey 2009 BRFSS *BRFSS reports on 14days 2008 Census Estimates ME SPO Data Center ME Dept Labor 2000 Census 2004 CMS, HRSA Area Resource File 2008 Census Estimates 2008 Census Estimates 2008 Census Estimates 2008 Census Estimates Household Survey Household Survey 2009 Census 2009 Census Bureau of Labor Statistics (Oct 2010) Kaiser State Health Facts (2007) 2009 Census 2009 Census 2009 Census 2009 Census BRFSS (2009) BRFSS (2009)

Household Survey

Household Survey Household Survey Household Survey

Household Survey

2009 CDC National Health Interview Survey

Household Survey

2009 CDC National Health Interview Survey

Household Survey Household Survey

2009 CDC National Health Interview Survey 2009 Health US 2010, Chartbook

MHDO Hosp ED

MHDO Hosp Inpatient

National Health Statistics Reports 2007 - Hosp. Discharge by First Diagnosis

MHDO Hosp Inpatient

TAPQ90

Ambulatory Care Sensitive Condition (ACSC), ED Visit Rate (Overall PQI*) Ages 0-17 MHDO Hosp Inpatient Ages 18-44 Ages 45-64 Ages 65+

TAPQ90

OneMaine Community Health Needs Assessment 2010

Detailed Data Sources for HEALTH STATUS PROFILE

Maine Counties Source US Source Defining Code

CARDIOVASCULAR HEALTH % Current Smokers (Age 18+) Risk Factors % Sedentary Lifestyle (measured by no physical activity) % Physical Activity (5 times a week at 30 min,) % Use aspirin daily (Age 35+) % Overweight (Ages 18+) % Obesity (Ages 18+) % High Cholesterol (ever told) % High Blood Pressure (ever told) % Heart Disease Congestive Heart Failure, Hospital Admissions Ages 45-64 Ages 65+ AMI, Hospital Admission Rate Ages 45-64 Ages 65+ Management Household Survey Household Survey Household Survey Household Survey Household Survey Household Survey Household Survey Household Survey Household Survey MHDO Hosp Inpatient 2009 BRFSS 2009 BRFSS 2009 BRFSS 2009 BRFSS 2009 BRFSS 2009 BRFSS 2008 BRFSS DRG v.24:127 DRG: v.25:291-293 National Health Statistics Reports 2007 - Hosp. Discharge by First Diagnosis DRG v. 24:121-123 DRG v.25:291-293

Disease Prevelan

MHDO Hosp Inpatient

Cerebrovascular Disease (stroke), Hospital Admission Rate MHDO Hosp Inpatient Ages 45-64 Ages 65+ CABG, Hospital Admission Rate MHDO Hosp Inpatient Ages 45-64 Ages 65+ % Advised to cut down on salt by doctor (ever) % Having Cholesterol Checked within the past year (Ages 21+) % Smokers advised to quit smoking in the past yr. AMI, Mortality Rate Ages 45-64 Ages 65+ Cerebrovascular Disease (stroke), Mortality Rate Ages 45-64 Ages 65+ Heart Disease, Mortality Rate Ages 45-64 Ages 65+ Household Survey Household Survey Household Survey ODRVS Mortality

