Rural health and associated factors of diabetes in Maryland

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Harford County is a relatively rural area of northern Maryland, approximately 30 minutes northeast of Baltimore City. Though suburban sprawl is rapidly developing the southern end of the county, healthcare infrastructure is relatively underdeveloped with volunteer-run emergency medical services systems and two small community hospitals. The prevalence of diabetes in Harford County is relatively moderate, but like Baltimore City and the rest of the nation, is on the rise and will likely become severe within the next decade.

The health inequalities associated with diabetes is the result of the economic expense of the lost productivity and likelihood of comorbid diseases. Coupled with frequent 911 use and high rates of emergency department admissions, Community Paramedicine will be a necessary component of any public health intervention for diabetes in Harford County.

Harford County, Maryland

Harford County is 437.09 square miles with 560.1 persons per square mile bordering Pennsylvania and the Chesapeake Bay in northern Maryland. Though largely rural and originally all farmland, Harford County has been experiencing a steady suburban sprawl spreading from Baltimore City and County in the southwest. Two small cities, Aberdeen and Bel Air, make up a large percentage of the county population. Bel Air is the county seat and there are 3 sub-county governments.

There are 12 fire and emergency medical services companies in Harford County that provide both emergent and non-emergent medical support to the county communities. All 12 companies are ran and staffed by volunteers, but supplement their staff with paid Emergency Medical Technicians and paramedics that work around-the-clock to offset the low volunteer participation in emergency medical services. Ambulances are the primary mode of emergency medical services response, but extra support units are routinely used to provide additional personnel to calls for service throughout the county.

There are two community hospitals, Upper Chesapeake Medical Center and Harford Memorial Hospital, that serve as the primary definitive care centers for the county. Most ambulance transports go to either of the two hospitals, both of which are designated as stroke centers and capable of treating most medical emergencies. Upper Chesapeake Medical Center is also a pediatric base station with a pediatric emergency department and a cardiac intervention center with cardiac catheterization lab.

The total population estimate in 2013 was 249,215 people, much less than Baltimore City's 622,104 people. Like Baltimore City, Harford County's population is steadily increasing with the most recent rate at 1.8 percent over 3 years. Minors account for 23.3 percent at slightly more than Baltimore City's 21.1 percent. Adults over 65 years of age account for 14.1 percent, also slighter higher than Baltimore City's 12.1 percent.

The vast majority of Harford County is white, at 81.1 percent of the population. This is dramatically more than Baltimore City at 31.6 percent. Blacks make up 13.2 percent of the population, dramatically less than Baltimore City's 63.3 percent. Similarly, Harford County and Baltimore City have small percentages of other minorities with Hispanics and Latinos at 4.0 percent and 4.6 percent, and Asians at 2.9 percent and 2.6 percent.

Harford County has a relatively high rate of high school graduation at 91.9 percent, higher than both Baltimore City at 79.6 percent and all of Maryland at 88.5 percent. A small portion of foreign-born residents and speakers of other languages live within Harford County, at 5.0 percent and 7.5 percent respectively.

There is a significant veteran population due to Aberdeen Proving Grounds and Edgewood Arsenal on the eastern shoreline of the county and multiple nearby VA hospitals. The estimated veteran population from 2008-2012 was 22, 270 veterans, with 6.7 percent from the World War II era, 9.7 percent from the Korean War era, 32.2 percent from the Vietnam War era, and 36.6 percent from the Gulf War era and later. Of the total veteran population in 2008-2012, 3,347 had a service-connected disability rating.

Diabetes in Harford County, Maryland

The prevalence of diabetes is on the rise, increasing from 7.3 percent in 2004 to 9.5 percent in 2011. At 9.5 percent, 17,145 Harford County citizens have been diagnoses with diabetes. Compared to the rest of the United States, the prevalence of diabetes in Harford County is moderate, but nearly bordering on severe.

The Centers for Disease Control and Prevention's data models, particularly the Diabetes Interactive Atlas and National Diabetes Fact Sheet, show that diabetes is on the rise nationwide and it would be reasonable to expect, given the data collected since 2004, that Harford County's prevalence of diabetes will be considered severe like that of Baltimore City by approximately 2020.

The use of 911 for both acute diabetic exacerbations and non-emergent diabetes assistance is a significant component of the total usage of 911 systems. Chronic diabetes not only requires daily maintenance of the disease, but also the prevention of acute exacerbations such as hypoglycemia, diabetic ketoacidosis, and hyperglycemic hyperosmolar non-ketotic state. In Baltimore City, between 2008 and 2010, 14.6 percent of the non-frequent 911 users had a past medical history of chronic diabetes. More significantly, 39.9 percent of the frequent 911 users had a past medical history of chronic diabetes.

Dr. Ben Lawner, an emergency physician in Baltimore City's University of Maryland Medical Center, Medical Director of the Baltimore City Fire Department and Community College of Baltimore County's Emergency Medical Technology Program, and active participant in the Maryland Institute for Emergency Medical Services Systems Research Interest Group, states that this trend of significant 911 use in persons with chronic diabetes can not only be extrapolated to Harford County, but also nationwide. Diabetes is a chronic disease epidemic in which there is poor health literacy on the condition and high associated costs, resulting in a significant disadvantage for low-income households and households with low educational attainment.

Acute diabetic exacerbations account for only a portion of patient calls for emergency services, and 911 use by chronic diabetics is often related to daily maintenance assistance or the comorbid conditions associated with diabetes. Since paramedics are often the first healthcare professionals that diabetics encounter during a perceived emergency, it is paramount to use their skill, knowledge base, and versatility to a public health advantage.

Paramedicine is rapidly expanding both professionally and academically, most notably with the introduction of Community Paramedicine. Community Paramedicine uses the paramedic's front-line healthcare provider advantage to promote prevention and mitigation of chronic conditions in the community.

For diabetes, community paramedics would be able to interface with patients on a non-emergent and routine basis to provide support, medical assistance, lifestyle assistance, and advice in order to prevent acute diabetes exacerbations and especially emergency department admissions. Community Paramedicine has shown exceptional efficacy in a variety of communities, both rural and urban, and is becoming one of the most significant healthcare trends for chronic disease intervention.

Disease comorbidity is a common problem with chronic diseases, especially diabetes. Diabetes is associated with obesity, heart disease, renal failure, peripheral nervous system disorders, and even depression. These comorbid conditions result in increased 911 use, emergency department admissions, and inpatient hospital admissions. Furthermore, comorbid diseases and associated health problems are correlated with dramatically higher healthcare expenditures.

The daily expense of diabetes is significant, and the added expense of comorbid diseases makes for extreme annual patient expenditures. At $11,744 per diabetic per year, the economic toll of diabetes on Harford County is a significant contributor to health inequality. Diabetes is associated with lost productivity and work hours, leading to decreased incomes, disability, and job loss.

With diabetes on the rise, it is essential that the quality and standard of care be upheld and prevention education initiated early and thoroughly. Community health centers are an important resource nationwide, primarily serving low-income households.

Due to the self-care component of diabetes intervention, research suggests that, along with improved clinician training, the current guidelines and delivery systems must improve in order to have a significant effect on quality and standard of care. This is an issue with healthcare infrastructure that ultimately has a nationwide effect. It suggests that poor-quality diabetes care for low-income households and community health center patients experienced in the Midwest is also pertinent to Maryland, and therefore Harford County.

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