Data Sources

All population-based rates use U.S. Census Bureau data from the corresponding year (2009-2011). U.S. Census Bureau. Table 1. Annual Estimates of the Population for the United States, Regions, States, and Puerto Rico: April 1, 2000 to July 1, 2009 (NST-EST2009-01) [updated 2009 Dec; cited 2012 Jun 12]; April 1, 2010 to July 1, 2011 (NSTEST2011-01) [updated 2012 Dec; cited 2012 Jun 12].; April 1, 2010 to July 1, 2012 (NST-EST2012-01) [updated 2012 Dec; cited 2013 Mar 5]. [Internet]. Suitland (MD): United States Census Bureau. Available from: http://www.census.gov/. 

ACCESS TO EMERGENCY CARE

Board-certified emergency physicians per 100,000 population
American Board of Medical Specialties. 2012 ABMS Certificate Statistics. Received via personal correspondence [2013 Mar 13]; American Osteopathic Board of Emergency Medicine. Unpublished data received via personal correspondence [2013 Mar 4].

Emergency physicians; Neurosurgeons; Orthopedists and hand surgeon specialists; Plastic surgeons; and ENT specialists per 100,000 population
AMA PHYSICIAN PROFESSIONAL DATA © 2012 by the American Medical Association. Unpublished data received via personal correspondence [2013 Jan 30].

Emergency physicians include physicians reporting a self-designated subspecialty of emergency medicine, internal medicine/emergency medicine/critical care, internal medicine - emergency medicine, pediatric emergency medicine, pediatrics - emergency medicine, emergency medical services, or emergency medicine/family medicine.

Neurosurgeons include physicians reporting a self-designated subspecialty of neurological surgery or pediatric neurological surgery.

Orthopedists and hand surgeons include physicians reporting a self-designated subspecialty of hand surgery, hand surgery/orthopedic surgery, orthopedic surgery of spine, orthopedic adult reconstructive surgery, orthopedic musculo-oncology, orthopedic pediatric surgery, orthopedic sports medicine, orthopedic surgery, orthopedic surgery - trauma, orthopedics (foot and ankle).

Plastic surgeons include physicians reporting a self-designated subspecialty of plastic surgery, plastic surgery - head and neck, facial plastic surgery, plastic surgery integrated, plastic surgery within the head and neck.

ENTs include physicians reporting a self-designated subspecialty of otolaryngology and pediatric otolaryngology.

Registered nurses per 100,000 population
U.S. Department of Labor, Bureau of Labor Statistics. Occupational Employment Statistics [Internet]. Washington (DC): May 2011 [cited 2012 April 11]. Available from: http://www.bls.gov/oes/ 

Additional primary care FTEs needed per 100,000 population; Additional mental health FTEs needed per 100,000 population
U.S. Department of Health and Human Services, Health Resources and Services Administration. Geospatial Data Warehouse, Health Professional Shortage Area (HPSA) data [Internet]. Washington (DC): U.S. Department of Health and Human Services [cited 2013 Mar 8]. Analysis conducted by Altarum Institute. Available from: http://datawarehouse.hrsa.gov/HPSADownload.aspx 

Percent of children able to see provider
Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health. National Survey of Children’s Health. NSCH 2011/2012 [Internet]. Portland (OR): Child and Adolescent Health Measurement Initiative; c2012 [cited 2013 Mar 26]. Available from: http://www.childhealthdata.org/

Level I or II trauma centers per 1 million population
American Trauma Society. Data from the American Trauma Society’s Trauma Information Exchange Program received via personal correspondence [2013 Mar 21].

Includes adult Level I or II trauma centers certified by the American College of Surgeons and/or designated by the state in which it is located. Counts of trauma centers within a state do not include trauma centers designated by that state, but located in a neighboring state.

Percent of population within 60 minutes of a Level I or II trauma center
American Trauma Society. Trauma Access Maps. [Internet] Upper Marlboro (MD). 2010 [cited 2013 Feb 20]. Available from: http://www.emergencymap.org/Trauma.aspx.

Includes access to Level I or II trauma centers in neighboring states.

Accredited chest pain centers per 1 million population
Society of Cardiovascular Patient Care. Data on Accredited Chest Pain Centers received via personal correspondence [2013 Apr 25].

Includes centers accredited by the Society for Cardiovascular Patient Care.

Percent of population with an unmet need for substance abuse treatment
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health. [Internet]. Washington (DC): SAMHSA. 2007 - 2010 [updated 2012 March; cited 2013 Jan 17]. Available from: http://www.samhsa.gov/data/NSDUH.aspx

Includes persons who reported that they needed, but did not receive, treatment for alcohol or illegal substance abuse at a treatment facility.

