HDG #026: A data profile of the Garden Isle (Kauai, HI)
Read time: 5 minutes
I’m baaaaaack, Gurus! I’ve been on radio silence the last month-ish as I was first vacationing (guess where?), then wrapping up some projects and getting caught up.
This “downtime” included co-curating and launching a new 4-week intensive for healthtech founders with some colleagues, which required my focus to prepare the curriculum and coordinate Guest Instructors. You’ll be hearing a lot more about this new endeavor soon!
It also included an entire brand refresh for HDG newsletter images+website content, and more than a couple of Midjourney and ChatGPT rabbit holes. I’ll share my tips and how I use those in the future. For now, I hope you love the brand refresh as much as I do, and that you didn’t miss your data fix too much.
Today I’m back in full swing, and I certainly missed all of you!
Creating a Regional Data Profile of Kauai Using Public Data
This week, I was inspired to use my recent vacation to Kauai, Hawaii to see what public data could help me learn more about healthcare on this absolutely enchanting island. This analysis focuses on Kauai County, which encompasses the entire island. Kauai is also known as the “Garden Isle” because of how lush and beautiful the greenery is.
Read on to see how all this shook out, in action, and to learn a little more about this amazing place.
Why Kauai?
Since all I do is think about data 24/7, even while on vacay, I kept thinking that even though Kauai has exotic landscapes and serene beaches, it also seemed to present a unique healthcare scenario and intersection with indigenous health—something I think a lot about here in my home state of New Mexico.
Using my previous Guide—How to Do a Community Health Needs Assessment in Minutes—I dove into all the data that I could find about healthcare in Kauai. In doing so, I learned of some new data sources and also ran into a frustrating lack of data on certain topics.
There are only 3 hospitals on the island—two of which are critical access.
The hospitals, albeit few, cater to a wide array of needs within the community. You can drive from the high North point (Hanalei) to the far most southeast point (Kekaha) in about 1-2 hours depending on traffic, and three (3) major hospitals are located along that path, with 2 of them being designated as Critical Access. This means 2 of the 3 are small, rural hospitals that provide “essential services” in rural communities.
This gives an idea of the dynamics for cities outside the main city of Lihue, which is where the airport (and the island’s most metro area) is.
SAMUEL MAHELONA MEMORIAL HOSPITAL: A 14-bed Critical Access facility, providing vital healthcare services to the eastern side of Kauai.
WILCOX MEMORIAL HOSPITAL: With 71 beds, this Short-term Acute hospital is one of the primary healthcare providers on the island.
KAUAI VETERANS MEMORIAL HOSPITAL: Another crucial establishment with 25 Critical Access beds, serving the veterans and inhabitants of the region.
Using my previous Guide—How to Do a Community Health Needs Assessment in Minutes—and searching for a couple of new or very specific data sources, I reviewed at least 10 different sources of data. It took me about 2 hours in total to find the data I needed and put this very high-level profile together. Certainly, more time and digging could reveal much more, but this gives you a sense of how much data is waiting to be discovered for a fairly low lift.
Kauai Boasts “Better” Health in Many Areas…
I can tell you after reviewing numerous public data sources that 95% of the indicators show Kauai faring “better” than the U.S. averages/estimates. Hawaii’s less-populated and less-traversed islands are known for fresh fruit, less pollution, and lifestyles that include many land and ocean activities. This has been proposed as one reason the island’s residents may have generally “better” health indicators overall than the U.S. average, despite some of the socioeconomic indicators that look more like their peer counties on the mainland.
I started by reviewing CDC Places data to determine the specifics. I like CDC Places for this because it draws on a number of different types of data and is easy to understand. It also compares the place of interest to the United States averages so you can tell if the values for a certain place are comparatively high or low.
Below is a snapshot of a few measures so you can get a feel for the data.
CDC Places data for Kauai, HI has dozens of other indicators you can peruse at your leisure.
Except…
A handful of preventative measures, such as screenings and vaccines, did reveal that Kauai’s older residents may not be as up-to-date on preventative and proactive services/screenings.
Overall, given all the other health outcomes that the island seems to fare better with, including actually showing lower prevalences of the conditions that they aren’t up-to-date on getting screened for, this didn't stand out to me as particularly notable or cause of further digging.
I turned my attention to Data USA’s data for Kauai, which has a lot more information about the community’s socioecomics and demographics than CDC Place’s very health-focused data, though Data USA also has some interesting health indicators in its own right.
Immediately, the data showed that 16.4% of residents were on Medicaid. Based on things I’d heard anecdotally, it seemed low.
I compared it to my own state’s data on % of the population covered by Medicaid. Sure enough, Data USA showed that 28.8% of New Mexico’s population was Medicaid in 2021 when I know that number to be closer to 40-50%. I’ve seen this happen in the past with Medicaid numbers when Medicaid managed care organizations (MCOs) don’t get included as “Medicaid” in hospital cost reporting (similar to Medicare FFS versus Medicare Advantage plans), or depending on the source of the data. The Data USA comes from Census Bureau ACS estimates so that is likely why.
