Association of Geographic Differences in Prevalence of Uncontrolled Chronic Conditions With Changes in Individuals' Likelihood of Uncontrolled Chronic Conditions

Key PointsQuestionTo what degree are geographic differences in leading risk factors for morbidity and mortality in the US associated with the place where people live? FindingsIn this retrospective cohort study of 5342207 adults, moving from a 10th to a 90th percentile zip code for a given outcome was associated with a significantly increased prevalence of uncontrolled blood pressure of 7 percentage points (from a baseline of 29%), uncontrolled diabetes of 1 percentage point (from a baseline of 7%), obesity of 2 percentage points (from a baseline of 39%), and depressive symptoms of 3 percentage points (from a baseline of 19%) among movers. MeaningA substantial percentage of the change in individuals' likelihood of having poor blood pressure control or depressive symptoms may be related to the place in which they live. ImportanceThe prevalence of leading risk factors for morbidity and mortality in the US significantly varies across regions, states, and neighborhoods, but the extent these differences are associated with a person's place of residence vs the characteristics of the people who live in different places remains unclear. ObjectiveTo estimate the degree to which geographic differences in leading risk factors are associated with a person's place of residence by comparing trends in health outcomes among individuals who moved to different areas or did not move. Design, Setting, and ParticipantsThis retrospective cohort study estimated the association between the differences in the prevalence of uncontrolled chronic conditions across movers' destination and origin zip codes and changes in individuals' likelihood of uncontrolled chronic conditions after moving, adjusting for person-specific fixed effects, the duration of time since the move, and secular trends among movers and those who did not move. Electronic health records from the Veterans Health Administration were analyzed. The primary analysis included 5342207 individuals with at least 1 Veterans Health Administration outpatient encounter between 2008 and 2018 who moved zip codes exactly once or never moved. ExposuresThe difference in the prevalence of uncontrolled chronic conditions between a person's origin zip code and destination zip code (excluding the individual mover's outcomes). Main Outcomes and MeasuresPrevalence of uncontrolled blood pressure (systolic blood pressure level >140 mm Hg or diastolic blood pressure level >90 mm Hg), uncontrolled diabetes (hemoglobin A(1c) level >8%), obesity (body mass index >30), and depressive symptoms (2-item Patient Health Questionnaire score >= 2) per quarter-year during the 3 years before and the 3 years after individuals moved. ResultsThe study population included 5342207 individuals (mean age, 57.6 [SD, 17.4] years, 93.9% men, 72.5% White individuals, and 12.7% Black individuals), of whom 1095608 moved exactly once and 4246599 never moved during the study period. Among the movers, the change after moving in the prevalence of uncontrolled blood pressure was 27.5% (95% CI, 23.8%-31.3%) of the between-area difference in the prevalence of uncontrolled blood pressure. Similarly, the change after moving in the prevalence of uncontrolled diabetes was 5.0% (95% CI, 2.7%-7.2%) of the between-area difference in the prevalence of uncontrolled diabetes; the change after moving in the prevalence of obesity was 3.1% (95% CI, 2.0%-4.2%) of the between-area difference in the prevalence of obesity; and the change after moving in the prevalence of depressive symptoms was 15.2% (95% CI, 13.1%-17.2%) of the between-area difference in the prevalence of depressive symptoms. Conclusions and RelevanceIn this retrospective cohort study of individuals receiving care at Veterans Health Administration facilities, geographic differences in prevalence were associated with a substantial percentage of the change in individuals' likelihood of poor blood pressure control or depressive symptoms, and a smaller percentage of the change in individuals' likelihood of poor diabetes control and obesity. Further research is needed to understand the source of these associations with a person's place of residence. This cohort study uses Veterans Health Administration data to estimate the change in prevalence of chronic cardiovascular disease (CVD) risk factors among veterans whose residential zip code changed vs remained the same between 2008 and 2018 to better understand the contribution of geography vs individual patient characteristics to poor risk factor control.