Physicians accepting Medicare per 100 beneficiaries
Centers for Medicare & Medicaid Services. State Report on Medicare Physician/Suppliers, 2009-2011. Unpublished data received via personal correspondence [2013 Mar 1]; Centers for Medicare & Medicaid Services. Medicare & Medicaid Statistical Supplement - 2012 Edition. Table 2.5 - Medicare Enrollment: Hospital Insurance and/or Supplementary Medical Insurance for Total, Fee-for-Service, and Managed Care Enrollees by Area of Residence, as of July 1, 2011 [Internet]. Baltimore (MD); [cited 2013 Mar 14]. Available from http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trendsand-Reports/MedicareMedicaidStatSupp/2012.html.

Number of physicians includes participating and non-participating physicians/suppliers practicing within the 50 United States and District of Columbia and utilized by Medicare fee-for-service beneficiaries as reflected on the Part B non-institutional claims. Count of Physician/suppliers is based on National Provider Identifier (NPI) reported as the rendering physician/supplier, and may be counted in more than one state, depending on where services were provided.

Number of beneficiaries includes those enrolled in hospital insurance and/or supplementary medical insurance fee-for-service programs.

Medicaid fee levels for office visits as a percent of the national average; Percent change in Medicaid fees for office visits (2007 to 2012)
2012 Medicaid fee levels were recorded directly from individual state websites or, where that was not available, directly from state Medicaid or health department personnel via personal correspondence. Website links to state websites containing Medicaid feel levels can be found on the American Academy of Family Physicians website at http://www.aafp.org.

2007 Medicaid fee levels are from the American Academy of Family Physicians (http://www.aafp.org).

In order to maintain comparability with the 2009 Report Card’s calculations, the rates used for both analyses were 99203 (new patient, low complexity); 99204 (new patient, moderate complexity); 99205 (new patient, high complexity); 99213 (established patient, low complexity); 99214 (established patient, moderate complexity). The five primary codes were weighted based on their relative contribution to Medicaid usage, as identified by Zuckerman et al (2004): 99203 (6.6%); 99204 (5.7%); 99205 (3.2%); 99213 (61.4%); 99214 (23.1%). (Zuckerman S, McFeeters J, Cunningham P, Nichols L. Changes in Medicaid Physician Fees, 1998-2003: Implications for physician participation. Health Affairs [online] June 2004.) Three states that do not have Medicaid participants enrolled in fee-for-service were excluded from the analysis: Idaho, Tennessee, and South Carolina.

Percent of adults with no health insurance; Percent of children with no health insurance; Percent of adults with Medicaid
U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement. Current Population Survey Table Creator [internet]. Washington (DC): [updated 2011; cited 2013 Feb 20]. Available from: http://www.census.gov/cps/data/cpstablecreator.html

Percent of adults underinsured
Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2011].

Includes adults who had health insurance, but reported that the cost of health care prevented them from seeking care when needed at least once in the past year.

Percent of children underinsured
Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health. National Survey of Children’s Health. NSCH 2011/2012 [Internet]. Portland (OR): Child and Adolescent Health Measurement Initiative; c2012 [cited 2013 Mar 26]. Available from: http://www.childhealthdata.org/

Includes children whose parents reported that the child had health insurance but that the out-of-pocket costs for health care were never or sometimes reasonable.

Pediatric specialty centers per 1 million population; Emergency departments per 1 million population; Hospital closures in 2011; Staffed inpatient beds per 100,000 population; Hospital occupancy rate per 100 staffed beds; and Psychiatric care beds per 100,000 population
American Hospital Association, AHA Annual Survey, FY 2011. Unpublished estimates acquired from Health Forum, LLC.

Pediatric specialty centers include hospitals with more than one neonatal intensive care unit or pediatric intensive care unit. Emergency departments include those that are hospital-owned freestanding or hospital-based EDs. Hospital occupancy rate is an estimate of the percentage of beds occupied on an average day.

Median time from ED arrival to ED departure for admitted patients (minutes)
Centers for Medicare & Medicaid Services. Medicare Hospital Compare Quality of Care [Internet]. Baltimore (MD); [updated 2013 Feb 1; cited 2013 Feb 21]. Available from http://www.medicare.gov/hospitalcompare.

Estimate is based on emergency department through-put, average median time per 1000 discharges.

State collects data on hospital diversion
American College of Emergency Physicians, State-by-State Survey of EMS Practices and Policies, 2013.

QUALITY & PATIENT SAFETY ENVIRONMENT

Funding for quality improvement within the EMS system; Funded state EMS medical director; Uniform system for providing pre-arrival instructions; CDC guidelines used as basis for state field triage protocols; State has or is working on a stroke system of care; Triage and destination policy in place for stroke patients; State has or is working on a PCI network or a STEMI system of care; Triage and destination policy in place for STEMI patients; Statewide trauma registry; Triage and destination policy in place for trauma patients
American College of Emergency Physicians, State-by-State Survey of EMS Practices and Policies, 2013.

