Bridging the Gap in Potentially Excess Deaths Between Rural and Urban Counties in the United States

Twenty percent of the US population, or about 60 million persons, live in rural areas. ¹ Rural and urban counties differ in their demographic, environmental, economic, and social characteristics, which influences health and the prevalence of disease risk factors. The rates of cigarette smoking, hypertension, obesity, and physical inactivity during leisure time are higher in rural areas than in urban areas. ² About 30% of persons living in rural counties live in poverty, whereas 19% of persons living in large central and large fringe metropolitan counties and 15% of persons living in medium and small metropolitan counties live in poverty. ³ The availability of preventive services and health care access also differ in rural and urban areas. Residents of rural counties are more likely to report lower levels of health care access and lower-quality care than residents of urban counties. ² Urban areas generally have a higher density and diversity of health care providers than rural areas. ^4,5

A series of studies from the Centers for Disease Control and Prevention (CDC) have drawn attention to the substantial gap in health between persons in rural and urban areas in the United States. ⁶ In November 2019, CDC reported that, in both rural and urban counties, the 5 leading causes of death in the United States during 2010-2017 were heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke, which together accounted for 1.72 million deaths (approximately 61% of all deaths) in 2017. ⁷ Furthermore, the number of potentially excess deaths—defined as deaths among persons aged <80 in excess of the number that would be expected—differed among and within public health regions and among US states. In addition, the percentage of potentially excess deaths from the 5 leading causes of death, nationally, across public health regions, and in most states is greater in rural counties than in urban counties. ⁷ Several factors may influence the rural–urban gap in potentially excess deaths, many of which are associated with sociodemographic differences. The rural–urban disparity was most striking for potentially excess deaths from unintentional injury, whereby increases in potentially excess deaths from unintentional injury in urban and suburban counties accelerated at a much faster pace than in all other county categories. From 2010 to 2017, the percentage of potentially excess deaths from cancer declined in all county categories, but it declined at a slower pace in rural counties than in urban counties. Intentionally, this study ⁷ did not control for conventional risk factors to demonstrate absolute differences.

In 2017, the percentage of potentially excess deaths from unintentional injury was 54%. ⁶ The number of deaths increased in both rural and urban counties from 2010 to 2017, but it increased at a faster pace in urban and suburban counties than in rural counties. Overall, during 2010-2017, the percentage of potentially excess deaths from unintentional injury was higher in rural counties than in urban counties. Several influences may help explain the higher percentage of excess deaths from unintentional injuries in rural counties than in urban counties; these influences include type of injury and treatment of injury. First, the percentage of potentially excess unintentional injury deaths is higher in rural areas because the ability to transport patients quickly to critical care facilities is better in urban areas than in rural areas. ⁸ As a result, a substantially higher proportion of trauma patients in rural areas than in urban areas die within 24 hours: 89.6% in rural areas vs 64.0% in urban areas. ⁹ Second, among subcategories of unintentional injury deaths for all ages, age-adjusted death rates for opioid poisonings are about 17% higher in urban areas than in rural areas. ¹⁰ For drug overdose, inconsistent training on, and use of, naloxone (a reversal drug used in opioid overdoses) in prehospital settings ¹¹ and insufficient access to naloxone and naloxone administration training in family settings contribute to higher mortality. ^12,13 Rural areas have a limited capacity to detoxify patients. Also, a patient’s ability to initiate medically assisted treatment is hampered by access to health care services, including a limited number of buprenorphine and methadone prescribers. ¹⁴ Third, behavioral factors, such as alcohol-impaired driving, ¹⁵ lack of seatbelt use, ¹⁶ or both, ¹⁷ contribute to higher injury rates in rural areas than in urban areas. Fourth, mortality from falls among older adults is increasing. ¹⁸ As the population ages, more persons will be at a higher risk for falls. In 2016, higher mortality rates from falls were found in medium metropolitan, small metropolitan, micropolitan, and noncore areas than in large central urban counties. ¹⁹ Many factors (eg, weakness, disease progression, anticoagulation use) can contribute to deaths from falls among older adults, and these factors present challenges for targeted interventions. CDC has focused on strength training, medication modification, ¹⁸ and improved trauma center transport for injured older adults using anticoagulants. ²⁰

