20-Year Data Highlight Little Progress in Rural Racial Health Disparities

Between 1999 and 2018, Black adults living in rural regions of the United States experienced high mortality rates due to diabetes, high blood pressure, heart disease, and stroke compared with White adults, according to new research published in the Journal of the American College of Cardiology.

Deidentified data, gleaned from the CDC Wonder Database, also showed that although racial disparities improved minimally in rural areas during this time frame, larger improvements were seen in urban areas, highlighting the need for targeted public health initiatives in certain geographical regions.

It has been previously shown that cardiovascular mortality rates in rural regions tend to be higher than in urban areas, with heart failure documented as a contributing factor in this trend.

And, despite numerous public health and policy initiatives aimed at reducing racial health disparities, “it is unclear whether these efforts have benefited Black persons living in rural and urban areas equally,” researchers wrote.

In the current study, investigators determined cause of death using International Classification of Disease-10th Revision codes, while racial information was obtained from death certificates. In addition, researchers compared annual age-adjusted mortality rates per 100,000 individuals for Black and White adults stratified by rural or urban area. All individuals included were aged 25 or older and disparities estimates were age-adjusted to the 2000 US census.

Throughout the 20-year study period, data showed annual age-adjusted mortality rates in rural areas were substantially higher for Black adults compared with White adults for the following conditions:

• Diabetes (average mortality rate 1999 to 2018 [SE], 76.2 [0.42] vs. 37.2 [0.07] deaths per 100,000; P < .001)
• Hypertension (31.3 [0.27] vs. 10.9 [0.04]; P < .001)
• Heart disease (425.0 [0.99] vs. 331.7 [0.22]; P < .001)
• Stroke (112.6 [0.51] vs. 73.9 [0.10]; P < .001)

In urban areas, higher average age-adjusted mortality rates were seen among Black adults compared with White adults, for diabetes (63.0 [0.14] vs. 30.7 [0.03]; P < .001), hypertension (25.3 [0.09] vs. 10.9 [0.02]; P < .001), heart disease (371.0 [0.34] vs. 291.8 [0.10]; P < .001), and stroke (89.4 [0.17] vs. 63.6 [0.05]; P < .001).

However, “the gap in annual age-adjusted mortality rates between Black and White adults narrowed more rapidly in urban compared with rural areas for diabetes,” during the study period (change in the Black vs. White difference, 0.94 [0.07] vs. 0.24 [0.10] deaths per 100,000 per year; P < .001 for interaction between rural area and time). This trend was also seen among hypertension diagnoses (0.30 [0.04] vs. 0.09 [0.07]; P = .03), a risk factor for diabetes.

“The racial gap in heart disease mortality declined at a similar rate in urban and rural areas (3.21 [0.26] vs. 3.65 [0.34]; P = .46), but it declined more rapidly for stroke in rural areas (0.80 [0.10] vs. 1.35 [0.13]; P = .02),” authors wrote.

Results indicate diabetes- and hypertension-related mortality are 2 to 3 times higher among Black adults compared with White adults in rural regions of America.

“While modest gains have been made in reducing racial health inequities in urban areas, large gaps in death rates between Black and white adults persist in rural areas, particularly for diabetes and hypertension. We haven't meaningfully narrowed the racial gap in outcomes for these conditions in rural areas over the last two decades," said study author Rishi Wadhera, MP, MPP, MPhil.

Previously, worse health outcomes in rural America have been attributed to higher rates of chronic disease, poverty, and fragmented health care, but these factors may disproportionately affect rural Black adults, authors explain. The stark racial disparities exhibited in rural areas relative to urban areas could reflect structural inequities that hinder access to primary, preventive, and specialist care for this cohort of patients.

However, the narrowed racial disparities in conditions like heart disease and stroke morality in rural areas could be due to improvements in emergency services, expansion of referral networks, development of stroke and myocardial infarction care centers, and implementation of time-to-procedure metrics.

“Given that diabetes, hypertension, and heart disease are preventable and treatable, targeted public health and policy efforts are needed to address structural inequities that contribute to racial disparities in rural health,” Wadhera said.

Reference

Aggarwal R, Chiu N, Loccoh EC, Kazi DS, Yeh RW, and Wadhera RK. Rural-urban disparities: diabetes, hypertension, heart disease, and stroke mortality among black and white adults, 1999-2018. J Am Coll Cardiol. Published online March 15, 2021. doi:10.1016/j.jacc.2021.01.032