All indicators were dichotomous (yes/no) with the exception of “CDC guidelines used as basis for state field triage protocols.” States could receive a maximum of 2 points based on the following responses: states using 2011 or 2006 CDC guidelines received 2 points, those not using CDC guidelines received 1 point, and those that did not have state field triage protocols did not receive any credit for this indicator.

Emergency medicine residents per 1 million population
Accreditation Council for Graduate Medical Education. List of Accredited Programs (within a specialty) with Approved and Filled Positions (Academic Year 2012-2013). Unpublished data received via personal correspondence [2013 Feb 13]; Accreditation Council for Graduate Medical Education. List of programs within a particular specialty for current academic year and those newly accredited programs with future effective dates (year ending June 30th, 2013). Unpublished data received via personal correspondence [2013 Feb 13].

American Osteopathic Association. Emergency Residents by State 2012. Unpublished data received via personal correspondence [2013 March 12].

Adverse event reporting requirement
National Academy for State Health Policy. Adverse Event Reporting Tools by State [Internet]. Washington (DC): National Academy for State Health Policy; c2013 [cited 2013 May 2]. Available from: http://www.nashp.org/pst-state-list/.

Oregon has a voluntary adverse event reporting system. Illinois enacted legislation in 2005, but has not implemented a reporting system, and so did not receive credit.

Percent of counties with Enhanced-911 capability
National Emergency Number Association, DDTI. Wireless Deployment Reports & Maps: Report 2. Percentage of counties that are E9-1-1 Capable [Internet]. Alexandria (VA): National Emergency Number Association. c2008 [cited 2012 Apr 10]. Available at: http://nena.ddti.net/NationalReport.aspx

Prescription drug monitoring program (PDMP)
Alliance of States with Prescription Monitoring Programs. Data received via personal correspondence [2012 Nov 11].

States could receive a total of 4 possible points: 2 points for having an operational PDMP; 1 point for having enacted legislation, but non-operational PDMP; an additional point was given for collecting data in real-time and for monitoring drug schedules II, III, IV, and V.

Percent of hospitals with computerized practitioner order entry; Percent of hospitals with electronic medical records
HIMSS AnalyticsTM Database (Derived from the Dorenfest IHDS+ DatabaseTM, 2012.

Percent of patients with acute myocardial infarction given percutaneous coronary intervention within 90 minutes of arrival; Median time to transfer to another facility for acute coronary intervention; Percent of patients with acute myocardial infarction who received aspirin within 24 hours
Centers for Medicare & Medicaid Services. Medicare Hospital Compare Quality of Care [Internet]. Baltimore (MD): Centers for Medicare & Medicaid Services; [updated 2013 Feb 1; cited 2013 Feb 12]. Available from: http://www.medicare.gov/hospitalcompare.

Percent of hospitals collecting data on race/ethnicity and primary language; Percent of hospitals having or planning to develop a diversity strategy or plan
American Hospital Association, AHA Annual Survey, FY 2011. Unpublished estimates acquired from Health Forum, LLC.

MEDICAL LIABILITY ENVIRONMENT

Lawyers per 10,000 population; Lawyers per physician; Lawyers per emergency physician
Number of lawyers was acquired from U.S. Department of Labor, Bureau of Labor Statistics. Occupational Employment Statistics, May 2011, Create customized tables [Internet]. Washington (DC); US Department of Labor [cited 2012 Jun 19]. Available from: http://www.bls.gov/oes/.

Number of physicians and emergency physicians are from AMA PHYSICIAN PROFESSIONAL DATA © 2012 by the American Medical Association. Unpublished data received via personal correspondence [2013 Jan 30].

ATRA judicial hellholes (Range 2 to –6)
American Tort Reform Association. Judicial Hellholes 2012-2013 [Internet]. Washington (DC); American Tort Reform Association, c2012 [cited 2013 Feb 21]. Available from: http://www.judicialhellholes.org/wp-content/uploads/2012/12/ATRA_JH12_04.pdf

ATRA assigns both positive and negative designations to specific counties and other jurisdictions within the states. 1 point was given for having a designated “point of light,” 0 points for not being mentioned, –1 point for having a “dishonorable mention,” –2 points for having a jurisdiction on the “watch list,” and –3 points for the presence of a “judicial hellhole.” A negative score therefore represents problem areas. Several states appear in multiple categories. Scores assigned to the states ranged from -6 to +2.

Malpractice award payments per 100,000 population; Average malpractice award payment; National Practitioner Databank reports per 1,000 physicians
National Practitioner Data Bank Public Use Data File, [31 DEC 2012], U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Practitioner Data Banks.

Malpractice award payments include the number of payments made by insurer, self-insured organization, and state compensation fund as the primary insurer. The average malpractice award payment was calculated by summing all of the malpractice payments and dividing by the number of payments made by an insurer, self-insured organization, and the state compensation fund as primary insurer. The number of Databank reports includes those for Physicians (MD), Physician Intern/Resident (MD), Osteopathic Physician (DO), and Osteopathic Physician Intern/Resident (DO).

