Rural-Urban Disparity in Mortality in the US From 1999 to 2019

Cross, Sarah H.; Califf, Robert M.; Warraich, Haider J.

doi:10.1001/jama.2021.5334

Cited by 78 publications

(68 citation statements)

References 8 publications

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“…Inequalities in mortality exist between people of different sexes, races, and ethnicities, and more recent work has highlighted widening gaps between urban and rural areas. 1 One less well studied factor is political environment, which is associated with policies, laws, and regulations that influence health, including safety net programmes (eg, Medicaid), tobacco control, gun laws, and environmental protections as well as national and state financial and budgetary decisions, especially for public health related programmes. In addition, political environment is also associated with communicable disease related health behaviors, such as social distancing and vaccine acceptance, as well as traditional health behaviors (healthy diet, exercise).…”

Section: Introductionmentioning

confidence: 99%

Political environment and mortality rates in the United States, 2001-19: population based cross sectional analysis

Warraich

Kumar

Nasir

et al. 2022

BMJ

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Objective To assess recent trends in age adjusted mortality rates (AAMRs) in the United States based on county level presidential voting patterns. Design Cross sectional study. Setting USA, 2001-19. Participants 99.8% of the US population. Main outcome measures AAMR per 100 000 population and average annual percentage change (APC). Methods The Centers for Disease Control and Prevention WONDER database was linked to county level data on US presidential elections. County political environment was classified as either Democratic or Republican for the four years that followed a November presidential election. Additional sensitivity analyses analyzed AAMR trends for counties that voted only for one party throughout the study, and county level gubernatorial election results and state level AAMR trends. Joinpoint analysis was used to assess for an inflection point in APC trends. Results The study period covered five presidential elections from 2000 to 2019. From 2001 to 2019, the AAMR per 100 000 population decreased by 22% in Democratic counties, from 850.3 to 664.0 (average APC −1.4%, 95% confidence interval −1.5% to −1.2%), but by only 11% in Republican counties, from 867.0 to 771.1 (average APC −0.7%, −0.9% to −0.5%). The gap in AAMR between Democratic and Republican counties therefore widened from 16.7 (95% confidence interval 16.6 to 16.8) to 107.1 (106.5 to 107.7). Statistically significant inflection points in APC occurred for Democratic counties between periods 2001-09 (APC −2.1%, −2.3% to −1.9%) and 2009-19 (APC −0.8%, −1.0% to −0.6%). For Republican counties between 2001 and 2008 the APC was −1.4% (−1.8% to −1.0%), slowing to near zero between 2008 and 2019 (APC −0.2%, −0.4% to 0.0%). Male and female residents of Democratic counties experienced both lower AAMR and twice the relative decrease in AAMR than did those in Republican counties. Black Americans experienced largely similar improvement in AAMR in both Democratic and Republican counties. However, the AAMR gap between white residents in Democratic versus Republican counties increased fourfold, from 24.7 (95% confidence interval 24.6 to 24.8) to 101.3 (101.0 to 101.6). Rural Republican counties experienced the highest AAMR and the least improvement. All trends were similar when comparing counties that did not switch political environment throughout the period and when gubernatorial election results were used. The greatest contributors to the widening AAMR gap between Republican and Democratic counties were heart disease (difference in AAMRs 27.6), cancer (17.3), and chronic lower respiratory tract diseases (8.3), followed by unintentional injuries (3.3) and suicide (3.0). Conclusion The mortality gap in Republican voting counties compared with Democratic voting counties has grown over time, especially for white populations, and that gap began to widen after 2008.

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Section: Introductionmentioning

confidence: 99%

Political environment and mortality rates in the United States, 2001-19: population based cross sectional analysis

Warraich

Kumar

Nasir

et al. 2022

BMJ

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“…It is not uncommon for residents to not seek out necessary healthcare in their rural communities due to financial barriers, distrust that physicians had been adequately trained, or a lack of transportation 10. There are higher rates of mortality in rural areas, and the disparity between rural and urban age-adjusted mortality rates tripled between 1999 and 2019 11. A partial solution to address the disparity in healthcare in rural communities is the implementation of telehealth.…”