DRG v. 24:14 DRG v.25:64-66

DRG v. 24:106,547-550 DRG v.25:231-236

Quality/Effectiveness

ODRVS Mortality

2007 CDC CDI

ODRVS Mortality

2007 CDC CDI

OneMaine Community Health Needs Assessment 2010

Detailed Data Sources for HEALTH STATUS PROFILE

Maine Counties Source US Source Defining Code

RESPIRATORY HEALTH % Current Smokers Male Female % Former Smokers % Current Asthma (Ages 18+) % Ever Asthma (Ages 0-17) % COPD Lung and Broncus Cancer, Males, Incidence Rate Lung and Broncus Cancer, Females, Incidence Rate % Received Flu Shot or Mist past 12 months Males Females % Ever Received Pneumoccal Vaccine (Ages 65+) Males Females Bronchitis and Asthma, Hospital Admission Rate Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+ Bronchitis and Asthma, ED Visit Rate Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+ COPD, Hospital Admission Rate Ages 45-64 Ages 65+ COPD, ED Visit Rate Ages 45-64 Ages 65+ Pneumonia, Hospital Admission Rate Ages 45-64 Ages 65+ Pneumonia, ED Visit Rate Ages 18-44 Ages 45-64 Ages 65+ Emphysema, Hospital Admission Rate Ages 45-64 Ages 65+ MHDO Hosp Inpatient National Health Statistics Reports 2007 - Hosp. Discharge by First Diagnosis MHDO Hosp Inpatient Risk Factors Household Survey Household Survey Household Survey Household Survey Household Survey ME CDC Cancer Reg ME CDC Cancer Reg Household Survey 2009 BRFSS 2009 BRFSS 2009 BRFSS

Disease Prevelance

2009 CDC National Health Interview Survey

Household Survey

MHDO Hosp Inpatient

DRG v.24:96-98 DRG: v.25:202-203

MHDO Hosp ED

ICD-9: 493,466, 4660 -4661,4930,4939,4661146619, 49300-49302, 49310-49312, 49390-49392.

Management

MHDO Hosp Inpatient

DRG v.24:88 DRG: v.25:190-192 ICD-9: 490-491, 492,494-496, 4910-4912,49184919, 4920,4928,4932, 4940-4941, 4950-4959, 49120-49121, 49320-49322

MHDO Hosp Inpatient

DRG v.24:89-91 DRG: v.25:193-195 ICD-9: 480-486, 4800-4803,4808-4809,4820-4823,48284831,4838,4841,4843,4845-4848, 48230-48232, 48239-48241,48249,4828148284,48289. DRG v.24:99-100 DRG: v.25:204

MHDO Hosp Inpatient

% Current Smokers advised to quit smoking in the past year Household Survey % Current smokers tried to quit in past year Household Survey % Current smokers ever used Maine Tobacco Quitline Household Survey Lung Cancer, Mortality Rate Males Females Quality/Effectiveness COPD, Mortality Rate Ages 45-64 Ages 65+ Pneumonia, Mortality Rate Ages 45-64 Ages 65+ Influenza, Mortality Rate Ages 45-64 Ages 65+ Smoking-Related Neoplasms, Mortality Rate Males Females ODRVS Mortality 07-09 ODRVS Mortality 07-09

ODRVS Mortality 07-09

ODRVS Mortality 07-09

ODRVS Mortality 07-09

OneMaine Community Health Needs Assessment 2010

Detailed Data Sources for HEALTH STATUS PROFILE

Maine Counties Source US Source Defining Code

CANCER HEALTH % Current Smokers (Age 18+) % Sedentary Lifestyle % Former smokers (Age 18+) % Overweight (Age 18+) % Obesity (Age 18+) % Diagnosed Cancer (Age 18+) All Cancers, Incidence Rate Bladder, Incident Rate Female Breast Cancer, Incidence Rate Female Cervix Uteri, Incidence Rate Colorectal, Incidence Rate Lung and Bronchus Cancer, Incidence Rate Melanoma, Incidence Rate Male Prostate, Incidence Rate % Reported Mammogram past year (40+) % Stage Female Breast, Local % Stage Female Breast, Distant % Reported Pap Smear past 2 years % Stage Cervix Uteri Female, Local % Stage Cervix Uteri Female, Distant Management / Patient Care % Reported Blood Stool Test Past Year (Age 50+) % Reported Having Sigmoid/Colonoscopy Past 5 Yrs (Age 50+) % Stage Colorectal, Local % Stage Colorectal, Distant % Stage Lung and Brunchus Male, Local % Stage Lung and Brunchus Male, Distant % Stage Lung and Brunchus Female, Local % Stage Lung and Brunchus Female, Distant % Reported Prostate Exam (PSA test) past 2 yrs (males Age 50+) % Reported Digital Rectal Exam past 2 years (males Age 50+) % Stage Prostate, Local % Stage Prostate, Distant All Cancers, Mortality Rate Bladder, Mortality Rate Female Breast Cancer, Mortality Rate Female Cervix Uteri, Mortality Rate Colorectal, Mortality Rate Lung, Mortality Rate Melanoma, Mortality Rate Male Prostate, Mortality Rate Quality/Effectiveness Household Survey Household Survey Household Survey Household Survey Household Survey Household Survey ME CDC Cancer Reg ME CDC Cancer Reg ME CDC Cancer Reg ME CDC Cancer Reg ME CDC Cancer Reg ME CDC Cancer Reg ME CDC Cancer Reg ME CDC Cancer Reg Household Survey ME CDC Cancer Reg ME CDC Cancer Reg Household Survey ME CDC Cancer Reg ME CDC Cancer Reg BRFSS 2006/2008 Household Survey ME CDC Cancer Reg ME CDC Cancer Reg ME CDC Cancer Reg ME CDC Cancer Reg ME CDC Cancer Reg ME CDC Cancer Reg 2000-2007 SEER Cancer Stats 2000-2007 SEER Cancer Stats 2000-2007 SEER Cancer Stats 2000-2007 SEER Cancer Stats 2000-2007 SEER Cancer Stats 2000-2007 SEER Cancer Stats 2009 BRFSS 2009 BRFSS 2009 BRFSS 2009 BRFSS 2009 BRFSS 2009 Health US 2010, Chartbook 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI 2008 BRFSS 2000-2007 SEER Cancer Stats 2000-2007 SEER Cancer Stats 2008 NHIS 2000-2007 SEER Cancer Stats 2000-2007 SEER Cancer Stats 2008 BRFSS Risk Factors Disease Prevelance