Apology inadmissibility laws
American Medical Association. Apology Inadmissibility Laws: Summary of State Legislation [Internet]. Chicago (IL): American Medical Association; c2012 [cited 21 February 2013]. Available from: http://www.ama-assn.org/resources/doc/arc/apology-inadmissibility-statelaws-charts.pdf

Patient compensation fund
National Conference of State Legislatures. Medical Liability/Medical Malpractice Laws [Internet]. Washington (DC); National Conference of State Legislatures, c2013 [updated 2011 Aug 15; cited 2012 Apr 13]. Available at: http://www.ncsl.org/issues-research/banking/medical-liability-medical-malpractice-laws.aspx; American Tort Reform Association. State and Federal Civil Justice Reforms [Internet]. Washington (DC): American Tort Reform Association; c2011 [cited 2012 Apr 13]. Available from: http://www.atra.org/legislation/states.

Although Colorado, Florida, Oregon, and Wyoming have passed legislation to create a patient compensation fund, these states did not receive credit because provisions have not been implemented.

Number of insurers writing medical liability policies per 1,000 physicians
National Association of Insurance Commissioners. Countrywide Survey of Medical Malpractice Insurance 1991-2011 [Internet]. Washington (DC): National Association of Insurance Commissioners, c2012 [cited 21 Feb 2013]. Available from http://www.naic.org/documents/research_stats_medical_malpractice.pdf.

Average medical liability insurance premium for primary care physicians; Average medical liability insurance premium for specialists
Medical Liability Monitor. Rate Survey Issue. October 2012, 37 (10): 48pp.

Amounts presented are unweighted averages of rates for regions within states and companies providing rates, as listed in the 2012 Medical Liability Monitor. Primary care physicians are represented by rates for Internal Medicine, and specialists are represented by rates for OB-GYN and General Surgery.

Presence of pretrial screening panels, Findings admissible as evidence; Periodic payments; Medical liability cap on non-economic damages; Joint and several liability abolished; Collateral source rule reform enacted and provides for awards to be offset
American Medical Association. State Laws Chart 1: Liability Reforms [Internet]. Chicago (IL): American Medical Association; c2012 [cited 21 February 2013]. Available from: http://www.ama-assn.org/resources/doc/arc/state-laws-chart-1-jan-2012.pdf

For pretrial screening panels, States were awarded one point for having a mandatory pretrial screening panel and one point for a voluntary pretrial screening panels. If a State had either voluntary or mandatory pretrial screening panels, additional credit was given if the findings of the panel are admissible as evidence. In Maine and Connecticut, findings are only admissible as evidence if the decision of the panel is unanimous; as such these states did not receive credit for this indicator.

For periodic payments, States received 2 points if periodic payments were required by the state; and 1 point if required upon the request or agreement of one or both parties or at the discretion of the court or the judge. Connecticut, Minnesota, and Pennsylvania did not receive credit for having periodic payments, because all parties must be in agreement for the option to be exercised.

For medical liability caps on non-economic damages, states were categorized based on the size of the cap. From best to worst, the categories were: a $250,000 cap; a cap greater than $250,000 to $350,000; greater than $350,000 to $500,000; greater than $500,000; and no cap.

For joint and several liability reform, States received 2 points if joint and several liability were fully abolishment and partial credit if only partially abolished.

States were scored on two measures related to collateral source rule reform: (1) whether such reforms had been enacted and (2) whether the state requires awards to be offset by collateral sources.

Additional liability protections for EMTALA-mandated emergency care
American College of Emergency Physicians, “Special Liability Protection for Emergency Care Providers State Statutory Language.” Unpublished.

State provides for case certification; Expert witness required to be of the same specialty as the defendant; Expert witness must be licensed to practice medicine in the state
American Medical Association. State Laws Chart 2: Liability Reforms [Internet]. Chicago (IL): American Medical Association; c2012 [cited 21 February 2013]. Available from: http://www.ama-assn.org/resources/doc/arc/state-laws-chart-2-jan-2012.pdf

Case certification includes affidavits/certificates of merit or other certification by an expert witness that the case has merit.

For expert witness laws, States were given credit for provisions requiring expert witness to be of the same specialty as the defendant. Pennsylvania did not get credit for requiring expert witnesses to be of the same specialty as the defendant because a court may waive this requirement under special circumstances. States were given credit for provisions requiring that expert witness must be licensed to practice medicine in the State.

PUBLIC HEALTH & INJURY PREVENTION

Percent of traffic fatalities alcohol related
National Highway Traffic Safety Administration, National Center for Statistics and Analysis. Traffic Safety Facts 2011 Data - Alcohol-Impaired Driving. DOT HS 811 700 [Internet]. Washington (DC): National Highway Traffic Safety Administration; 2012 [cited 2013 Mar 22]. Available from: http://www-nrd.nhtsa.dot.gov/Pubs/811700.pdf.

