US County Level Research Articles

Geographic Variation in Trends and Disparities in Acute Myocardial Infarction Hospitalization and Mortality by Income Levels, 1999-2013.

During the past decade, the incidence and mortality associated with acute myocardial infarction (AMI) in the United States have decreased substantially. However, it is unknown whether these improvements were consistent across communities of different economic status and geographic regions since efforts to improve cardiovascular disease prevention and management may have had variable impact. To determine whether trends in US county-level, risk-standardized AMI hospitalization and mortality rates varied by county-based median income level. In this observational study, county-level risk-standardized (age, sex, and race) hospitalization and 1-year mortality rates for AMI from January 1, 1999, to December 31, 2013, were measured for Medicare beneficiaries 65 years or older. Data analysis was performed from June 2 through December 1, 2015. Counties were stratified by median income percentile using 1999 US Census Bureau data adjusted for inflation: low- (<25th), average- (25th-75th), or high- (>75th) income groups. The effect of income on the slope of AMI hospitalizations and mortality, measured as differences in the rate of change in AMI hospitalizations and mortality by county income and by the 4 US geographic regions, and a possible lag effect among low-income counties. In the 15-year study period, AMI risk-standardized hospitalization and mortality rates decreased significantly for all 3 county income groups. Mean hospitalization rates were significantly higher among low-income counties compared with high-income counties in 1999 (1353 vs 1123 per 100 000 person-years, respectively) and in 2013 (853 vs 648 per 100 000 person-years, respectively). One-year mortality rates after hospitalization for AMI were similar across county income groups, decreasing from 1999 (31.5%, 31.4%, and 31.1%, for high-, average-, and low-income counties, respectively) to 2013 (26.2%, 26.1%, and 25.4%, respectively). Income was associated with county-level, risk-standardized AMI hospitalization rates but not mortality rates. Increasing 1 interquartile range of median county consumer price index-adjusted income ($12 000) was associated with a decline in 46 and 37 hospitalizations per 100 000 person-years for 1999 and 2013, respectively; interaction between income and time was 0.56. The rate of decline in AMI hospitalizations was similar for all county income groups; however, low-income counties lagged behind high-income counties by 4.3 (95% CI, 3.1-5.9) years. There were no significant differences in trends across geographic regions. Hospitalization and mortality rates of AMI declined among counties of all income levels, although hospitalization rates among low-income counties lag behind those of the higher income groups. These findings lend support for a more targeted, community-based approach to AMI prevention.

Local business ownership and local economic performance: evidence from US counties

ABSTRACTLocal business ownership and local economic performance: evidence from US counties. Regional Studies. A rich US county-level dataset is utilized to obtain a statistical characterization of the relationship between the size of the local-based business sector and local economic performance. The study also disaggregates the local businesses sector by establishment size. The results do not provide conclusive evidence that the size of the local businesses sector is positively and significantly associated with local economic performance. The disaggregated results show some evidence of a significant and positive association of smaller local businesses with local economic performance compared with larger local businesses.

What determines health: a causal analysis using county level data

This article revisits the long-standing issue of the determinants of health outcomes. We make two contributions to the literature. First, we use a large and comprehensive US county level health data set that has only recently become available. This data set includes five measures of health outcomes and 24 health risk factors in the categories of health behaviors, clinical care, social and economic factors, and physical environment. Second, to distinguish causality from correlation, we implement an emerging data-driven method to study the causal factors of health outcomes. Among all included potential health risk factors, we identify adult smoking, obesity, motor vehicle crash death rate, the percent of children in poverty, and violent crime rate to be major causal factors of premature mortality. Adult smoking, preventable hospital stays, college or higher education, employment, children in poverty, and adequacy of social support determine health-related quality of life. Finally, the Chlamydia rate, community safety, and liquor store density are three important factors causally related to low birth weight. Policy implications of these findings are discussed.

Federal, state, and local governments: evaluating their separate roles in US growth

We use US county level data from 1970 to 1998 to explore the relationship between economic growth and government employment at three levels: federal, state and local. Increases in federal, state and local government employments are all negatively related to economic growth. We find no evidence that government is more efficient at lower levels. While we cannot separate out the productive and redistributive services of government, we document that the county-level income distribution became slightly more unequal from 1970 to 1998. We conclude that a release of government-employed labor inputs to the private sector would be growth-enhancing.