Household Survey Household Survey ME CDC Cancer Reg ME CDC Cancer Reg ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality

** 2008 BRFSS reports on 40+_

2000-2007 SEER Cancer Stats 2000-2007 SEER Cancer Stats 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI 2002-2006 CDC CDI

OneMaine Community Health Needs Assessment 2010

Detailed Data Sources for HEALTH STATUS PROFILE

Maine Counties Source US Source Defining Code

DIABETES HEALTH Risk Factors % Sedentary Lifestyle (measured by no pysical activity) % Adults consume fruits and vegetables 5 or more times/day % Overweight (Age 18+) % Obesity (Age 18+) % Diagnosed Diabetes Ages 18-44 Ages 45-64 Ages 65+ % Reported hemoglobin A1c measurement (at least once) in past year (Age 18+) % Reported pupil dilation eye exam in past yr (age 18+) % Reported foot examination in past yr (Age 18+) % Reported ever taken diabetes self management course (Age 18+) Diabetes, Hospital Admission Rate Ages 18-44 Ages 45-64 Ages 65+ Diabetes Short-term Complications, ACSC ED Visit Rate Diabetes Long-term Complications, ACSC ED Visit Rate Diabetes Uncontrolled, ACSC ED Visit Rate Diabetes, Mortality Rate Ages 45-64 Ages 65+ Household Survey BRFSS 2007 & 2009 Household Survey Household Survey 2009 BRFSS 2009 BRFSS 2009 BRFSS 2009 BRFSS

