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Disclosures: Cross reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
May 12, 2020
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Prevalence of CVD death higher in rural vs. metropolitan areas

Source/Disclosures
Disclosures: Cross reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Haider J. Warraich

Between 1999 and 2017, rural areas experienced a greater prevalence of age-adjusted CV mortality compared with metropolitan areas, regardless of subgroup, researchers reported.

Decline in CV mortality persisted over time, but at a slower rate within rural communities.

According to a research letter published in JAMA, investigators analyzed the CDC WONDER database to assess age-adjusted differences in CV mortality between large metropolitan ( 1 million residents), medium and small metropolitan (50,000-999,999 residents) and rural (< 50,000 residents) counties.

Researchers observed that although large metropolitan areas had the greatest overall number of CVD-related deaths (49.6% of the overall cohort), rural areas experienced consistently higher age-adjusted mortality rates per 100,000 population per year:

  • 1999; 371.6 rural vs. 343.7 medium/small metropolitan vs. 347.6 large metropolitan;
  • 2011; 258.1 rural vs. 228.4 medium/small metropolitan vs. 219.3 large metropolitan; and
  • 2017; 251.4 rural vs. 221.8 medium/small metropolitan vs. 208.6 large metropolitan.

Moreover, from 1999 to 2011, the annual percent change in the in age-adjusted mortality was 4.1% (95% CI, 4.3 to 3.9) in large metropolitan areas, 3.7% (95% CI, 3.9 to 3.5) in medium and small metropolitan areas and 3.2% (95% CI, 3.4 to 3.1) in rural areas.

Then, between 2011 and 2017, researchers observed an annual change of 0.7% (95% CI, 1 to 0.4) in large metropolitan areas, 0.5% (95% CI, 0.7 to 0.2) in medium and small metropolitan areas and only 0.3% (95% CI, 0.5 to 0.2) in rural areas.

"Risk factors for CVD, such as high BP, diabetes, obesity, smoking and lack of exercise, are all more common in rural Americans than they are in urban areas. That may surprise some people because when we think of rural America, we think of lots of space and access to potentially better nutrition, but over time we’ve exported a lot of our bad habits from big cities into smaller towns,” Haider J. Warraich, MD, associate director of the heart failure program for the VA Boston Healthcare System and associate physician at Brigham and Women’s Hospital, told Healio. “This is an indictment of the rural health system and rural hospitals. The rural health system was developed after World War II. Thousands of hospitals were built, and the focus was on acute conditions. But when it comes to the management of chronic conditions like heart disease, high BP and diabetes, we just don’t have much of a framework to help patients. Even the acute management of CV conditions is getting more difficult as we’ve seen a rash of rural hospital closures."

“This disparity is likely driven by a combination of demographic changes, the economic slowdown, the high prevalence of cardiovascular disease risk factors, and poorer access to health care,” the researchers wrote.

In other findings, researchers found that not all subgroups experienced annual decline in CVD-related death. Between 2011 and 2017, age-adjusted mortality increased among individuals aged 25 to 64 years who were living in medium and small metropolitan areas by 0.8% (95% CI, 0.5-1) and 1.3% in rural areas (95% CI, 1.2-1.5).

“The rural health care system is in dire need of transformation. We need to start focusing on chronic disease management, whether that is through new technologies like telemedicine or empowering people across the health care ecosystem such as community health workers, nurse practitioners and pharmacists to be able to fill in some of the gaps in care that exists,” Warraich said in an interview. “We also need to do a better job educating rural Americans about their heart disease risks and what they can do in their lives to mitigate that risk. There is no silver bullet. It would need to be a process that starts in the clinic by talking to the patient and goes all the way up to the health policy and health system level.” – by Scott Buzby

Disclosures: Warraich reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.