Urban–rural disparities in diabetes-related mortality in the USA 1999–2019

Our findings demonstrate that the overall temporal decrease in diabetes-related mortality in the USA has been observed only in urban areas and mainly among female and older patients. Rural areas have experienced either minimal gains or, as in the case of male and younger patients, worsening temporal trends in diabetes-related AAMR. The highest AAMRs have been in American Indian and Black patients residing in rural areas. The rural–urban mortality gap related to diabetes has tripled over time.

We observed increasing rates of diabetes-related mortality among younger adults over the last 20 years, compared with the older population. The increased mortality among the younger adults may be related to the increasing prevalence of type 2 diabetes in adolescents and young adults. Early-onset type 2 diabetes is associated with more aggressive disease and higher rates of premature complications [5]. Moreover, a previous study reported worse glucose control among younger adults with type 2 diabetes [6]. The fact that male individuals are more likely to be diagnosed with diabetes at an early age [7], may explain the widening male–female diabetes-related mortality gap in both urban and rural areas.

Residents of rural areas are at increased risk of diabetes as the prevalence of obesity and the metabolic syndrome is higher in rural areas [8, 9]. Furthermore, rural residents are less likely to have participated in diabetes self-management education programmes [10]. Indeed, rural patients were found to have higher rates of diabetes-related emergency department use compared with urban patients [11].

Our finding of an increasing gap in diabetes outcomes is in concordance with previous studies that reported greater improvements in blood pressure and cholesterol control for urban adults with diabetes than for those in rural areas over the last two decades. These differences remained significant even after multiple adjustments for ethnicity, education, poverty levels and clinical characteristics [12]. The management of diabetes and its complications requires expertise that may be difficult to access in rural communities. Residents of rural counties are less likely to have usual primary care provided by physicians [13]. Furthermore, there has been a disproportionate closure of hospitals in rural areas [14].

The role of socioeconomic deprivation and structural racism in the incidence of cardiovascular risk factors, progression of diabetes, and survival rates must also be considered, particularly in American Indian and Black individuals. Cardiometabolic risk varies across ethnic groups and areas, and is inextricably linked with social determinants of health, including education, economic resources, psychological stress and access to preventive healthcare [15]. Healthcare equity, expansion of Medicaid, and telemedicine initiatives that extend access to specialty care may mitigate some of the rural–urban disparities in mortality. However, the ultimate solutions may lie in economic and policy interventions that broaden our focus from treating disease to preventing it.

Limitations

There are some limitations to note. First, we were able to examine disparities only by key sociodemographic characteristics that were available in the CDC WONDER database (e.g. age and race/ethnicity). Furthermore, the use of bridged race categories (e.g. the Asian or Pacific Islander race category includes Chinese, Filipino, Hawaiian, Japanese and Other Asian or Pacific Islanders) may lead to a heterogeneous group of patients where findings are difficult to interpret in relation to race. Second, we were not able to adjust for baseline comorbidities, nor for other important potential confounders, such as socioeconomic status, education and occupation. Third, the urbanisation status was defined by the place of death. We cannot rule out the possibility of that individuals toward the end of life chose to migrate (i.e. for social support and care by relatives).

Conclusions

While diabetes-related mortality rates decreased in urban counties in the USA over the last two decades, they did not decrease in rural counties. We report that the rural–urban diabetes-related mortality gap has tripled in the USA during this period, mainly among male patients and those younger than 55 years old. A synchronised effort is required to improve cardiovascular health indices and healthcare access in rural areas and to decrease diabetes-related mortality.

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