Disease Prevelance

Household Survey

2009 CDC CDI

Household Survey Household Survey Household Survey Household Survey

2007 CDC CDI 2007 CDC CDI

Management

MHDO Hosp Inpatient

DRG v.24:294-295 DRG: v.25:637-639 TAPQ 01 TAPQ 03 TAPQ 14 2007 CDC CDI

MHDO Hosp Inpatient MHDO Hosp Inpatient MHDO Hosp Inpatient ODRVS Mortality

Quality/ Effective

OneMaine Community Health Needs Assessment 2010

Detailed Data Sources for HEALTH STATUS PROFILE

Maine Counties Source US Source Defining Code

MENTAL HEALTH Risk Factors % 11+ Days Mental Health Not Good Ages 18-44 Ages 45-64 Ages 65+ % needed, but did not get, mental health treatment in past 12 months % receiving outpatient mental health treatment in past 12 mos % At Risk for Clinical Depression Based on MHI5 (18+) % Diagnosed Depression (ever, 18+) % Current Depression (18+) % Diagnosed Other Psychiatric Disorder (ever, 18+) % Developmental Delay/Learning Disability (Ages 0-17 Psychoses Hospital Admission Rate Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+ Senility and Organic Mental Disorders, Hospital Admission Rate Ages 18-64 Ages 65+ Major Depressive Disorder, Hospital Admission Rate Ages 0-17 Ages 18-64 Ages 65+ Bipolar Disorder, Hospital Admission Rate Ages 0-17 Ages 18-64 Ages 65+ Schizophrenia, Hospital Admission Rate Management Ages 18-64 Ages 65+ Anxiety, Hospital Admission Rate Ages 0-17 Ages 18-44 Ages 45-64 Ages 65+ Senility and Organic Mental Disorders, ED Rate MHDO Hosp ED ICD-9: 290,310, 2900-2904,2908-2909,3100-3102,3108-3109, 29010-29013,29020-29021,29040-29043. ICD-9: 2962-2964,3004, 29620-29626,29630-29636. ICD-9: 297, 2965-2973,2978-2979 29640-29646,29650-29656,29660-29666,2968029682,29689,29690,29699. ICD-9: 295,2950-2959,2990-2991,2998-2999, 29500-29505,29510-29515,29520-29525,2953029535,29540-29545,29550-29555,2956029565,29570-29575,29580-29585,2959029595,29900-29901,29910-29911,2998029981,29990-29991. ICD-9: 300-316 MHDO Hosp Inpatient National Health Statistics Reports 2007 - Hosp. Discharge by First Diagnosis MHDO Hosp Inpatient National Health Statistics Reports 2007 - Hosp. Discharge by First Diagnosis DRG v.24:430 DRG: v.25:885

BRFSS 2008 + 2009

Household Survey Household Survey Household Survey Household Survey Household Survey Household Survey Household Survey

Disease Prevalence

MHDO Hosp Inpatient

ICD-9: 290,310, 2900-2904,2908-2909,3100-3102,3108-3109, 29010-29013,29020-29021,29040-29043.

MHDO Hosp Inpatient

National Health Statistics Reports 2007 - Hosp. Discharge by First Diagnosis

ICD-9: 2962-2964,3004, 29620-29626,29630-29636.

MHDO Hosp Inpatient

ICD-9: 297, 2965-2973,2978-2979 29640-29646,29650-29656,29660-29666,2968029682,29689,29690,29699. ICD-9: 295,2950-2959,2990-2991,2998-2999, 29500-29505,29510-29515,29520-29525,2953029535,29540-29545,29550-29555,2956029565,29570-29575,29580-29585,2959029595,29900-29901,29910-29911,2998029981 29990 29991 ICD-9: 300-316

MHDO Hosp Inpatient

Major Depressive Disorder, ED Rate

MHDO Hosp ED

Bipolar Disorder, ED Rate

MHDO Hosp ED

Schizophrenia, ED Rate

MHDO Hosp ED

Anxiety Disorder, ED Rate Suicide, Mortality Rate Males Females

MHDO Hosp ED ODRVS Mortality

Quality

OneMaine Community Health Needs Assessment 2010

Detailed Data Sources for HEALTH STATUS PROFILE

Maine Counties Source US Source Defining Code

SUBSTANCE ABUSE % Chronic Heavy Drinking - Past Month Ages 18-64 Ages 65+ % Binge Drinking -Past Month Ages 18-44 Ages 45-64 Ages 65+ % Ever diagnosed with Substance Abuse Problem % Current Substance Abuse Problem % Overdose Past 12 mos (Households) % have used any street drugs in past 30 days % have used any prescription drugs for non-prescribed purpose in past 30 days Substance Abuse, Hospital Admission Rate Ages 18-64 Ages 65+ Acute Alcohol-Related Mental Disorders, Hospital Admission Rate Ages 0-17 Ages 18-64 Ages 65+ Alcohol-Related Psychoses, Hospital Admission Rate Ages 18-64 Ages 65+ Acute Drug-Related Mental Disorders, Hospital Admission Rate MHDO Hosp Inpatient Ages 18-64 Management Ages 65+ Drug-Related Psychoses, Hospital Admission Rate Ages 18-64 Ages 65+ Acute Alcohol-Related Mental Disorders, ED Rate BRFSS 2008 & 2009

