Conflict of InterestDisclosures: Dr Pompeii reported receiving grants from the Centers for Disease Control and Prevention during the conduct of the study. Dr Kraft reported receiving grants from the National Institute for Occupational Safety and Health during the conduct of the study and serving on a scientific advisory board for Rebiotix outside the submitted work. Dr Lane reported receiving grants from the Centers for Disease Control and Prevention during the conduct of the study. Dr Benavides reported receiving grants from the Centers for Disease Control and Prevention during the conduct of the study. No other disclosures were reported.
The economic, social, and political challenges facing rural areas in the US have implications for the entire country. Even though rural-urban disparities in mortality from such diseases as chronic lung disease and cardiovascular disease have been described, 1,2 less is known about recent trends in ruralurban differences in age-adjusted mortality rates (AAMRs) overall in the US. Methods |We analyzed all deaths occurring in the US using the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2019. We used the National Center for Health Statistics Urban-Rural Classification Scheme to create the following population categories per the 2013 US Census classification: large metropolitan area (≥1 million), small-or medium-sized metropolitan area (50 000-999 999), and rural area (<50 000). 3 The AAMRs per 100 000 population were calculated by multiplying the age-specific death rate for each age group by the corresponding weight from the 2000 standard US population, summing across all age groups, and then multiplying by 100 000. We stratified the results by age, sex, and race/ ethnicity. We also analyzed these subgroups among individuals aged 25 to 64 years.We estimated the annual percentage change (APC) in AAMR using Poisson regression with log-link and robust standard errors and included an interaction term to test for differences in time trends. We performed all analyses using Stata version 16 (StataCorp), considering a 2-tailed P < .05 as statistically significant. The data were publicly available and deidentified and therefore informed consent was not applicable per HHS regulation 45 CFR 46.101(c).Results | From 1999 to 2019, rural areas had the highest AAMRs. The overall AAMR in large metropolitan areas decreased from 861.5/100 000 to 664.5/100 000 and in rural areas it decreased from 923.8/100 000 to 834.0/100 000 (P < .001 for time trend) (Figure and Table). The absolute difference in the AAMRs between large metropolitan areas and rural areas increased from 62.3/100 000 (95% CI, 59.2/100 000-65.4/ 100 000) in 1999 to 169.5/100 000 (95% CI, 167.0/100 000-172.1/100 000) in 2019, which was an increase of 172%.From 1999 to 2019, the AAMRs declined for all ages except for rural residents aged 25 to 64 years, in whom the AAMR increased from 398.7/100 000 to 447.0/100 000 (APC, 0.6%; 95% CI, 0.4%-0.7%). Across areas, men had greater AAMRs than women (P < .001); however, men experienced a greater APC reduction in the AAMRs. Among men, the AAMR in large metropolitan areas decreased from 1044.6/100
OBJECTIVES To assess trends and factors associated with place of death among individuals with Alzheimer's disease‐related dementias (ADRD). DESIGN Cross‐sectional analysis. SETTING Centers for Disease Control and Prevention Wide‐ranging OnLine Data for Epidemiologic Research, 2003‐2017. PARTICIPANTS Natural deaths occurring between 2003 and 2017 for which ADRD was determined to be the underlying cause. MEASUREMENTS Place of death was categorized as hospital, home, nursing facility, hospice facility, and other. Aggregate data included age, race, Hispanic ethnicity, sex, urbanization, and census division. Individual‐level predictors included age, race, Hispanic ethnicity, sex, marital status, and education. RESULTS From 2003 to 2017, nursing facility and hospital deaths declined from 65.7% and 12.7% to 55.0% and 8.0% while home and hospice facility deaths increased from 13.6% and .2% to 21.9% and 6.2%, respectively. Odds of hospital and hospice facility deaths declined with age while odds of nursing facility deaths increased with age. Male sex was associated with higher odds of hospital or hospice facility death and lower odds of home or nursing facility death. Nonwhite race, Hispanic ethnicity, and being married were associated with increased odds of hospital or home death and reduced odds of nursing facility death. More education was associated with higher odds of home or in a hospice facility death and reduced odds of death in a nursing facility or hospital. Significant disparities in place of death by urban‐rural status were also noted. CONCLUSION As ADRD deaths at home increase, the need for caregiver support and home‐based palliative care may become more critical. Further research should examine the care preferences and experiences of ADRD patients and caregivers, the financial impact of home death on families and insurers, and explore factors that may contribute to differences in actual and preferred place of death. J Am Geriatr Soc 68:250–255, 2020
Education for patients, caregivers, and community members about the roles and benefits of PC will be needed to successfully expand community-based PC.
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