Texas Health Atlas

Texas Health Atlas

by Lawrence E. Estaville, Kristine Egan, Abel Galaviz

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 The authors have mined an immense array of previously scattered information and created a singular resource that provides a geographical perspective on the state’s health care system, medical services, insidious diseases, harmful behaviors, and health disparities among various segments of its population.

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 The authors have mined an immense array of previously scattered information and created a singular resource that provides a geographical perspective on the state’s health care system, medical services, insidious diseases, harmful behaviors, and health disparities among various segments of its population.

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The Eagle

"...it's quite a comprehensive accumulation and presentation of health data about Texas (illustrated by 350 color maps) that should be useful to medical researches and policymakers."--Glen Dromgoole, The Eagle

— Glen Dromgoole

The Eagle - Glen Dromgoole

"...it's quite a comprehensive accumulation and presentation of health data about Texas (illustrated by 350 color maps) that should be useful to medical researches and policymakers."--Glen Dromgoole, The Eagle

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Texas A&M University Press
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Texas Health Atlas

By Lawrence E. Estaville, Kristine Egan, Abel A. Galaviz

Texas A&M University Press

Copyright © 2012 Lawrence E. Estaville, Kristine Egan, and Abel A. Galaviz
All rights reserved.
ISBN: 978-1-60344-748-5



THIS CHAPTER HIGHLIGHTS THE Demographic profile that contextualizes Texas' main ethnic groups, their educational attainment, and economic conditions as they relate to the data and maps in the following chapters about the state's healthcare system, medical services, diseases, harmful behaviors, and health disparities.

About 75% of Texans live in the "Texas Population Triangle" bounded by Dallas–Fort Worth (DFW) south along I-45 to Houston, then west on I-10 to San Antonio, and back north to DFW on I-35 through Austin and Waco. Indeed, half the Texas population lives in the Dallas–Fort Worth (6.5 million) and Houston (6.0 million) metropolitan areas. Both of these population facts underscore that 88% of Texans are urbanites (US Census Bureau 2009). In 2009, the US Census Bureau projected that the Texas population, at its current growth rate, will approach 30 million people by 2020.

Texas demographics have changed dramatically in the past 20 years. Texas became a "majority-minority" state with no single ethnic group in the majority in 2004. The total 2008 population was 47.3% white, 36.3% Hispanic, and 11.4% black. At their current population growth rate, Hispanics will increase to about 15 million people and become the majority population in Texas by 2020. The Hispanic population will continue to become younger while the white population ages during the next 10 years. One reason for this difference in ages between the white and Hispanic populations is that Texas has the highest teen birth rate in the nation, and Hispanics have the highest rates of teen pregnancies in Texas (Kluever and Deviney 2007; DSHS 2009e). The Hispanic population is migrating into counties throughout Texas, particularly into urban areas and the Panhandle, but the largest Hispanic population cluster remains in South Texas in the Lower Rio Grande Valley. Blacks live mostly in the large urban areas but are also spread across rural East Texas; yet no Texas county has a black majority population (US Census Bureau 2000a, 2009; Claritas 2008; Petersen and Assanie 2005).

Lack of education is a primary cause of poverty. In 2007, less than 80% of Texans aged 25 years and older had high school diplomas (national average was 84.5%). In the 2007–2008 Texas school year, 88.8% of white students graduated, 70.8% of Hispanics, and 71.8% of blacks (TEA 2009). Education data for 2008 showed that less than one-third of Texans aged 25 years or older had college degrees (Claritas 2008). Table 1.1 shows that increased levels of education resulted in 2007 in far higher median annual earnings for fulltime, year-round workers in the United States. The lowest 2008 median family household incomes in Texas persisted in the Lower Rio Grande Valley (Claritas 2008).

The 2006 US Census American Community Survey listed Texas as having the fifth-highest poverty rate in the nation—one of six Texans was poor (defined using a set of income thresholds that vary by family size and composition). Texas also had the fifth-highest rate of child poverty (one of five children lived in poverty) and the eighth-highest rate of elderly living in poverty (one of eight Texans aged 65 and older) (US Census Bureau 2007a; DeLuna Castro and Kluever 2006). From 2000 to 2008, the highest rates of poverty remained in the Hispanic populations of the Lower Rio Grande Valley and in the Panhandle.