Prevelance

BRFSS 2008 & 2009

Household Survey Household Survey Household Survey Household Survey Household Survey MHDO Hosp Inpatient DRG-MDC 20

MHDO Hosp Inpatient

ICD-9: 303,3030, 3039, 3050, 30300-30303

MHDO Hosp Inpatient

ICD-9:291, 2910-2919,29181-29189

MHDO Hosp Inpatient

ICD-9: 304,3040-3049,3051-3059, 30400-30403,30410-30413,30420-30423,3043030433,30440-30443,30450-30453,3046030463,30470-30473,30480-30483,3049030493,30500-30503,30520-30523,3053030533,30540-30543,30550-30553,3056030563 30570 30573 30580 30583 30590 30593 ICD-9: 292, 2921-2922,2928-2929, 29211-2912,29281-29284,29289.

MHDO Hosp ED

ICD-9: 303,3030, 3039, 3050, 30300-30303

Alcohol-Related Psychoses, ED Rate

MHDO Hosp ED

ICD-9:291, 2910-2919,29181-29189 ICD-9: 304,3040-3049,3051-3059, 30400-30403,30410-30413,30420-30423,3043030433,30440-30443,30450-30453,3046030463,30470-30473,30480-30483,3049030493,30500-30503,30520-30523,3053030533,30540-30543,30550-30553,3056030563,30570-30573,30580-30583,30590-30593.

Acute Drug-Related Mental Disorders, ED Rate

MHDO Hosp ED

Drug-Related Psychoses, ED Rate

MHDO Hosp ED

ICD-9: 292, 2921-2922,2928-2929, 29211-2912,29281-29284,29289.

Smoking-Related Neoplasms, Mortality Rate Males Females Alcohol-Related Mortality Rate Males Females Alcohol Liver Disease, Mortality Rate Motor Vehicle Accidents, Mortality Rate Males Females

ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality ODRVS Mortality

Quality / Effectiveness

OneMaine Community Health Needs Assessment 2010

Detailed Data Sources for HEALTH STATUS PROFILE

Maine Counties Source US Source Defining Code

REPRODUCTIVE HEALTH % Binge Drinking Females (past month) 2 or more sex partners in past yr (ages 18-34) % used condom last time had sex (ages 18-34) Teen Birth Rate (10-17yrs) Per 1,000 Females High Risk Pregancy, Hospital Admission Rate (10-44 year old females) C-Section Rate per 100 births % Adequate Prenatal Care (of live births) % Inadequate Prenatal Care (of live births) % Low Birthweight (<2500 grams) % Prematurity (< 37 weeks) Infant Mortality Rate (deaths to infants from birth through 364 days of age) per 1,000 live births Neonatal Mortality Rate (deaths to infants under 28 days) per 1,000 live births Post-Neonatal Mortality Rate (deaths to infants 28 through 364 days of age) per 1,000 live births Management BRFSS 2008 & 2009 Household Survey Household Survey ODRVS Birth MHDO Hosp Inpatient ODRVS Birth ODRVS Birth ODRVS Birth ODRVS Birth ODRVS Birth ODRVS Mortality ODRVS Mortality ODRVS Mortality 2009 BRFSS