Still, this data can be a good “proportional” or “directional” pointer, as I like to say.
Data USA also has some similar health indicators of interest. As expected, most of the data showed the county faring “better” than whatever it was being compared to, but the two graphs below did stand out to me.
Both diabetes and obesity appeared on the rise since 2018 in Kauai.
High cholesterol and heart failure also surfaced.
While the island can rightly take pride in having “better” health indicators in a lot of areas, these concerns with preventative screening and diabetes management gave me some areas to focus on.
I reviewed both Medicare chronic condition and provider data to learn that the prevalence of hyperlipidemia (high cholesterol) among Medicare beneficiaries in Kauai was higher than some of Kauai’s sister islands and the mainland/national average as a whole as of the most recent data published.
See below:
CMS provider data also showed that the #1 inpatient discharge at the island’s largest hospital (Wilcox Memorial) was due to HEART FAILURE AND SHOCK WITH MCC (44 per year). This beckoned a deeper exploration into population-specific analysis.
So I turned my attention to the Medicaid managed care plans covering Hawaiians.
This took me to the State of Hawai’i Department of Human Services’ site, which is the state’s Medicaid office (Med-QUEST). This source outlines how many Hawaiins were covered by the five (5) different managed care plans as of June 2022, and how many by island:
I found Census did indeed grossly underestimate the % of Kauains on Medicaid.
For funsies, I spot-checked the earlier “16.4%” Medicaid estimate from the Census Bureau that Data USA cited. Hawaii had a population of about 1.5 million in 2021, and according to Med-QUEST, there were about 450,000 Hawaiians covered by Medicaid managed care, representing approximately 30% of Hawaii’s population—quite higher than the 16.4% that the Census Bureau/Data USA estimated. And this doesn’t appear to include Medicaid direct/fee-for-service, though I’m unclear on that.
Kauai, by contrast, had a population of about 73,000 in 2021 and approximately 27,000 Kauains were covered by Medicaid managed care—closer to 37% of the island, compared to the Census Bureau’s/Data USA’s showing of 18.7% of Kauains on Medicaid in 2021.
Reviewing the MCOs’ HEDIS scores showed more areas of interest.
I popped over to NCQA to review all of the plans’ 2023 Health Plan Ratings results.
Not surprisingly by reputation alone, Kaiser leads the pack with a 4.5/5 overall NCQA/HEDIS rating.
Exploring each of these plans’ scores one by one revealed different pockets of opportunity or challenge, broken down by NCQA’s key domains: Treatment, Prevention and Equity, and Patient Experience. In previous years to 2023, these categories were more robust, including: Effectiveness of Care; Access/Availability of Care; Utilization; Risk Adjusted Utilization; and Measures Reported Electronically, which could have also led to some interesting findings.
HMSA covers about 50% of Medicaid managed care membership in the state, so I reviewed their data particularly closely. Access seems to be an issue across the board for all the plans, not altogether surprising considering the island’s limited and water-locked nature. Below are HMSA’s access scores:
HMSA’s Patient Experience-Getting Care 2023 scores
Aside from Patient Experience/Access, the areas with the most opportunity (or lowest scores) for this MCO were, in no particular order: prenatal checkups in the first trimester; postpartum care; chlamydia screening; asthma control; appropriate antibiotics for bronchitis; steroids after COPD hospitalizations; diabetic patients with controlled blood pressure; diabetic and cardiovascular disease patients receiving statin therapy (and statin adherence); controlling high blood pressure; and some other miscellaneous measures related to follow-ups after events, mental health/substance use-related measures and medication adherence for the same.
This tracked anecdotally with some of the challenges we identified earlier, such as the prevalence of diabetes and general trends in preventative care/screening, as well as health conditions that tend to impact indigenous populations in different ways and proportions, such as diabetes and obesity.
Interestingly, even the high-scoring Kaiser health plan indicated some opportunity for improvement in patient experience/access, further hinting at potential systemic or logistical challenges in healthcare delivery and management.
You can review the data for each health plan (and every other health plan in the nation) here.
Bringing it All Together 🌸
While none of this data is a “slam dunk” in itself because there is nuance and caveat to everything, having even some of this information now equips service providers, health tech vendors, and analysts to tailor their approaches.
Whether it be designing a new health improvement program for the region, pitching a service or solution, or just generally understanding the lay of the land, this information is more than enough to get a very high-level or 30,000-foot idea of what the region faces.
The evident gaps in preventative care, coupled with the prevalence of certain chronic conditions, hint towards potential areas where targeted interventions could make a significant impact. This data helped us understand:
Regional Risks: The geographical isolation and limited healthcare facilities pose a unique challenge in addressing emergent and specialized healthcare needs.
