Aaron Hedquist, MSc, Jessica Phelan, MSc, Rishi Wadhera, MD, MPP, & Jose F. Figueroa, MD, MPH
Harvard T.H. Chan School of Public Health
Overview
The County Health Rankings & Roadmaps (CHR&R) provides a comprehensive index of multiple determinants of health at the county level, allowing policymakers to easily identify potential areas for improvement. This includes data on health outcomes, health-creating behaviors, and socioeconomic factors. Each year, CHR&R produces an annual within-state ranking of counties calculated by combining several publicly available datasets. The rankings are widely cited in academic literature and public policy.
CHR&R is a valuable tool that can help inform and guide policymaking, but it is important for public health and policy officials to understand both the strengths and limitations of the data. In a comprehensive systematic review of the literature to date funded by the Episcopal Health Foundation, we outlined key limitations, methodological concerns, current uses of CHR&R tool, and highlight key insights for policymakers to consider. We summarize the key findings below that can be useful for public health leaders or policymakers to consider.
1. Use Individually Reported Measures to Supplement Community Health Needs Assessments
The overall health ranking of US counties is extremely limited, and we generally recommend against using the overall ranking to compare a given county with another county. This is particularly relevant for counties in Texas that have vast differences with regards to the social determinants of health and population demographics across the state. Rather than focusing on a county’s specific ranked position, policymakers and public health leaders would be better served using the individually reported measures compiled by CHR&R to pinpoint underlying health issues and disparities. For example, rates of drinking or smoking within a given county may be useful if there are interventions that the local health leaders may be trying to invest in to reduce use of alcohol consumption or smoking within a given community. The tool can also be used to supplement community health needs assessments—for example, helping to determine which clinical, socioeconomic, or environmental factors most correlate with the county’s health status. This type of data is easily accessible and valuable for strategically allocating resources or designing new policies. A major strength is that the CHR&R compiles numerous measures across many different data sources that can facilitate this type of activity for local county leaders and state officials.
2. Examine Data Values, Not Just Relative Measures
It is also important for policymakers and public health officials to examine the actual data values used to create each measure, not just relative measures. Two counties with similar ranks could have vastly different underlying rates, and the composition of health outcomes may differ. Many of the data measures are created based on specific populations that may vary substantially within a given county. For example, several health care utilization and outcome measures are based on the Medicare population over the age of 65 years. If a given county has very few people above the age 65 and enrolled in Medicare, than the measure based on that population is more limited for that given county. Additionally, where data is available, conducting additional analysis using local health data to identify inequities within counties is especially important. Ideally, this data should be as timely as possible. As an aggregated index, CHR&R focuses broadly on overall population health. Within individual counties, however, disparities may exist that are not completely captured by CHR&R.
3. Track Directional Trends in Underlying Measures
When using CHR&R to benchmark progress over time, public health leaders and policymakers must recognize the limitations of comparing rankings year-to-year. Even small changes to a county’s performance may result in significant rank fluctuations due to the index’s methodology. Instead of rankings, tracking directional trends in the underlying measures themselves provides a more reliable view of impact.
4. Use CHR&R to Inform Priorities, not Outcomes
Policymakers should be aware that CHR&R may have reduced validity in certain regions, especially sparsely populated, rural areas with incomplete or unreliable data. In these locations, the tool is better utilized for informing priorities rather than measuring the outcomes of specific programs. Additionally, where possible, local data sources may need to complement CHR&R.
In summary, the CHR&R is a valuable starting point to identify health challenges. But for policymaking or decision making for local public health leaders, it is most effective when officials consider the specific measures and values, examine disparities, verify trends over time, and understand limitations for their jurisdiction. A nuanced interpretation of this data, paired with local knowledge, can optimize impact.
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