Medical Services

AS THEY ARE IN OTHER STATES, Healthcare personnel, hospitals, and various medical facilities, such as trauma centers, medical radiation units, assisted-living facilities, and hospices, are concentrated in Texas' large cities. The Texas Medical Center in Houston, the largest in the world, has highly rated hospitals, internationally recognized medical experts, and cutting-edge research (TMC 2010). Yet, ironically, in 2009 the US Department of Health and Human Services (USHHS) classified most of Texas' 254 counties as Medically Underserved Areas, and the next year the USHHS identified numerous Texas counties that had serious shortages of primary care, dental health, and mental health professionals. The low numbers of primary care and mental health professionals occurred across the state, whereas the largest deficiency of dental health professionals was throughout the Lower Rio Grande Valley. A foremost health concern in Texas is therefore medically underserved populations, especially Hispanics, blacks, and residents of isolated rural areas (3 million people live in rural Texas, 12% of the state's 2009 population) (DSHS 2009b; USDA 2009).

Although Texas ranked second in population in the nation in 2007, the state had only about 43,000 physicians and ranked forty-fifth in the ratio of physicians to population. The projection for the state's rapid population growth and the current critical shortage of nurses has caused Texas leaders to formulate a nursing workforce plan that calls for the number of nurses to increase by 86% from 2005 to 2020, certainly a huge undertaking that will continue to depend on recruiting nurses from other countries (DSHS 2009d).

The Texas Department of State Health Services (DSHS) Division for Regional and Local Health Services manages a system of 11 public health service regions divided into 8 geographic areas with headquarters in El Paso, Lubbock, Arlington, Tyler, Temple, Houston, San Antonio, and Harlingen. The DSHS (2010c) also collaborates with local communities to operate 64 local health agencies and 39 mental health community centers across the state. The US Army and Air Force care for their service members and families at 9 medical installations in Texas. In fact, the air force's largest medical facility, Wilford Hall Medical Center, and the Brooke Army Medical Center, both located in San Antonio, are being consolidated to form one of the largest military medical complexes in the nation (TMMCH 2009). The US Department of Veteran Affairs operates 9 hospitals in Texas (VA 2010).

In 2005, of a population of 22.5 million, approximately 15.3 million Texans (66%) confirmed that they had health insurance (US Census Bureau 2005); about 5.6 million people (25%) reported that they had no health insurance at all; and the remaining 1.6 million people (about 8%) did not report. The highest rates of uninsured were in the Lower Rio Grande Valley, the Panhandle, and the Dallas-Fort Worth and Houston metropolitan areas, where more than 20% of the population had no health insurance (Texas State Demographer 2005). From 2004 to 2007, the highest rates of Medicare patients were in South Texas, the Panhandle, and East Texas, and Texans enrolled in Medicaid followed the same geographic patterns.

This chapter introduces data compiled in 2008 from the Texas Hospital Discharge Public Use Data File from the DSHS Center for Health Statistics that shows the distributions of health-care payments across Texas. The data sets in the file are the only ones of their kind that can produce trustworthy comparisons among maps of various healthcare data. Importantly, the file reported cases of disease for locations of patient residences, thereby discounting other spatial influences such as sites of health-care providers or medical centers and hospitals. To provide dependable data stability, we aggregated the data for temporal comparisons of maps into two 4-year periods: 2000–2003 and 2004–2007. As with other large data sets, however, the hospital discharge file contains errors, mainly sampling errors in which all cases of a certain health-care variable were not counted in the file because they were not a part of a facility that the DSHS tracked, or in which some cases may have been counted more than once because patients are readmitted into hospitals for additional care and then discharged again. Another important factor in creating sampling error is the lack of access to health-care services and hospitals by certain populations, mainly Hispanic, black, and rural. Nevertheless, like the US Census with its inherent sampling errors, the hospital discharge data file is the most comprehensive source for valid, reliable healthcare data that can be compared across all 254 counties in Texas (DSHS 2008b). With the guidance of a professional medical coder, we derived most of the health-care maps in the following chapters from this digital data file. Finally, for map comparisons across health topics and disease classes, we mapped these crude hospital discharge data without any statistical manipulation such as data standardization or age-adjustment for cancer maps.


