Over roughly the last two decades, disparities in mortality have widened greatly between rural and urban America. Most alarmingly, the mortality rate has worsened for rural residents at an age when people are generally in the prime of life.
Those are the findings of an article published last week in the Journal of the American Medical Association that examined age-adjusted mortality between rural and urban areas using data from the Centers for Disease Control and Prevention.
In areas with a population of more than 1 million, the annual mortality rate per 100,000 fell from 861 to 664 between 1999 and 2019. In areas with a population of less than 50,000, it also declined, from 923 to 834. However, the mortality gap between rural and urban America was much wider in 2019 than in 1999.
“The difference in death rates tripled over the last two decades,” said Dr. Haider Warraich, a physician and researcher at the VA Boston Healthcare System and Brigham and Women’s Hospital and a co-author of the article. “One would not expect that. As our medical advances get better and as we have more innovation, we would expect that the gap between the haves and have nots would go down. But for [age-adjusted mortality], the gap has widened considerably.”
What accounts for the bulk of the widening gap is increasing mortality among rural residents ages 25-64. Mortality increased among this group, from 398 per 100,000 in 1999 to 447 in 2019.
There are multiple factors at play in this disparity in mortality between rural and urban areas and the rising mortality among rural residents 25-64. One that many experts point to is the opioid crisis in rural America.
According to the CDC, deaths from both natural and synthetic opioids grew in rural areas from 1999 to 2019, with deaths from synthetic opioids rising precipitously after 2015. But from 2015 to 2019, the death rate from synthetic opioids in urban areas surpassed the rate in rural areas, suggesting that the opioid crisis at best only partially explains the gap.
“Some of the attention to deaths [from opioids] has overshadowed the need to address the disparities in chronic disease as well,” said Sarah Cross, another co-author of the article who will be starting a postdoctoral fellowship at the Emory School of Medicine this summer.
Warraich and Cross were also coauthors of another JAMA article that examined age-adjusted cardiovascular mortality from 1999 to 2017. During that time, cardiovascular mortality fell 40% in urban areas but only 32% in rural areas. Perhaps the most interesting finding was among those ages 25-64. Cardiovascular mortality fell among that age group 28% in urban areas, but only 7% in rural areas. Indeed, in 2017, there were about 105 deaths among those ages 25-64 in rural areas compared to 69 in urban ones.
Mark Holmes, the director of the Cecil B. Sheps Center for Health Services Research at the University of North Carolina, offered one explanation for the disparity in heart disease.
“The tremendous gains we’ve made in reducing smoking rates have been disproportionately in urban areas, whereas it’s been flat in rural areas,” Holmes said.
Data from the CDC show that the rate of smoking is about 12% higher in rural areas. Rural areas also have higher rates of smoking-related illnesses, such as lung cancer and chronic obstructive pulmonary disease.
The poorer health outcomes are likely related to the rates at which rural areas have access to healthcare.
“We see less access to primary care and less access to mental or behavioral or mental healthcare,” said Michael Topchik, the national leader for the Chartis Center for Rural Health. “This is true in rural versus urban generally.”
Indeed, an article in the American Journal of Preventative Medicine found that 81% of people in urban areas had a regular source of healthcare versus 74% in rural areas. Providers in rural areas were also less likely to offer evening or weekend hours. According to research from the journal Psychiatric Services, rural counties also have some of the highest unmet needs for mental healthcare.
Warraich warned that the urban-rural gap shows that rural healthcare is in crisis.
“It is a multitude of factors that have coalesced into what we’re seeing now that I consider a full-blown public health crisis,” he said.
Holmes offered a warning that was a bit less dire.
“I hope we don’t jump to the conclusion that all of rural America is really suffering and stagnating. We are talking about a broad cross section of America, and there certainly are rural communities that are thriving,” Holmes said. “But this speaks to the overall state of rural health, and a lot of those areas need some help.”
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Original Author: David Hogberg
Original Location: Rural-urban mortality gap points toward a healthcare crisis