2008 NVSR

2008 NVSR

2007 Baseline HP 2020 2007 Baseline HP 2020 2006 Baseline HP 2020 2006 Baseline HP 2020 2006 Baseline HP 2020

OneMaine Community Health Needs Assessment 2010

Detailed Data Sources for HEALTH STATUS PROFILE

Maine Counties Source US Source Defining Code

CHILD/YOUTH HEALTH % Sad/Hopeless (two weeks in a row, stopped usu. activities) % Seriously Considered Suicide % Current Smoker (Past Month) (Grade 9-12) % Current Smokeless Tobacco User % Alcohol Use (Past Month) (Grade 9-12) % Binge Drink (5+ in a row) Past Month) (Grade 9-12) % Marijuana Use (Past Month) (Grade 9-12) % Sniffed Glue or Other Inhalant (Past Month) (Grade 9-12) % Used Rx Drug w/out Rx (Past Month) (Grade 9-12) % Regular Physical Activity (at least 60 min on 5 of last 7 dys) % Consume fruits and vegetables 5 or more times/day % Drank sugar sweetened beverage in past week Teen Birth Rate (10-17yrs) Per 1,000 Female Population % Ever Been Diagnosed with Asthma (0-17) parental report Prevalance % Overweight/Obesity Problem (0-17) parental report % Overweight (Grade 9-12) % Obese (Grade 9-12) % with developmental delay or learning disability (0-17) parental report ACSC, ED Rate - Overall PQI (Ages 0-17) ACSC, Hospital Admission Rate - Overall PQI (Ages 0-17) Asthma and Bronchitis, Hospital Admission Rate (Ages 0-17) Pneumonia, Hospital Admission Rate (Ages 0-17) Psychoses Hospital Admission Rate (Ages 0-17) Management Major Depressive Disorder, Hospital Admission Rate (Ages 0-17) Bipolar Disorder, Hospital Admission Rate (Ages 0-17)

MIYHS 2009 MIYHS 2009 MIYHS 2009 MIYHS 2009 MIYHS 2009 MIYHS 2009 MIYHS 2009 MIYHS 2009 MIYHS 2009 MIYHS 2009 MIYHS 2009 MIYHS 2009 ODRVS Birth Household Survey Household Survey MIYHS 2009 MIYHS 2009 Household Survey MHDO Hosp Inpatient MHDO Hosp Inpatient MHDO Hosp Inpatient MHDO Hosp Inpatient MHDO Hosp Inpatient

2009 BRFSS 2009 BRFSS 2009 BRFSS 2009 BRFSS

2009 BRFSS

TAPQ 90 TAPQ 90 DRG v.24:96-98 DRG: v.25:202-203 DRG v.24:89-91 DRG: v.25:193-195 DRG v.24:430 v.25:885 ICD-9: 2962-2964,3004, 29620-29626,29630-29636. ICD-9: 297,2965-2973,2978-2979 29640-29646,29650-29656,29660-29666,2968029682,29689,29690,29699. ICD-9: 493,466, 4660 -4661,4930,4939,4661146619, 49300-49302, 49310-49312, 49390-49392. ICD-9: 480-486, 4800-4803,4808-4809,4820-4823,48284831,4838,4841,4843,4845-4848, 48230-48232, 48239-48241,48249,4828148284,48289. DRG:

MHDO Hosp Inpatient MHDO Hosp Inpatient

Asthma and Bronchitis, ED Rate (Ages 0-17)

MHDO Hosp ED

Pneumonia, ED Rate (Ages 0-17)

MHDO Hosp ED

OneMaine Community Health Needs Assessment 2010

Detailed Data Sources for HEALTH STATUS PROFILE

Maine Counties Source US Source Defining Code

ORTHOPEDICS % Diagnosed Arthritis Ages 18-44 Ages 45-64 Ages 65+ Hip Procedures, Hospital Admission Rate Ages 65+ Wrist/Hand Fracture, Hospital Admission Rate Ages 65+ Head Brain Injury, Hospital Admission Rate Ages 65+ INFECTIOUS DISEASE HIV/AIDS, Hospital Admissions Rate HIV/AIDS Mortality Rate HIV-Infection, Incidence Rate Hepatitis C, Incidence Rate Sexually Transmitted Disease Incidence Rate: Gonorrhea Chlamydia INTIMATE PARTNER VIOLENCE % Ever physically hurt by Intimate Partner % Past yr physical violence or unwanted sex from Intimate Partner Household Survey Household Survey MHDO Hosp Inpatient ODRVS Mortality HIV-Surveillance-Report-2009 (Table 8) ME CDC Infect Disease 2009 DRG-MDC 25 2007 NVSS 2007 NVSS

BRFSS 2007 & 2009

2009 BRFSS

MHDO Hosp Inpatient MHDO Hosp Inpatient MHDO Hosp Inpatient

DRG v.24:210-212 DRG: v.25:480-482 ICD-9: 814-817 ICD-9: 800-801,803-804,850-854.

ME CDC Infect Disease 2008

2008 CDC STDSS