This percentage includes traffic fatalities where the Blood Alcohol Content (BAC) of the driver was .01+ g/dL.

Traffic fatalities (drivers/passengers) per 100,000 population
National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS) Encyclopedia, FARS Data Tables [Internet]. Washington: National Highway Traffic Safety Administration; 2010 [cited 2013 Jan 23]. Available from: http://www-fars.nhtsa.dot.gov/.

Includes number of fatalities occurring among vehicle occupants (drivers and passengers).

Bicyclist fatalities per 100,000 daily cyclists; Pedestrian fatalities per 100,000 daily pedestrians
Alliance for Biking & Walking, Bicycling and Walking in the United States 2012 Benchmarking Report [Internet]. Washington (DC): Alliance for Biking & Walking, c2012 [cited 2013 Jan 23]. Available from: http://www.peoplepoweredmovement.org/site/index.php/site/memberservices/2012_benchmarking_report/.

Rates were calculated using Fatality Analysis Reporting System (FARS) 2007-2009 data for fatalities and American Community Survey (ACS) 2007-2009 data for population estimates, using 3-year averages. The pedestrian fatality rate was calculated by dividing the average number pedestrian fatalities by the average population count (adjusting for the proportion of the population walking to work). The bicyclist fatality rate was calculated by dividing the average number bicycle fatalities by the 3-year average population count (adjusting for the proportion of the population biking to work).

Front occupant restraint use (%)
U.S. Department of Transportation, National Highway Traffic Safety Administration. Traffic Safety Facts: Seat Belt Use in 2011—Use Rates in the States and Territories [Internet]. Washington (DC): National Highway Traffic Safety Administration; 2012 [cited 2013 Jan 22]. Available from: http://www-nrd.nhtsa.dot.gov/Pubs/811651.pdf.

Includes front occupants using a seat belt at the time of the survey.

Helmet use required for all motorcycle riders
Insurance Institute for Highway Safety, Highway Loss Data Institute. Current US motorcycle and bicycle helmet laws [Internet]. Arlington (VA): Insurance Institute for Highway Safety; c1996-2013 [updated 2013 Jan; cited 2013 Jan 21]. Available from: http://www.iihs.org/laws/HelmetUseCurrent.aspx; National Conference of State Legislatures. “NCSL Transportation Reviews: Motorcycle Safety.” [online] January 2012. http://www.ncsl.org/documents/transportation/Motorcyclesafety2012.pdf, accessed 04/10/12.

Data for Puerto Rico are from the National Conference of State Legislatures; all other data are from the Insurance Institute for Highway Safety.

Child safety seat and seat belt legislation (score out of possible 10 points)
Insurance Institute for Highway Safety, Highway Loss Data Institute. Safety belt and child restraint laws [Internet]. Arlington (VA): Insurance Institute for Highway Safety; c1996-2013 [updated 2013 Jan; cited 2013 Jan 21]. Available from: http://www.iihs.org/laws/safetybeltuse.aspx.

States received 2 points for having an adult seat belt law with primary enforcement of the law; 1 point for covering all ages and all seats; and 1 point for having any fine or 2 points for having a fine of at least $25 and loss of at least one point on driver’s license. Up to an additional 5 points were awarded for each year of age over age 3 children are required to use a restraint/booster seat. A point was deducted for secondary enforcement of child safety seat laws.

Distracted driving legislation (score out of possible 4 points)
Insurance Institute for Highway Safety, Highway Loss Data Institute. Cellphone and texting laws [Internet]. Arlington (VA): Insurance Institute for Highway Safety; c1996-2013 [updated 2013 Jan; cited 2013 Jan 21]. Available from: http://www.iihs.org/laws/cellphonelaws.aspx.

State received 1 point for each of the following: Ban on handheld cell phone use for all drivers; Primary enforcement of cellphone use ban; Ban on texting while driving for all drivers; Primary enforcement of texting ban.

Graduated drivers licenses legislation (score out of a possible 5 points)
Insurance Institute for Highway Safety, Highway Loss Data Institute. Young driver licensing systems in the U.S. [Internet]. Arlington (VA): Insurance Institute for Highway Safety; c1996-2013 [updated 2012 Nov; cited 2013 Jan 21]. Available from: http://www.iihs.org/laws/GraduatedLicenseCompare.aspx.

State received 1 point for each of the following: Minimum permit age of 16; Minimum intermediate license age of 17; Minimum of 65 supervised practice hours; Ban on all teen passengers during intermediate license stage; Night driving restrictions starting at 8 pm during intermediate license stage.

Percent of children immunized, aged 19-35 months
Centers for Disease Control and Prevention, National Immunization Program. National Immunization Survey, Jan – Dec 2011 [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; [updated 2012 September; cited 2013 Jan 21]. Available from: http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nis.