People-Centric Approach: Understanding the demographics, cultural nuances, and social determinants that influence healthcare accessibility and outcomes.
Preventative Care: Addressing the evident gap in preventative screenings and managing chronic conditions like diabetes and hyperlipidemia.
But don’t forget: every data point is a person.
Every person has a history. Every history combines into a collective culture.
While the information I’ve shared above gives us insight into data about a region, having just visited this enchanting island, it also glaringly highlights the absence of the human and cultural element that every region, community, or neighborhood has deeply rooted—which data could never describe. This was particularly noticeable since I had just visited and, frankly, become absolutely enchanted with the island’s people, culture, and vibe.
Arguably, understanding this qualitative element is infinitely more important than the data alone, and it is especially important when we talk about crafting “culturally relevant" care or programs. It is this human element that shapes the culture, attitudes, and beliefs that influence behaviors, decisions, and lives in a very real way. That means health outcomes and engaging with one’s own healthcare, but it means so much more, too.
Kauai, as an example, is a melting pot of cultures, traditions, and histories. Some absolutely relevant points of interest that I discovered during my visit that the data above doesn’t even begin to speak to are cultural nuances like:
Unique diet: Musubi is a popular snack and lunch food in Kauai. It's a testament to the blend of Japanese and American influences on the island. The combination of sushi rice, spam (introduced by American military personnel), and nori (seaweed) is a beloved treat found in convenience stores and lunch spots across the island. Poi, made from taro root, is a staple in Hawaiian cuisine and holds cultural and historical significance. Poke (cubes of marinated sushi-grade fish) is a staple.
Matriarchal Culture: Hawaiian culture traditionally places significant importance on the role of women, especially in spiritual and community leadership. This matriarchal influence is evident in the reverence for figures like Queen Liliʻuokalani, the last monarch of the Hawaiian Kingdom.
A blend of Asian Ethnicities: Kauai, like the rest of Hawaii, has a significant population of people of Asian descent, including Japanese, Filipino, Chinese, and Korean. This blend is evident in the island's festivals, foods, and traditions. For instance, the Bon Dance Festival, a Japanese Buddhist custom, is widely celebrated in Kauai, bringing together people of all backgrounds.
Aloha Spirit: Beyond just a greeting, the "Aloha Spirit" is a way of life in Kauai. It embodies love, peace, compassion, and a mutual understanding of respect between people and the land. This spirit is deeply ingrained in the island's culture and influences daily interactions, hospitality, and the general way of life.
Hula and Chants: Hula is not just a dance but a way of preserving and narrating the stories, traditions, and beliefs of the Hawaiian people. Along with hula, oli (chants) play a crucial role in passing down histories and tales of gods, goddesses, and heroes.
Ohana and Community: 'Ohana means family in Hawaiian, but it extends beyond just immediate family members. It encompasses friends, neighbors, and the community at large. This sense of community is evident in gatherings, celebrations, and the general support system among Kauai residents. Luaus, traditional Hawaiian parties or feasts, are occasions where the community comes together to celebrate, eat, sing, and dance.
Land and Sea Connection: Kauai residents have a profound connection to the land (‘āina) and sea (kai). This bond is reflected in their respect for nature, conservation efforts, and the sustainable use of resources. Fishing, for instance, isn't just a livelihood but a tradition passed down through generations, with specific customs and rituals.
Language and Pidgin: While English is widely spoken, the Hawaiian language still holds cultural significance, with many words and phrases used in daily conversation. Additionally, Pidgin, a Creole language in Hawaii, is a blend of English and several other languages, reflecting the islands' multicultural heritage.
Respect for Ancestors and Spirits: Many residents believe in the presence of ancestral spirits and supernatural beings, like the mischievous Menehune or the night marchers (ghostly apparitions). These beliefs influence customs, rituals, and even daily activities.
. . .
Actionable Idea of the Week:
This week, let’s ponder how we could use information like this to design healthcare solutions with a community-centric and culturally relevant approach. Some food for thought:
How can data guide us in crafting interventions that are not only medically sound but also culturally sensitive, logistically feasible, and socially supportive?
How can healthcare interventions be tailored to address unique needs, given a region’s unique culture and specific challenges?
Which specific healthcare outcomes can or should be targeted for significant and sustainable improvement?
How could interventions be designed to ensure tangible and impactful Return on Investment, whether it be social impact, financial, health-related, or otherwise?
What would be the structure, scale, and scope of a pilot program to test the proposed interventions look like? How could it be designed to be more culturally specific and thus (hopefully) more widely and successfully adopted?
If you want to replicate an analysis like this for another area, check out my previous Guide—How to Do a Community Health Needs Assessment in Minutes—for some starter data sources.
. . .
Until next week, stay curious my Gurus!
Mahalo,
-Stefany
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