Section: Discussionmentioning

confidence: 99%

Perspectives on recovery from older adult trauma survivors living in rural areas

Duchin

Neisinger

Reed

et al. 2022

Trauma Surg Acute Care Open

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BackgroundOlder patients living in rural areas face unique challenges after trauma that may hinder optimal recovery. This study aims to qualitatively assess postdischarge challenges in this vulnerable population.MethodsWe conducted remote interviews with older trauma survivors in Washington State previously hospitalized in 2019 and residing in rural areas as determined by rural–urban commuting area code. Participants were identified through our institution’s trauma registry and linked with postdischarge data. All eligible participants were contacted. Interview questions focused on needs relating to discharge transition, medical needs, housing, and daily living. Transcribed interviews underwent content analysis to derive a code hierarchy and themes.ResultsWe conducted 18 interviews out of 83 survivors queried. Compared with non-participants, interviewees had a higher rate of secondary insurance (61% vs 34%), and fewer had an emergency department visit within 1 year (22% vs 34%). Content analysis yielded four major themes: discharge transitions, loss of control, rural insights, and self-efficacy. Most patients felt prepared for discharge and had social support. Regardless of disposition type, most patients needed therapy sessions after discharge. Geography and transportation issues were among the biggest barriers. Most participants were never offered a telemedicine appointment but would have used it if offered. Subthemes of self-efficacy included financial security, leisure, personal outlook, physical and logistical resources, and participants’ support systems.DiscussionOlder trauma patients from rural areas face unique challenges after discharge. Key strategies to improve patient experience might include more telemedicine appointments and increased awareness of resources in rural communities.Level of evidenceIII.

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“…Since then, mortality rates in rural America have exceeded urban rates, and the gap has accelerated since 1999, even when adjusted for age. 38,34,35 This mortality disparity has been referred to as "the nonmetropolitan penalty," 39, and some experts believe that structural urbanism is widening the gap. 40 Similar findings are noted among nonmetropolitan counties for common causes of death, including heart disease, cancer, chronic lower respiratory disease, unintentional injury, and stroke.…”

Section: Discussionmentioning

confidence: 99%

Higher hospitalization and mortality rates among SARS-CoV-2 infected Persons in Rural America

Anzalone

Horswell

Hendricks

et al. 2021

Preprint

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IMPORTANCE: Rural communities are among the most underserved and resource-scarce populations in the United States (US), yet there are limited data on COVID-19 mortality in rural America. Furthermore, rural data are rarely centralized, precluding comparability across urban and rural regions. OBJECTIVE: The purpose of this study is to assess hospitalization rates and all-cause inpatient mortality among persons with definitive COVID-19 diagnoses residing in rural and urban areas. DESIGN, SETTINGS, AND PARTICIPANTS: This retrospective cohort study from the National COVID Cohort Collaborative (N3C) examines a cohort of 573,018 patients from 27 US hospital systems presenting with SARS-CoV-2 infection between January 2020 and March 2021, of whom 117,897 were hospitalized. A sample of 450,725 hospitalized persons without COVID-19 diagnoses was identified for comparison. EXPOSURES: ZIP Codes provided by source hospital systems were classified by urban-rural gradient through a crosswalk to the US Department of Agriculture Rural-Urban Commuting Area Codes. MAIN OUTCOMES AND MEASURES: Primary outcomes were hospitalization and all-cause mortality among hospitalized patients. Kaplan-Meier analysis and mixed effects logistic regression were used to estimate 30-day survival in hospitalized patients and associations between rurality, hospitalization, and inpatient mortality while controlling for major risk factors. RESULTS: Rural patients were more likely to be older, white, have higher body mass index, and diagnosed with SARS-CoV-2 later in the pandemic compared with their urban counterparts. Rural compared with urban inhabitants had higher rates of hospitalization (23% vs. 19%) and all-cause mortality among hospitalized patients (16% vs. 11%). After adjustment for demographic and baseline differences, rural residents (both urban adjacent and non-adjacent) with COVID-19 were more likely to be hospitalized (Adjusted Odds Ratio (AOR) 1.41, 95% Confidence Interval (CI), 1.37-1.45 and AOR 1.42, CI 1.35-1.50) and to die or be transferred to hospice (AOR 1.62, CI 1.30-1.49 and 1.38, CI 1.30-1.49), respectively. Similar differences in mortality were noted for hospitalized patients without SARS-CoV-2 infection. CONCLUSIONS: Hospitalization and inpatient mortality are higher among rural compared with urban persons with COVID-19, even after adjusting for several factors, including age and comorbidities. Further research is needed to understand the factors that drive health disparities in rural populations.

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Rural-Urban Disparity in Mortality in the US From 1999 to 2019

Cited by 78 publications

References 8 publications

Political environment and mortality rates in the United States, 2001-19: population based cross sectional analysis

Political environment and mortality rates in the United States, 2001-19: population based cross sectional analysis

Perspectives on recovery from older adult trauma survivors living in rural areas

Higher hospitalization and mortality rates among SARS-CoV-2 infected Persons in Rural America

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