Includes children receiving the 4:3:1:3:3:1 series of vaccinations.

Percent of adults aged 65+ who received flu vaccine in the last 12 months; Percent of adults aged 65+ who ever received pneumococcal vaccine; Percent of adults with BMI > 30; Current smokers, percent of adults; Binge alcohol drinkers, percent of adults
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Behavioral Risk Factor Surveillance System, 2011: Prevalence and Trends Data [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; [updated unknown; cited 2013 Jan 21]. Available from: http://apps.nccd.cdc.gov/brfss/

Fatal occupational injuries per 1 million workers
U.S. Department of Labor, Bureau of Labor Statistics. Economic News Release. Table 5. Fatal occupational injuries by state and event or exposure, 2010-2011 [Internet]. Washington (DC): US Department of Labor; [updated 2012 Sep 20; cited 2013 Jan 21]. Available from: http://www.bls.gov/news.release/cfoi.t05.htm

Homicides and suicides (non-motor vehicle); Unintentional fall-related fatal injuries; Unintentional fire/burn-related fatal injuries; Unintentional firearm-related fatal injuries; Unintentional poisoning-related fatal injuries per 100,000 population
Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1999-2010. CDC WONDER Online Database, compiled from Compressed Mortality File 1999-2010 Series 20 No. 2P, 2013 [Internet]. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Health Statistics; 2013 [cited 2013 Feb 25]. Available from: http://wonder.cdc.gov/cmf-icd10.html.

Rates of homicides and suicide, unintentional fall-related deaths, and unintentional poisoning-related deaths are from 2010. Estimates presented for poisoning-related deaths for D.C. may be unreliable and should be interpreted with caution. Unintentional fire/burn-related deaths are from 2008-2010, and estimates for North Dakota, Vermont, and Wyoming may be unreliable and should be interpreted with caution. Unintentional firearm-related deaths are from 2003-2010, and estimates for Alaska, Maine, Massachusetts, New Hampshire, and North Dakota should be interpreted with caution as they may be unreliable.

Total injury prevention funds per 1,000 population; Dedicated funding source identified for childhood injury prevention; Dedicated funding source identified for elderly injury prevention; Dedicated funding source identified for occupational injury prevention
Safe States Alliance. (2013) State of the States: 2011 Survey. [Data file]. Retrieved from the Safe States Alliance, Atlanta, GA.

Gun-purchasing legislation (score out of 8 possible points)
Brady Campaign. Brady Campaign 2011 State Scorecards [Internet]. Washington (DC); Brady Campaign; 2012 [cited 2012 February]. Available from: http://www.bradycampaign.org/stategunlaws/; U.S. Department of Justice, Bureau of Alcohol, Tobacco, Firearms and Explosives. ATF Publication 5300.5 - State Laws and Published Ordinances — Firearms, 2010 – 2011 — 31st Edition [Internet]. Washington (DC); Department of Justice, Bureau of Alcohol, Tobacco, Firearms and Explosives [cited 2013 Jan 21]. Available from: http://www.atf.gov/publications/firearms/state-laws/31st-edition/index.html.

Data for DC and Puerto Rico are from ATF, 2011; all other state data are from the Brady Campaign, 2011

One point was awarded for each of the following indicators (partial credit was given): Firearm owners are required to report all lost or stolen guns to law enforcement; Background checks are required on all gun sales; Safety training and/or testing required to receive a permit; State requires locking devices be sold with guns; Gun owners are held accountable for leaving guns accessible to kids; State participation in the NICS

Anti-smoking legislation (score out of a possible 3 points)
Henry J. Kaiser Family Foundation, State Smoking Restrictions for Worksites, Restaurants, and Bars, 2012 [Internet]. Data derived from the State Tobacco Activities Tracking and Evaluation (STATE) System, Centers for Disease Control and Prevention, 2012. Menlo Park (CA): Kaiser Family Foundation; [cited 2012 July 19]. Available from: http://www.statehealthfacts.org/; Laws of Puerto Rico Annotated, Smoking Regulations in Public and Private Areas, 24 L.P.R.A. § 892 (2009).

States received 1 point each for banning smoking in all restaurants, private worksites, and all bars.

Infant mortality rate per 1,000 live births
Murphy SL, Kochanek KD. Deaths: Final data for 2010. National vital statistics reports; vol 61 no 4 [Internet]. Hyattsville (MD): National Center for Health Statistics; 2012 [cited 2013 Apr 25]. Forthcoming. Tables available from: http://www.cdc.gov/

Percentage of children that are obese (95th percentile or above)
Data Resource Center for Child and Adolescent Health, National Survey of Children’s Health 2011-2012 [Internet]. Portland (OR): c2013 [cited 2013 Apr 24]. Available from: http://www.childhealthdata.org.

