Abstract
Adults in rural counties in the United States (US) experience higher rates broadly of cardiovascular disease (CVD) compared with adults in urban counties. Mortality rates specifically due to heart failure (HF) have increased since 2011, but estimates of heterogeneity at the county-level in HF-related mortality have not been produced. The objectives of this study were 1) to quantify nationwide trends by rural-urban designation and 2) examine county-level factors associated with rural-urban differences in HF-related mortality rates. We queried CDC WONDER to identify HF deaths between 2011-2018 defined as CVD (I00-78) as the underlying cause of death and HF (I50) as a contributing cause of death. First, we calculated national age-adjusted mortality rates (AAMR) and examined trends stratified by rural-urban status (defined using 2013 NCHS Urban-Rural Classification Scheme), age (35-64 and 65-84 years), and race-sex subgroups per year. Second, we combined all deaths from 2011-2018 and estimated incidence rate ratios (IRR) in HF-related mortality for rural versus urban counties using multivariable negative binomial regression models with adjustment for demographic and socioeconomic characteristics, risk factor prevalence, and physician density. Between 2011-2018, 162,314 and 580,305 HF-related deaths occurred in rural and urban counties, respectively. AAMRs were consistently higher for residents in rural compared with urban counties (73.2 [95% CI: 72.2-74.2] vs. 57.2 [56.8-57.6] in 2018, respectively). The highest AAMR was observed in rural Black men (131.1 [123.3-138.9] in 2018) with greatest increases in HF-related mortality in those 35-64 years (+6.1%/year). The rural-urban IRR persisted among both younger (1.10 [1.04-1.16]) and older adults (1.04 [1.02-1.07]) after adjustment for county-level factors. Main limitations included lack of individual-level data and county dropout due to low event rates (<20). Differences in county-level factors may account for a significant amount of the observed variation in HF-related mortality between rural and urban counties. Efforts to reduce the rural-urban disparity in HF-related mortality rates will likely require diverse public health and clinical interventions targeting the underlying causes of this disparity.
Highlights
The excess burden of cardiovascular mortality experienced by rural communities in the United States (US) has recently come to the forefront of national conversations on health disparities, highlighted by the recent American Heart Association Call to Action on Rural Health [1]
age-adjusted mortality rates (AAMR) were consistently higher for residents in rural compared with urban counties (73.2 [95% CI: 72.2–74.2] vs. 57.2 [56.8–57.6] in 2018, respectively)
Efforts to reduce the ruralurban disparity in heart failure (HF)-related mortality rates will likely require diverse public health and clinical interventions targeting the underlying causes of this disparity
Summary
The excess burden of cardiovascular mortality experienced by rural communities in the United States (US) has recently come to the forefront of national conversations on health disparities, highlighted by the recent American Heart Association Call to Action on Rural Health [1]. Rural-urban disparities have continued to widen in recent years, and rural communities have over a 20% higher all-cause mortality rate than their urban counterparts [1]. Several recent studies have demonstrated significant heterogeneity in how age and race-sex subgroups have been affected by these shifting HF-related mortality rates [13, 14]. Identifying county-level factors that are associated with differences in rural and urban HF-related mortality rates may help to identify potential targets for policy interventions. Adults in rural counties in the United States (US) experience higher rates broadly of cardiovascular disease (CVD) compared with adults in urban counties. The objectives of this study were 1) to quantify nationwide trends by rural-urban designation and 2) examine countylevel factors associated with rural-urban differences in HF-related mortality rates
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