Addressing Diseases of Despair in a Rural Community

Andrea Murray, Community-Engaged Research Project Manager, leads a discussion to collect qualitative data in the second phase of Penn State’s Translation of Despair and Healthcare project.

Penn State Clinical and Translational Science Institute is working to understand the effects of social and economic issues on health in rural communities. These issues have contributed to a decline in American life expectancy.

Many rural Pennsylvania communities are experiencing unique challenges related to the health of residents. Deaths related to heart and liver diseases, diabetes, accidental opioid overdose, and suicide are rising in American small towns. These are referred to as “diseases of despair.” Research suggests that diseases of despair are related to social and economic conditions. For example, Pennsylvania has seen the peak and decline of several industries, including coal and steel.

“We want to learn more about how diseases like depression and substance abuse develop because of these social and economic conditions,” Lawrence Sinoway, M.D., principal investigator and director of the institute, said. “We want to learn how they affect the communities that surround us and understand whether we can predict who will develop these diseases. Most importantly, can we treat and prevent them?”

Sinoway developed an interest in this topic after the release of a paper by economists Case and Deaton (PNAS, 2015), who helped propose the concept of diseases of despair. The institute secured an administrative supplement (NOT-TR-18-18-022) from NCATS for a pilot program. This program identified hot spot communities with higher rates of disease of despair diagnoses in Pennsylvania and will now learn what factors may be contributing to these diseases to develop potential interventions.

The institute partnered with Highmark Health Enterprise Analytics Data Science Research to identify hot spots for further analysis to determine potential interventions. The Data Science Research Group, a part of Highmark Health insurance company, supported the project through its expertise in machine learning and artificial intelligence.

“Our partnership with Highmark Health was essential to the success of our efforts,” Sinoway said. “They identified trends in their commercial insurance, Affordable Care Act, Medicare and Medicaid plans that we incorporated into Penn State datasets acquired through a variety of related efforts.”

The findings of this work include the following:

  • Rates of diseases of despair were significantly higher in 2018 than they were in 2009 for both men and women across nearly every age group.
  • The odds of having a disease of despair diagnosis in 2018 were 7.4 times higher among Medicaid members than among members of other types of plans.
  • Rising rates of diseases of despair are driven not only by substance-related disorders. The rate of alcohol-related disorders has increased significantly among women ages 18–74 and among men ages 35 and older.
  • The rates of diagnosis of suicide ideation/behaviors have significantly increased for both men and women of all age groups. Among those younger than age 35, the incidence of suicide ideation/behavior diagnoses has tripled.
  • Neighborhood-level socioeconomic indicators are extremely valuable in predicting which areas are likely to experience high rates of diseases of despair. These findings can ultimately guide targeted prevention and intervention efforts.

“We have seen great value in collaborating with Penn State to understand and address the challenges facing rural communities,” Curren Katz, Ph.D., director of data science research at Highmark Health, said. “Both Highmark and Penn State have a deep interest in improving health care for members and patients. Our partnership has enhanced understanding and will help improve health in the communities we serve.”

A second phase of the project, led by Danny George, MS.c., Ph.D., associate professor of humanities and public health sciences and a co-investigator on the project, is working with health care professionals and community organizations in the hot spot communities to explore what contributors to poor health are missed and why. Understanding how clinics and organizations can adapt to this emerging health crisis and what opportunities exist for better training will be explored through focus groups.

“This problem is particularly troubling in poorer rural areas, such as Appalachia,“ George said. “These communities have suffered, for example, from decades of loss of industry, loss of social safety nets, reduced union membership, stagnant wages, reduced access to higher education and the infiltration of opioid drugs.”

Jennifer Kraschnewski, M.D., M.P.H., associate professor of medicine and public health sciences, and a co-investigator on the project, helped identify local partnerships both within and outside the health system.

“Rural Pennsylvania has been particularly impacted by these diseases,” Kraschnewski said. “Our Clinical and Translational Science Institute is eager to partner with our surrounding rural communities to address the rising rate of diseases of despair.”

The institute is currently exploring additional projects and initiatives to build on this initial research.

“This is important work,” Sinoway said. “These are issues that affect our friends, families and neighbors. Penn State is positioned to work with our neighboring communities and health systems to have a positive effect on these challenges.”

References

Anne Case, Angus Deaton. Rising midlife morbidity and mortality, US whites. Proceedings of the National Academy of Sciences Dec 2015, 112 (49) 1