Cardiovascular disease disparity ratio
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Behavioral Risk Factor Surveillance System, 2009-2011 [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; [cited 2013 03 04]. Analysis conducted by Altarum Institute.

Disparity ratio was calculated by first creating estimates of the percent of the population having ever been told by a health professional that they have cardiovascular disease for each race/ethnicity, and then creating a ratio of the highest prevalence of cardiovascular disease across races/ethnicities to the lowest prevalence. Prevalence estimates with a relative standard error of >30% or based on 20 or fewer cases were considered unreliable and were not used. A ratio of 1.0 indicates equal rates; the greater the value over 1.0 the greater the racial/ethnic disparity in that state.

HIV diagnoses disparity ratio
Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas [Internet]. Atlanta (GA): Centers for Disease Control and Prevention [cited 2013 Jan 10]. Available from: http://gis.cdc.gov/GRASP/NCHHSTPAtlas/main.html. Analysis conducted by Altarum Institute.

HIV diagnosis rates were calculated by summing all reported cases from 2007-2010 and dividing by the Census population counts for each race; rates with a relative standard error of >30% or based on fewer than 20 cases were considered unreliable and were not used. Disparity ratios were calculated by dividing the highest HIV diagnosis rate among each race by the lowest HIV diagnosis rate of each race in the state. A ratio of 1.0 would indicate equal rates; the greater the value over 1.0 the greater the racial/ethnic disparity in that state.

Note: Data on diagnoses of HIV infection should be interpreted with caution. HIV surveillance reports may not be representative of all persons infected with HIV because not all infected persons have been tested and results of anonymous testing are not reported. The completeness of reporting of HIV infection is estimated at more than 80%.

Infant mortality disparity ratio
Mathews, TJ & MacDorman, MF. Infant Mortality Statistics from the 2009 Period Linked Birth/Infant Death Data Set. National Vital Statistics Reports; vol. 61 no 8 [Internet]. Hyattsville (MD): National Center for Health Statistics; 2011 [cited 2013 Jan 23]. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_08.pdf.

The infant mortality disparity ratio was calculated by dividing the highest infant mortality rate among each race/ethnicity by the lowest infant mortality rate among each race/ethnicity. A ratio of 1.0 would indicate equal rates; the greater the value over 1.0 the greater the racial/ethnic disparity in that state.

DISASTER PREPAREDNESS

Per capita federal disaster preparedness funds
Department of Homeland Security. FY2012 Preparedness Grants Overview [Internet]. Washington (DC): Federal Emergency Management Agency, 2012 [cited 2013 March 7]. Available from: http://www.fema.gov/pdf/government/grant/2012/fy12_overview.pdf; Levi, J, Segal, LM, St. Laurent, R., & Lang, A. Investing in America’s Health: A State-by-State Look at Public Health Funding and Key Health Facts [Internet]. Washington (DC): Trust for America’s Health, 2013 [cited 2013 May 14]. Available from http://healthyamericans.org/assets/files/TFAH2013InvstgAmrcsHlth05%20FINAL.pdf

Includes ASPR Hospital Preparedness Program funding; CDC funding for Public Health Preparedness and Emergency Response; DHS funding for the State Homeland Security Grant Program, the Urban Areas Security Initiative, and Emergency Management Performance Grants Program).

State budget line item for funds specific to health care surge; ESF-8 plan shared with all EMS and essential hospital personnel; Emergency physician input into the state planning process; Public health and emergency physician input during an ESF-8 response; Special needs patients in medical response plan; Patients on medication for chronic conditions in medical response plan; Medical response plan for supplying dialysis; Mental health patients in medical response plan; Medical response plan for supplying psychotropic medication; Mutual aid agreements with behavioral health providers; Long-term care and nursing home facilities must have written disaster plan; State able to report number of exercises with long-term care or nursing home facilities; “Just-in-time” training systems in place; Statewide medical communication system with one layer of redundancy; Statewide patient tracking system; Statewide real-time or near real-time syndromic surveillance system; Real-time surveillance system in place for common ED presentations; State or regional strike teams or medical assistance teams; Disaster training required for essential hospital and EMS personnel
American College of Emergency Physicians, State-by-State Survey of Disaster Preparedness Practices and Policies, 2013.

Indicators were treated as dichotomous (yes/no) with the following exceptions:

• ESF-8 plan shared with all EMS and essential hospital personnel: states received a maximum of 2 points – 1 point each for sharing plan with all EMS personnel and all hospital personnel.
• Public health and emergency physician input during an ESF-8 response: states received a maximum of 2 points – 1 for incorporating input from public health physicians and 1 for incorporating input from emergency physicians.
• Mutual aid agreements with behavioral health providers: states received a maximum of 2 points – 2 for having statewide agreements in place with any entities, 1 for have local-level agreements in place with any entities, and 0 for having neither.
• Just in time training systems in place: states received a maximum of 2 points for having statewide systems in place, 1 point for having either county- or city-wide systems or systems across coalitions, and no points for having no such system.
• Real-time surveillance system in place for common ED presentations: states received a maximum of 2 points for having a statewide system, 1 point for having a system in metro areas only, and 0 points for having no system.
• Disaster training required for essential hospital and EMS personnel: states received a maximum of 2 points – 1 point each for requiring training in disaster management and response to biological and chemical terrorism for the two groups of professionals.