Two concerns that affect a person’s chance of surviving serious injury are travel and access to treatment for trauma and drug poisoning. Travel is often delayed and access is often limited in rural areas. Rapid treatment is important for survival. Because persons in rural areas tend to be further from health care facilities than persons in urban areas, rural emergency medical service providers take longer to reach patients and transport them to the optimal treatment facility than do urban medical service providers. Most life-threatening trauma is better treated in advanced trauma centers than in non–trauma centers, which are usually located in urban areas; care at these centers has been associated with 25% lower mortality. ²¹ Trauma centers have advanced equipment and specialized staff members who are available 24 hours per day, 7 days per week.

In 2017, the number of potentially excess deaths from cancer was approximately 39 000 in the United States. ⁷ Cancer had the lowest (9.2%) percentage of potentially excess deaths among the 5 leading causes of death, ranging from 3.2% in large central metropolitan counties (urban classification) to 21.7% in noncore counties (rural classification). These numbers mirror lower incidence and higher death rates found in nonmetropolitan counties compared with metropolitan counties. ²² A comprehensive approach to cancer control and prevention (eg, prevention, early detection, treatment, and survivorship) has helped address cancer disparities during the past 20 years in the United States, ²³ and a more focused approach for reducing rural–urban disparities could be developed in the future. For prevention and early detection, several evidence-based interventions ⁷ focus on reducing tobacco use and overweight, both of which are risk factors for some types of cancers. In 2016, data from the National Survey on Drug Use and Health showed that the prevalence of cigarette smoking for persons aged ≥12 years was 37.8% in a completely rural county compared with 27.1% in a large metropolitan county. ²⁴ Some rural communities have limited access to healthy food options and spaces to be physically active, ²⁵ which could create barriers for achieving and maintaining a healthy weight. Some recommended screening tests use specialized equipment that may not be accessible in rural communities. ²⁶ Once diagnosed with cancer, persons in rural areas may have limited access to medical specialists to obtain necessary care in a timely manner. ²⁷ The transition to survivorship care may be different for cancer survivors living in rural settings than in urban settings because more specialists practice in urban areas. To reduce the transportation time to see specialists, cancer survivors living in rural settings may have their survivorship care managed by primary care physicians in conjunction with specialists. Also, cancer survivors living in rural areas have higher rates of health-related unemployment than cancer survivors living in urban areas, possibly because the types of occupations in rural areas (eg, production, transportation, service) may have less job flexibility for cancer treatment than the types of occupations in urban areas (eg, business, managerial positions). ²⁸

The MMWR Special Series on Rural Health generated additional insights on condition-specific disparities between rural and urban areas in the United States. ²⁹ CDC has worked through its grant programs and technical assistance to reduce health disparities, especially in rural areas. In rural South Carolina, for example, the risk of cancer-related death is a complex public health problem. The St. James–Santee Family Health Center launched the Black Corals program ³⁰ in 2008 to increase cancer screening among women, using The Community Guide ³¹ as a resource to help the program increase the number of women who received breast and cervical cancer screenings in their community. Research and evaluation are important for generating evidence to develop tools, such as The Community Guide, and to tailor the application of these tools based on the specific needs of communities. In rural areas, strong social and community networks may be leveraged as platforms for providing support systems for persons who have or are recovering from opioid use disorders. Evidence-based toolkits for rural community health, ³² such as the Robert Wood Johnson Foundation's County Health Rankings & Roadmaps (https://www.countyhealthrankings.org), can be adapted to fit the needs of each community, allowing stakeholders to explore approaches to community health challenges, discover what works and why, identify common barriers to implementation, connect with programmatic experts, and evaluate health programs to show impact.