Race and Medicine

Race and Medicine

Disclosures: Wadhera reports he served as a consultant for Regeneron. Please see the study for all other authors’ relevant financial disclosures.
March 15, 2021
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Racial CVD disparities minimally improved in rural areas over past 2 decades

Disclosures: Wadhera reports he served as a consultant for Regeneron. Please see the study for all other authors’ relevant financial disclosures.
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From 1999 to 2018, Black adults in rural communities continuously experienced greater risk for death from diabetes, hypertension, heart disease and stroke compared with white adults, researchers reported.

According to a research letter published in the Journal of the American College of Cardiology, although the disparity gap between Black and white adults for CV death has narrowed, progress in the past 20 years in rural areas of the United States was minimal.

From 1999 to 2018, Black adults in rural communities continuously experienced greater risk for death from diabetes, hypertension, heart disease and stroke compared with white adults. Information was derived from Aggarwal R, et al. J Am Coll Cardiol. 2021;doi:10.1016/j.jacc.2021.01.0322.

Disparities in mortality related to hypertension and diabetes improved more in urban areas than rural areas, whereas the reverse was true for stroke mortality, and there was no difference by urban/rural status in the trends for disparities in CHD mortality, according to the researchers.

“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 2 decades,” Rishi Wadhera, MD, MPP, MPhil, cardiologist at Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, said in a press release. “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.”

For this analysis, researchers utilized data from the CDC WONDER Database for 1999 to 2018 to determine how racial disparities and mortality associated with diabetes, hypertension, CVD and stroke have changed among Black and white adults in rural vs. urban communities.

Rural vs. urban communities

From 1999 to 2018, annual age-adjusted mortality in rural communities was higher among Black adults compared with white adults for all conditions:

  • diabetes (76.2 vs. 37.2 deaths per 100,000; P < .001);
  • hypertension (31.3 vs. 10.9 deaths per 100,000; P < .001);
  • CHD (425 vs. 331.7 deaths per 100,000; P < .001); and
  • stroke (112.6 vs. 73.9; P < .001).

Additionally, age-adjusted mortality was also higher for Black adults compared with white adults living urban areas:

  • diabetes (63 vs. 30.7 deaths per 100,000; P < .001);
  • hypertension (25.3 vs. 10.9 deaths per 100,000; P < .001);
  • heart disease (371 vs. 291.8 deaths per 100,000; P < .001); and
  • stroke (89.4 vs. 63.6 deaths per 100,000; P < .001).

Narrowing the disparity gap

According to the study, from 1999 and 2018, the gap in annual age-adjusted mortality between Black and white adults narrowed more rapidly in urban compared with rural communities for diabetes (0.94 vs. 0.24 deaths per 100,000 per year; P for interaction < .001) and hypertension (0.3 vs. 0.09 deaths per 100,000 per year; P = .03).

However, the racial gap in CHD mortality declined at a similar rate in both urban and rural areas (3.21 vs. 3.65 deaths per 100,000 per year; P = .46) but declined faster for stroke in rural communities (0.8 vs. 1.35 deaths per 100,000 per year; P = .02).

“The striking and persistent racial disparities for diabetes- and hypertension-related mortality in rural areas, relative to urban areas, may reflect structural inequities that impede access to primary, preventive and specialist care for rural Black adults,” the researchers wrote. “In contrast, racial disparities have narrowed for heart disease and stroke mortality in rural areas. These changes may reflect improvements in emergency services, the expansion of referral networks, the development of stroke and MI care centers and the implementation of time-to-procedure metrics.”