Liability protections for health care workers (4 points possible)
Uniform Law Commission. Legislation [Internet]. Chicago (IL): Uniform Law Commission, c2013 [cited 5 May 2013]. http://www.uniformlaws.org/Legislation.aspx; American College of Emergency Physicians, State-by-State Survey of Disaster Preparedness Practices and Policies, 2013.

States passing Uniform Emergency Volunteer Health Protection Act (UEVHPA) model legislation Alternative A received all 4 points; states passing UEVHPA Alternative B received 3 points with possiblity to earn 4 if separate legislation provides protections for entities hosting or deploying health care workers during an event (survey). Non-UEVHPA states received one point each for having: Immunity from civil liability for volunteers providing health services; Protections for entities that send or host volunteer health care workers; Liability protections tied to a declared public health emergency; “Good Samaritan” laws.

Number of drills, exercises conducted with hospital personnel, equipment, facilities per hospital; Bed surge capacity per 1 million population
Office of the Assistant Secretary for Preparedness and Response. Unpublished data from FY2012 year-end reporting received via personal correspondence [2013 Mar 15].

Includes drills, table top exercises, functional exercises, and full scale exercises that included hospital personnel, equipment, or facilities presented as a rate per the number of hospitals in the state (AHA Annual Survey, FY 2011).

Bed surge capacity is the number of beds statewide, above the current daily staffed bed capacity that the state is capable or surging beyond within 24 hours after a disaster event.

Accredited by the Emergency Management Accreditation Program
Emergency Management Accrediation Program. Accredited Programs [Internet]. Lexington (KY): Council of State Governments [Updated 2012 Oct; cited 2013 Mar 7]. Available from http://www.emaponline.org/index.php?option=com_content&view=article&id=175&Itemid=139

Physicians registered in ESAR-VHP per 1 million population; Nurses registered in ESAR-VHP per 1 million population; Behavioral health professionals registered in ESAR-VHP per 1 million population
Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) data submitted September 30, 2012. Unpublished data received via personal correspondence [2013 Feb 19].

Registered physicians include: Allopathic Physicians (M.D.); Osteopathic Physicians (D.O.); Physician - Unknown if M.D. or D.O.

Nurses include: Advanced Practice Nurse; Advanced Practice RN; Certified Nurse Anesthetists; Certified Nurse Midwives. Clinical Nurse Specialists; Licensed Practical Nurses and Licensed Vocational Nurses; Nurse Practitioners; Psychiatric/Mental Health Nurse; Public Health Nurse; Registered Nurses.

Behavioral health professionals include: Mental Health Counselors; Mental Health Practitioner; Professional Counselors; Psychologist; Social Worker; Social Worker (non-clinical); Social Worker, Medical and Public Health; Social Worker, Mental Health and Substance Abuse; Clinical Social Workers, Licensed Master Social Worker (no privileges); Licensed Professional Counselors; Licensed Social Worker; Licensed Social Worker (LSW) (LISW) ; Marriage and Family Therapists; Substance Abuse and Behavioral Disorder Counselor, Substance Abuse and Behavioral Health Counselor; Chemical Dependency Professional; Licensed Alcohol and Drug Counselor; Certified Substance Abuse Counselor.

ICU beds per 1 million population
American Hospital Association, AHA Annual Survey, FY 2011. Unpublished estimates acquired from Health Forum, LLC. Includes medical/surgical, cardiac, neonatal, pediatric, and other ICU beds.

Burn unit beds per 1 million population
American Burn Association. Burn Care Facilities, United States [Internet]. Chicago (IL): American Burn Association [updated 2013 Feb 6; cited 2013 Mar 7]. Available from: http://www.ameriburn.org/BCRDPublic.pdf

Verified burn centers per 1 million population
American Burn Association. Burn Center Verification [Internet]. Chicago (IL): American Burn Association [cited 2013 Mar 7]. http://www.ameriburn.org/verification_verifiedcenters.php

Percent of registered nurses that received disaster training
U.S. Department of Health and Human Services, Health Resources and Services Administration. National Sample Survey of Registered Nurses 2008. [Public use data files available online] http://datawarehouse.hrsa.gov/nursingsurvey.aspx, accessed 04/13/12. Analysis conducted by Altarum Institute.

Includes training for biological attack, chemical attack, nuclear radiation attack, natural disaster, and/or outbreak of infectious disease.