BackgroundIn the U.S., inequality is widespread and still growing at nearly every level conceivable. This is vividly illustrated in the long-standing, well-documented inequalities in outcomes between rural and urban places in the U.S.; namely, the rural mortality penalty of disproportionately higher mortality rates in these areas. But what does the concept of “rural” capture and conjure? How we explain these geographic differences has spanned modes of place measurement and definitions. We employ three county-level rural-urban definitions to (1) analyze how spatially specific and robust rural disparities in mortality are and (2) identify whether mortality outcomes are dependent on different definitions.MethodsWe compare place-based all-cause mortality rates using three typologies of “rural” from the literature to assess robustness of mortality rates across these rural and urban distinctions. Results show longitudinal all-cause mortality rate trends from 1968 to 2020 for various categories of urban and rural areas. We then apply this data to rural and urban geography to analyze the similarity in the distribution of spatial clusters and outliers in mortality using spatial autocorrelation methodologies.ResultsThe rural disadvantage in mortality is remarkably consistent regardless of which rural-urban classification scheme is utilized, suggesting the overall pattern of rural disadvantage is robust to any definition. Further, the spatial association between rurality and high rates of mortality is statistically significant.ConclusionDifferent definitions yielding strongly similar results suggests robustness of rurality and consequential insights for actionable policy development and implementation.
Background: The Mississippi Delta has one of the highest rates of diabetes in the nation, but patients in these rural, minority-majority counties have lower access to specialty care. At the start of a hybrid diabetes management program at two rural health clinics in the Delta, 53.1% of patients with diabetes had uncontrolled HbA1c levels. We analyze the specific effect of integrating endocrinology specialists into this intervention. Patients could access this care via telemedicine or in-person. Methods: We conducted a quasi-experimental study with clinical data from electronic health records for patients diagnosed with diabetes or prediabetes (aged ≥ 18). We followed two cohorts of the same patients over time for the first 18 months of the program, each matched on elevated HbA1c levels (≥8% at baseline). The treatment group comprised program participants; the control group comprised general clinic patients at-risk of diabetes. We also followed patients in the treatment group who received endocrine services in addition to other program benefits. Results: Among the control group, HbA1c increased an average of 0.04 points; the treatment group saw an average decrease of 0.42 points. The treatment group's endocrinology subset saw an even greater decrease of 0.85 points. The average HbA1c score for this group went down three points in a two-year period (7/20-7/22). Conclusions: The study results indicate that receiving coordinated endocrinology services has been especially effective in reducing HbA1c levels among program participants. As care continuity is associated with better glycemic control for diabetic patients, sustained program participation will likely help the patient population best manage their diabetes and avoid further adverse health outcomes. Additionally, as this diabetes program takes place in a rural, low-income minority area with low access to specialty care, the results demonstrate promising practices for strengthening the rural health care system. Disclosure C.Brindley: None. W.James: None. J.R.Bennett: None. K.F.Matthews: None. Funding Health Resources and Services Administration, Federal Office of Rural Health Policy (HRSA-20-025, D06RH37500)
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