Rural Americans at Higher Risk for Five Leading Causes of Death

Diana Phillips

January 12, 2017

Americans living in rural areas are at a greater risk of dying from the five leading causes of death than their urban counterparts, and many of the deaths are potentially preventable, the Centers for Disease Control and Prevention (CDC) reported today.

From 1999 to 2014, annual age-adjusted death rates from the five leading causes of death — heart disease, cancer, chronic lower respiratory disease, cerebrovascular diseases (stroke), and unintentional injuries — were higher in nonmetropolitan areas than in metropolitan areas, as was the percentage of potentially excess, or preventable, deaths related to these causes, researchers report in an article published in the January 13 issue of the Morbidity and Mortality Weekly Report.

In particular, the age-adjusted risk for death from unintentional injury was approximately 50% higher in nonmetropolitan areas for most of this period.

The findings reflect a "striking gap in health" that puts the 46 million Americans who currently live in rural areas at increased risk for early death, CDC Director Thomas Frieden, MD, MPH, said in a news statement.

Using mortality data from the National Vital Statistics System, CDC researchers determined that approximately 62% (1,622,304) of all deaths in the United States in 2014 were attributable to the five leading causes of death.

Although annual age-adjusted death rates for heart disease and stroke decreased in nonmetropolitan and metropolitan areas between 1999 and 2014, "the rate of decrease for heart disease was slower in nonmetropolitan areas, whereas the rates of decrease for stroke were similar," the authors write.

For the analysis, counties were characterized as nonmetropolitan (rural) or metropolitan (urban) based on the National Center for Health Statistics' six-level urban–rural classification scheme. As with heart disease and stroke, death rates for cancer decreased in both settings, but the rate of decrease was slower in nonmetropolitan areas. With respect to chronic lower respiratory disease, death rates decreased in metropolitan areas and increased in nonmetropolitan areas. Death rates for unintentional injury increased at similar rates in both settings.

The researchers also computed county-level estimates of potentially preventable deaths attributable to each of the five leading causes. These were defined as deaths for each cause among individuals younger than 80 years in excess of those that occurred among the three states with the lowest rates.

During the period of study, the population of individuals younger than 80 years in nonmetropolitan areas decreased an average of 0.1% per year. Coincident with the population decrease, the number of potentially preventable cancer deaths in nonmetropolitan areas decreased an average of 2.7% annually, whereas those associated with chronic lower respiratory disease increased an average of 3.2%. The rates of potentially preventable deaths resulting from heart disease, stroke, and unintentional injury in this population remained the same.

However, the percentages of potentially excess deaths in nonmetropolitan areas were higher than in metropolitan areas. For example, in 2014, the respective rates for potentially preventable heart disease, unintentional injury, and chronic lower respiratory disease were 42.6%, 57.5%, and 54.3% in nonmetropolitan areas and 27.8%, 39.2%, and 30.9% in metropolitan areas.

The authors hypothesize that the high percentage of potentially preventable deaths in rural areas might be a reflection of the poorer physical and mental health that has been reported among rural Americans, as well as limited socioeconomic resources and limited access to high-quality emergency and specialty care.

"These findings suggest that a greater percentage of deaths in nonmetropolitan areas might be potentially excess deaths and thus are relevant for public health prevention efforts focused on rural populations," the authors write. They note that ongoing efforts to reduce smoking and obesity in rural populations "are particularly important because these risk factors contribute to increased risk for heart disease, stroke, chronic lower respiratory disease, and cancer."

Strategy for Care

In an associated commentary focusing on ways to bridge the rural–urban gap in death rates and potentially excess deaths, CDC officials call for needs-based allocation of resources and a "focus on strengthening the health care delivery system while improving and increasing the integration of primary, specialty, and substance abuse services."

With respect to the widening gap in deaths from unintentional injuries between rural and urban areas, "special attention should be given to designing, implementing, and monitoring locally informed initiatives in rural communities for the effective prevention and treatment of opioid misuse, including treatment of opioid overdose," they write.

Among the specific suggestions, the authors recommend the following.

  • high blood pressure screening and control,

  • increased cancer prevention and early detection,

  • education and encouragement around physical activity and nutrition,

  • smoking cessation resources and education,

  • motor vehicle safety education and interventions, and

  • safe opioid prescribing practices and education.

"Although not all potentially excess deaths can be prevented, many might represent deaths that could be prevented through improved public health programs that support healthier behaviors and neighborhoods and better access to health care services," the commenters note.

The authors have disclosed no relevant financial relationships.

Morb Mortal Wkly Rep. 2017;66;1-8. Article full text, Commentary full text

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