Perinatal and Birth Conditions and Anomalies

TEXAS COUNTIES HAD A MEAN RATE OF 85 teenage birth mothers per 100,000 population in 2006. Yet several of the Hispanic-majority counties in the Lower Rio Grande Valley and some counties in the Panhandle had rates of more than 120, the highest in the state. An examination of each of the state's three major ethnic groups shows the rate of teenage birth mothers per 100,000 population was 165 for Hispanics, 61 for blacks, and 42 for whites. The county rates for the onset of prenatal care within the first trimester followed somewhat the geographic patterns of the teenage birth mothers and encompassed large urban areas as well. When the data are disaggregated into ethnic groups, Hispanics in counties in South and West Texas have the lowest rate of prenatal care in the first trimester (DSHS 2008b).

Abortions, a perennially passionate topic of debate, occurred throughout Texas in 2006 with an overall county mean rate of 821 per 100,000 population but also included rates greater than 1,000, mostly in urban areas. Blacks led the state in the mean rate of abortions per 100,000 population with 563; followed by Hispanics, 489; and whites, 180 (DSHS 2009e). A comparison of the 2000–2003 and 2004–2007 data sets for preterm births shows the overall rate per 100,000 population decreased slightly from 74 to 73, particularly as a response to a substantial decline in the rate for blacks from 109 to 89. From 2003 to 2007, rates for babies with congenital anomalies were highest in South Texas, and Hispanics statewide had the highest rates, averaging 43.6 per 100,000 births.



CANCER IS THE OUT-OF-CONTROL GROWTH of abnormal cells and accounts for nearly one of every four deaths in the United States. Cancer is the second most common cause of death in the United States, exceeded only by heart disease. According to the American Cancer Society (2010), cancer will strike one of two men and one of three women in the United States at some time in their lives and will soon become the leading medical cause of death in the nation. The 2009 estimate for cancer-related deaths in the United States was more than 560,000, and in Texas the estimate was 36,000 (ACS 2010; Chustecka 2010).

This chapter spotlights nine common yet dreadful cancers: breast, cervical, colon, leukemia, lung, lymphoma, melanoma, ovarian, and prostate. The most striking spatial pattern of these cancers is the six areas of high rates of cancer in East Texas, especially lung cancer, and, to lesser degrees, colon, leukemia, melanoma, ovarian, and prostate. Such a unique clustering of the six cancers may suggest that research should be undertaken to determine contributing factors, perhaps including low educational attainment; low family income; high poverty level; lack of health insurance; inadequate access to health-care facilities; environmental conditions and hazards, including paper and pulp mills (SRS 2005) and petrochemical plants (EIA 2010); and geographic isolation. The highest concentration of rural blacks corresponds roughly to this East Texas cancer clustering (DSHS 2008b; Claritas 2008).

If detected and diagnosed early enough, many of these types of cancers can be treated and managed. Besides being cognizant of their family histories regarding cancer, people can help in prevention or early detection of some of these cancers, particularly lung (quit smoking), melanoma (stay out of direct sunlight and tanning salons), colon (change diet; have a colonoscopy), cervical (get the HPV vaccine; have a Pap smear), and breast (do a self-exam; have a mammogram). Today in the United States, more than two of three people stricken with cancer survive longer than five years, and more than 11 million cancer survivors are still alive (ACS 2010; NCI 2010; MDA 2010).


Diseases of Body Systems

JUST AS HIGH RATES OF CANCERS HAVE been shown to occur in certain areas, in the period 2004–2007 diseases of body systems also display geographic groupings in Texas, particularly in East and South Texas and, to a far lesser degree, in the Panhandle. Table 5.1 encapsulates the ethnic clusters of high rates for several diseases of body systems (number of hospital patients discharged per 100,000 population).

Large cities in Texas have the highest case totals for diseases of body systems. As clearly shown in Table 5.2 for 2004–2007, of the five largest Texas metro areas—Dallas-Fort Worth, Houston, San Antonio, Austin, and El Paso—only 10 diseases had high rates, mostly for hereditary asthma (three cities) and diabetes (four cities). In the five cities 11 disease rates decreased between 2000–2003 and 2004–2007, and 10 disease rates increased between the two periods. Significantly, the rates for heart attacks in Dallas-Fort Worth, Austin, and El Paso decreased; yet rates for strokes increased in all of the major metros except Austin. Austin was the only large Texas city that had a decrement in the rate of diabetes.


