In terms of health, where you live can make a huge difference, according to a detailed study by the nonprofit Commonwealth Fund .

It looked at 43 indicators of health system performance in four major areas: access, prevention and treatments, costs and potentially avoidable hospital use, and health outcomes. The nation is broken down into 306 local health markets; their boundaries are determined by the service areas of local hospitals.

The list of the nation's top 10 local markets was dominated by Midwestern cities, according to the Fund's Scorecard on Local Health System Performance. Minnesota claimed four of the top spots, and California and Wisconsin each had two. Here are the top 10 local healthcare markets:

St. Paul, Minn.

Dubuque, Iowa

Rochester, Minn.


Appleton, Wis.

Santa Rosa, Calif.

La Crosse, Wis.

St. Cloud, Minn.

Manchester, N.H.

San Mateo County, Calif.

"The report finds that access, quality, costs, and health outcomes all vary significantly from one local community to another," the Scorecard said, "often with a two- to threefold variation in key indicators between leading and lagging communities."

Cathy Schoen, a senior vice president at the Commonwealth Fund, says the report shows that a region's health system's performance reflects the importance of cooperation and communication among local health providers. Patients' medical literacy varies. They move in and out of different care settings and see multiple doctors and healthcare professionals. Their treatment needs and oversight can easily fall through the cracks.

Among the 43 indicators, Schoen mentioned nine that she felt deserved special attention.

1. Percent of adults ages 18–64 with health insurance : Best 94.6 percent; worst 46.8 percent. Top three: Boston; Springfield, Mass.; Worcester, Mass.

"We have huge areas of the country where more than one in four or one in five adults are uninsured," Schoen says. Such communities tend to generate higher use of emergency rooms and poorer health outcomes. When people don't have health insurance, "it pulls down the quality of care in the entire community," she says.

2. Percent of adults age 50 and older who received recommended screening and preventive healthcare services : Best 58.8 percent; worst 26.0 percent. Top three: Arlington, Va.; Manchester, N.H.; Worcester, Mass.. Even the best markets could do a lot better, the Scorecard says.

3. Percent of Medicare beneficiaries who received at least one drug that should be avoided in the elderly: Best 11.4 percent; worst 44.0 percent. Top three: Bronx, N.Y.; East Long Island, N.Y.; White Plains, N.Y.

4. Percent of Medicare beneficiaries with dementia, hip/pelvic fracture, or chronic renal failure who received prescription in an ambulatory care setting that is contraindicated for that condition: Best 9.5 percent; worst 30.6 percent. Top three: Portland, Maine; Rochester, Minn.; Santa Cruz, Calif. "These two measures are signs that physicians are not always practicing evidence-based medicine and may not be up on the latest treatments," Schoen says. "It also can be a sign of patients seeing more than one physician and the physicians not talking to each other."

5. Hospital readmissions within 30 days of discharge as percent of all admissions among Medicare beneficiaries: Best 12.5 percent; worst 24.8 percent. Top three: Bend, Ore.; Ogden, Utah; Rapid City, S.D. There are several overlapping causes for high readmissions rates, Schoen says. Patients may have been discharged too early or left the hospital with an infection. They, their families, or their doctors may not have been given the proper care instructions.

6. Potentially avoidable emergency room visits among Medicare beneficiaries, per 1,000 beneficiaries: Best 129; worst 294. Top three: Everett, Wash.; Grand Junction, Colo.; Santa Cruz, Calif.. Because Medicare beneficiaries by definition have health insurance, the reasons for unnecessary visits tend to involve incorrect or confusing diagnoses by healthcare professionals or poor access and communications between providers and patients.

7. Potentially preventable mortality, deaths per 100,000 population: Best 51.5; worst 169.0. Top three: Boulder, Colo.; Everett, Wash.; Grand Junction, Colo. This measure includes conditions affecting people at different ages. For older patients, Schoen says, "even if they have a chronic condition, it shouldn't reach the stage" of causing a premature death if they receive proper care.

8. Percent of adults who smoke: Best 6.2 percent; worst 30.9 percent. Top three: Provo, Utah; San Mateo, Calif.; Santa Barbara, Calif.

9. Percent of adults ages 18–64 who are obese: Best 15.3 percent; worst 45.6 percent. Top three: Boulder, Colo.; Bridgeport, Conn.; San Francisco.

Twitter: @PhilMoeller

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