Health Care Utilization and the Proportion of Primary Care Physicians

Background The impact of primary care physicians on health care utilization remains controversial. Some have hypothesized that primary care physicians decrease health care utilization through enhanced coordination of care and a preventive care focus. Methods Using data from the Area Resource File (a Health Resources and Services Administration US county-level database) for the years 1990, 1995, and 1999, we performed a retrospective cross-sectional analysis with generalized estimating equations to determine if measures of health care utilization (inpatient admissions, outpatient visits, emergency department visits, and surgeries) were associated with the proportion of primary care physicians to total physicians within metropolitan statistical areas. Results The average proportion of primary care physicians in each metropolitan statistical area was 0.34 (SD 0.46, range 0.20-0.54). Higher proportions of primary care physicians were associated with significantly decreased utilization, with each 1% increase in proportion of primary care physicians associated with decreased yearly utilization for an average-sized metropolitan statistical area of 503 admissions, 2968 emergency department visits, and 512 surgeries (all P <.03). These relationships were consistent each year studied. Conclusions Increased proportions of primary care physicians appear to be associated with significant decreases in measures of health care utilization across the 1990s. National efforts aimed at limiting health care utilization may benefit from focusing on the proportion of primary care physicians relative to specialists in this country.

Federal, State, and Local Governments: Do Any of Them Promote Growth?

We use US county level data (3,058 observations) from 1970 to 1998 to explore the relationship between economic growth and the extent of government employment at three levels: federal, state and local. We find that increases in federal, state and local government employments are all negatively associated with economic growth. We find no evidence that government is more efficient at more decentralized levels - and thus reject Oates' (1972) decentralization theorem. Furthermore, while we cannot separate out the productive and redistributive services of government, we document that the county-level income distribution became slightly wider from 1970 to 1998. For those who justify government activities in terms of equity concerns - perhaps even trading off economic growth for equity - the burden falls on them to show that the income distribution would have widened significantly more in the absence of government activities. We conclude that a release of government-employed labor inputs to the private sector would be growth-enhancing.

Federal, State, and Local Governments: Evaluating Their Separate Roles in US Growth

We use new US county level data (3,058 observations) from 1970 to 1998 to explore the relationship between economic growth and the size of government at three levels: federal, state and local. Using 3SLS-IV estimation we find that the size of federal, state and local government all either negatively correlate with or are uncorrelated with economic growth. We find no evidence that government is more efficient at more or less decentralized levels. Furthermore, while we cannot separate out the productive and redistributive services of government, we document that the county-level income distribution became slightly wider from 1970 to 1998. Our findings suggest that a release of government-employed labor inputs to the private sector would be growth-enhancing.

A risk-based environmental Kuznets curve for US hazardous waste sites

The Environmental Kuznets Curve (EKC) hypothesis is investigated for US hazardous waste sites. Where past studies have typically focused on cross-country analyses of conventional air and water pollutants, here, US county level data and assessed risk is used as the measure of environmental degradation.

Women's Changing Participation in the Labor Force: A World Perspective

This paper describes how the composition of the labor force changes with economic development. It considers recent trends in women's labor force participation and the type of jobs held in various sectors as national per capita income increases. The paper notes that women are more likely to work in the family or informal labor market if the labor costs to firms exceed the opportunity costs of female labor to family enterprises. Firms are at a relative disadvantage compared with families in the employment of less experienced and less skilled labor, presumably because their labor costs are affected by such regulations as minimum wage, social insurance premiums and limits on firing. In Asia and Africa, an increase in the proportion of employment in firms within the major sectors accounts for most of the rapid growth in women's overall share of wage employment. In Latin America, however, growth in the proportion of firm employment has been slower than elsewhere, and the share of women in wage employment has even fallen overall in several countries. It is not unreasonable to assume that women have lost more than men from market regulations and distortions, but little research has addressed this proposition. If it is true, however, these interventions in the labor market may be responsible for slowing women's transition from nonmarket and family work to firm employment. This in turn may affect the rate and structure of economic growth.