Harmful Behaviors, Infectious Diseases, and Injuries

OBESITY IS AN EPIDEMIC IN TEXAS, Especially among the Hispanic and black populations. The National Institutes of Health (2010) defines obesity as a score of 30 or more on its Body Mass Index. Texas ranked tenth in the nation for the proportion of its population who were obese in 2005–27% (6.2 million people). The mean for the nation was 24.4%. By 2010, 28.8% of Texans (7.3 million) were obese. At the current rate of increase, 31.7% of Texans (9.1 million) will be obese in 2020; and 36.7% (12.2 million), in 2030. The estimated cost of this obesity crisis for Texas in 2010 is more than $15 billion (CDC 2010b; US Census Bureau 2010; Texas Demographer 2009; Lochhead and D'Onofrio 2009).

In 2008, about 63,000 people were living with HIV/AIDS in Texas. Annual increases of cases for the past several years have been hovering near 3,500. The HIV/AIDS rates for blacks far exceed those of whites and Hispanics (DSHS 2010d).

The June 2010 report from the DSHS "Substance Abuse Trends in Texas" (2010d) included this information:

• Heroin use by a younger population has increased.

• Cocaine indicators have decreased.

• Methamphetamine smoking has increased, while injections have decreased.

• Marijuana homologs (synthetics) are appearing in the state.

• Marijuana use by schoolchildren is declining.

• Alcohol is the primary drug of abuse in Texas, and the Panhandle had the highest rate of binge drinking (DSHS 2010d).

The rates per 100,000 people for infectious and parasitic diseases in 2008 followed the East and South Texas geographic patterns for poor health and disease. Whites and blacks had peak rates in East Texas, and rates for whites and Hispanics were acute in South Texas. The highest contiguous county rates for injuries and poisonings were in East Texas, and whites had the most substantial rates throughout the state. Whites, mostly in East Texas, had the highest rates and totals for number of people using emergency rooms. The sharpest rates of traffic fatalities were mainly in West Texas (DSHS 2008b).


Mental Diseases

IN 2010, AN ESTIMATED 5.3 MILLION Americans had Alzheimer's disease (AD), and, of these, 340,000 were Texans. Unless a cure or prevention is found, the incidence of AD will triple by 2050. Alzheimer's affects up to 10% of people 65 and older and up to 50% of those 85 and older. Direct and indirect costs of AD and other dementias nationally are more than $170 billion annually. Texas ranks third in the United States in the number of Alzheimer's disease cases and second in the number of AD deaths (DSHS 2010a; Fairchild and Lyon 2008).

Mapped populations with mental disorders follow roughly the map in chapter 1 for the Texas population who are 65 or older. The rates as well as the total patient counts for those people with dementia or Alzheimer's disease are substantially higher for whites, especially in the elderly populations in East Texas and the Panhandle (DSHS 2008b).


County Health Factors and Outcomes

Five health factors maps and three Health Outcomes maps summarize the health data profile for Texas. In 2010, the University of Wisconsin Population Health Institute published County Health Rankings, an online report for the entire United States based on county-1 evel data. Two of the major research findings resulted in sets of maps by state for health factors and health outcomes.

Four types of weighted health factors influence the health of a county, and each of the four types has its own measurable weighted variables:

• Health Behaviors (30%): Tobacco Use (33.3%), Diet and Exercise (33.3%), Unsafe Sex (16.6%), and Alcohol Use (16.6%)

• Clinical Care (20%): Access to Care (50%), Quality of Care (50%)

• Social and Economic (40%): Education (25%), Employment (25%), Income (25%), Family and Social Support (12.5%), Community Safety (12.5%)

• Physical Environment (10%): Environmental Quality (50%), Built Environment (50%)


Excerpted from Texas Health Atlas by Lawrence E. Estaville, Kristine Egan, Abel A. Galaviz. Copyright © 2012 Lawrence E. Estaville, Kristine Egan, and Abel A. Galaviz. Excerpted by permission of Texas A&M University Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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