Disparities in diabetes-related mortality widen between urban and rural areas in US
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Diabetes-related mortality declined in the U.S. from 1999 to 2019 in urban counties, but not in rural counties, according to study findings published in Diabetologia.
“There has been a reduction in diabetes-related mortality, but this seems to have occurred mainly in individuals living in urban areas,” Mamas A. Mamas, DPhil, BMBCh, professor of cardiology at Keele University, U.K., told Healio. “In contrast, diabetes-related mortality has remained fairly constant in rural areas. This has meant that over the past 20 years, the urban-rural gap in mortality has increased threefold. This work highlights disparities in health care outcomes between urban and rural communities and highlights missed opportunities for reducing disparities in outcomes.”
Mamas and colleagues collected data from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) Multiple Cause of Death database. Deaths in which diabetes was the underlying cause of death or a contributing cause of death from 1999 to 2019 were included. The study population was divided into urban and rural groups based on 2013 U.S. Census classifications. Mortality rates were age-adjusted.
There were 1,572,536 deaths with diabetes as the underlying cause and 5,025,745 deaths with diabetes as a contributing cause included in the study. About 79% of deaths occurred among people living in urban counties.
Urban areas had a 16.7% decrease in age-adjusted mortality rate for diabetes as an underlying cause of death and a 13.5% decrease in mortality rate for diabetes as contributing cause of death from 1999 to 2019 (P < .001 for both). There was no change in mortality rate in which diabetes was the underlying or contributing cause of death in rural areas. The difference in mortality rate between urban and rural areas for diabetes as an underlying cause of death increased from two deaths per 100,000 population in 1999 to 6.8 deaths per 100,000 population in 2019, and from 6.8 deaths per 100,000 population in 1999 to 24.3 deaths per 100,000 population in 2019 for diabetes as a contributing cause.
“This work highlights how underinvestment in health care in rural areas, closure of services and socioeconomic deprivation may contribute to such disparities,” Mamas said. “It highlights the need for health care investment into rural communities as well as utilization of digital solutions to reach communities in rural areas that may not be well served by physical services.”
Diabetes mortality rates were higher for men than women in both rural and urban areas, and women had a more significant decrease in mortality rate during the study period than men. Among people younger than 55 years, mortality rates increased 59% for diabetes as an underlying cause of death and 65.2% for diabetes as a contributing cause of death in rural areas. In urban areas, diabetes mortality as an underlying cause of death increased 14.7% and as a contributing cause of death increased 13.8% (P < .001 for all). Adults aged 55 years and older had a decrease in mortality rate for diabetes as an underlying cause of death of 20.6% and in mortality rate for diabetes as a contributing cause of death of 15.6% (P < .001). No change was observed in rural areas for older adults.
American Indian and Black adults had higher diabetes-related mortality rates than Asian and white adults. American Indian adults had decreases in diabetes mortality rates in urban and rural areas, but decreases in diabetes mortality for Black adults were observed only in urban areas.
“We need to understand how differences in health care provision, risk factor management and access to physicians and health care services may contribute to these findings,” Mamas said. “A broader study around socioeconomic disparities and how structural racism may contribute to these. We need to change our focus from treating diabetes to preventing it through policy and investment in rural services.”
For more information:
Mamas A. Mamas, DPhil, BMBCh, can be reached at m.mamas@keele.ac.uk.
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