Rural-Urban Gap Widens for Cardiometabolic Health Disparities

There is a widening gap between urban and rural areas of the United States when it comes to the number of deaths attributable to heart disease and diabetes, with the widest rural-urban disparities evident in the southern states, according to a new analysis.

For every 100,000 people, there were 1.06 rural deaths from heart disease for each urban death in 1999, but the age-adjusted mortality rate ratio widened by 2017, such that there were 1.21 deaths from heart disease in rural areas for every death in a metropolitan region (P < 0.01). Similarly, for every single death from diabetes in an urban area in 1999, there were 1.09 deaths from diabetes in rural areas per 100,000 people. By 2017, there were 1.30 deaths from diabetes in rural areas for every lone death from diabetes in urban centers (P < 0.01).

“To me, the interesting and concerning finding is not just that the [rural-urban divide] exists, but that it may be worsening,” senior investigator Sadiya Khan, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), told TCTMD. Historically, living in big cities posed the biggest health risk, given the density, poor water quality, and inadequate sewage. But that trend has long since reversed as cardiovascular disease replaced infectious disease as the leading cause of death, she said.

Lead investigator Nilay Shah, MD, MPH (Northwestern University Feinberg School of Medicine), said disparities between rural and urban areas with respect to all-cause mortality have been documented previously, with rural areas tending to have worse health outcomes and higher rates of earlier mortality compared with urban centers. Rates of diabetes, obesity, hypertension are higher in rural areas, while other socioeconomic measures, such as access to care, tend to be worse in rural areas across all regions, he said.

The last few months spent in lockdown with COVID-19 have seen a rise in the use of telemedicine, and its continued use after the pandemic could be a tool to address the gaps between rural and urban centers.

“Telemedicine, as a strategy, can help address these urban-rural differences, especially in rural areas where access to physicians may be more difficult,” said Shah. “We’ve learned quite a bit about how to deploy telemedicine in our practice, and we’re learning there’s quite a bit of infrastructure necessary for it to be effective and successful: access to a computer and reliable internet, for example. But I think telemedicine may represent an innovative strategy that deserves some focus when we’re talking about differences in rural versus urban health.”     

CDC WONDER Database

Researchers wanted to determine if urban-rural differences existed in the rate of deaths from heart disease and diabetes and look at how those trends were changing over time. Some of their prior work, said Shah, has shown that heart disease mortality rates have declined since 2010, which led them to question whether those changing mortality patterns were evident in different settings.   

Using data from the Centers for Disease Control and Prevention’s WONDER database, they calculated the burden of deaths from diabetes, heart disease, and cerebrovascular disease in rural and urban areas in the Northeast, Midwest, Southern, and Western regions of the United States. Despite the widening rural-urban divide in deaths attributable to diabetes and heart disease, the same temporal trend wasn’t observed with cerebrovascular disease. There were more deaths per 100,000 individuals from cerebrovascular disease in rural areas, but the rural-urban age-adjusted mortality ratio was stable between 1999 and 2017. 

In 2017 alone, the largest disparity in deaths across rural and urban lines was observed in the South, a region that includes Mississippi, Alabama, Georgia, Louisiana, and Texas, among other states. For example, there were 1.32 and 1.40 rural deaths from heart disease and diabetes, respectively, for every urban death from the same causes.

Black men living in rural areas had the highest rate of death attributable to heart disease and cerebrovascular disease. Overall, cause-specific age-adjusted mortality rates were higher in men than in women. Over time, however, the age-adjusted mortality rate ratio for rural-urban deaths attributable for heart disease and diabetes increased in all individuals regardless of ethnicity or sex.

“It is a continuum,” said Khan. “There are probably smaller rural areas that are more affluent, and probably larger urban areas that aren’t as affluent, so it’s likely an oversimplification to just call places rural or urban. That’s why we wanted to look at both white and Black men and women within the community, to be able to be as granular as we could with these disparities that affect ethnic groups differently.”

Addressing the Problem

The reason for the higher rate of deaths from cardiometabolic causes in rural areas is multifactorial, say investigators, but a higher burden of risk factors, socioeconomic factors, and access to care may partially explain the disparity.

“Because there is not only a difference between rural and urban areas, but a widening gap, I think strengthening local systems of care is an important strategy to address these differences in mortality,” said Shah. “That includes access to clinicians and provider networks, and especially in regions that are most affected, potentially considering Medicaid expansion, which a lot of states in these regions have not yet adopted.”

Khan also stressed the importance of thinking “upstream,” emphasizing the importance of social determinants of health, such as social and community context, economic stability, education, neighborhood/environment, and access to healthcare. Even within the city of Chicago, for example, there are massive differences in life expectancy across different neighborhoods, some just a few miles apart.

Like Shah, Khan said healthcare access is critical, noting that studies have shown there are hundreds of US counties without a single primary-care physician. Hospital closures in rural areas also have a detrimental effect on a community’s health and there is a need for sustainable funding models to allow hospitals, clinics, and physicians to stay in these nonurban centers so they can provide affordable care.

“Telemedicine is a really appealing way to provide access to care and expand specialist care, especially in terms of cardiovascular and metabolic health management,” she said. “Insurance is another really important factor, such as being able to equitably provide Medicaid access to low-income individuals. The idea is that both rural and urban areas within a state need access to healthcare if they have not yet expanded Medicaid, but there may be greater income or socioeconomic burdens in rural areas.”