Higher Diabetes Mortality In Rural Areas Underscores Chronic Disease Disparities

U.S. rural residents are more likely to die from diabetes than their urban counterparts, according to a recent study published in JAMA Network Open. Those findings add to the growing literature detailing a higher prevalence of chronic disease in rural regions, disparities that call for innovative approaches and increased resources.

Rural residents face disproportionate disease toll

About 20% of Americans live in rural regions, areas with more space, less people and increased risk of poor health outcomes. Rural residents face numerous health disparities, according to the Centers for Disease Control and Prevention. They are more likely to die prematurely from five of the leading causes of death nationwide, including heart disease and chronic lower respiratory disease.

Study finds higher diabetes mortality rate in rural areas

The recent JAMA study used death certificate data to determine whether the “striking disparities in diabetes care" in rural areas impacted diabetes mortality. Researchers found that rural counties had the highest overall diabetes mortality rates in the country, disparities that were particularly pronounced for men and people living in the South.

Highlighting these “persistent rural disparities" is important because it could lead to identifying areas for more investigation and interventions, the authors noted.

New findings support previous chronic disease disparities

The diabetes findings build on longstanding research on other chronic conditions and their increased prevalence in rural areas. Overall, people living in rural areas are more likely to have multiple chronic health conditions compared with those in urban areas, notes a 2020 study published in Preventing Chronic Diseases.

These overarching findings are also evident when focusing on specific chronic conditions. For example, women living in rural areas face increased morality from premature coronary artery disease, according to findings published in 2020 in the Journal of the American Heart Association.

Historically marginalized people face converging inequities

As rural communities become more racially and ethnically diverse, populations already facing health inequities may encounter additional environmental challenges. A Brookings Institute analysis of 2020 census findings described rural America's increasing racial and ethnic diversity. Between 2010 and 2020, the median rural county saw residents of color increase by 3.5 percentage points.

“In 2020, two-thirds of rural counties consisted of at least 10% people of color, one-third were over a quarter people of color and 10% of rural counties are majority people of color," the report found.

Historically marginalized people already shoulder a disproportionate chronic disease burden. For example, consider the diabetes rates for Black (15%), Hispanic (12%) and American Indian/Alaska Native (14%) adults compared to White adults (10%), data documented in a 2022 Kaiser Foundation report.

Pandemic's impact “particularly profound" on persons with chronic disease

The pandemic only worsened existing health inequities for the country's socially and economically marginalized populations, including those living with chronic diseases. Risk factors associated with increased risk of death from COVID-19 include many chronic diseases such as cardiovascular disease, diabetes, cancer, and respiratory disease, according to the authors of a Nature study.

“For those with chronic disease, the impact has been particularly profound," write the authors of a CDC report looking at the intersection of COVID-19 and chronic disease.

There's also evidence that a COVID-19 infection can heighten someone's risk of developing diabetes, especially for people already at a higher risk, according to findings published in The Lancet Diabetes & Endocrinology.

“When this whole pandemic recedes, we're going to be left with the legacy of this pandemic — a legacy of chronic disease" for which healthcare systems are unprepared, said study co-author Ziyad Al-Aly, chief researcher for the Veterans Affairs (VA) St Louis Healthcare System in Missouri in a Nature article describing the study's results.

What's causing these rural chronic disease disparities?

In the JAMA diabetes study, authors acknowledged that the reasons for rural chronic disease disparities are “incompletely understood." At the same time, they pointed to factors that could influence one's health in these regions. These include findings that rural residents are less likely to have a healthcare provider and may defer care because of medical costs. Lower annual incomes in many rural regions may also place those residents at greater risk for foregoing adequate diabetes care.

More broadly, the CDC highlights specific lifestyle factors in rural areas that could impact health outcomes, including higher rates of cigarette smoking and obesity. Rural residents report less “leisure-time physical activity," higher rates of poverty, and less health insurance, the agency notes.

Built environment also influences health

Living in rural areas can create structural challenges to living a healthy life, according to a National Institutes of Health report. There may be fewer grocery stores to buy healthy foods, less public transportation options, and less sidewalks for convenient walking. While there have been strides in expanding health insurance, rural residents are still more likely to live without health insurance compared to their urban counterparts, according to Census figures.

Overall, rural communities have fewer resources to treat chronic diseases than urban areas, according to the Rural Health Information Hub. For those with multiple chronic conditions, the costs and care required is even more difficult to manage. Another contributing factor: rural areas also tend to have a higher percentage of older adults, the Hub notes.

Rural hospital closures and provider shortages contribute, too

On a system-wide level, there are less health care providers, hospitals, and specialty care in rural areas. Rural hospitals are closing at an alarming rate. Between 2010 and 2021, 136 rural hospitals closed, according to a report from the American Hospital Association. As the pandemic took hold in 2020, there was a record 19 closures.

The report pointed to longstanding pressures, including low reimbursements, staffing shortages, and low patient volumes as well as the widespread challenges associated with the overall pandemic. The decline is alarming for patient care and wellbeing, especially as it relates to these ongoing health disparities.

Improving financial health of rural health systems & hospitals

While many hospitals and health systems are facing unprecedented challenges, those faced in rural America are unique," said AHA President and CEO Rick Pollack in a news release on the closure report. “We must ensure that hospitals have the support and flexibility they need to continue to be providers of critical services and access points for patients and communities.

The AHA report proposes several approaches that could improve the financial health of these troubled rural hospitals, including state Medicaid expansion, flexible models of care, and federal program that support geographically isolated rural hospitals with low patient numbers.

Managing chronic diseases before they become acute

More broadly, the healthcare system needs to better align financial incentives to encourage providers and payers to better prevent, treat and manage chronic diseases before they become acute, write the authors of an editorial in The Hill.

Primary care doctors – and specialist referrals – are integral to this effort. Along with removing barriers to access primary care, this effort would also integrate preventative care, they note.

Incorporating the pandemic's lessons to improve rural health equity

While these efforts make sense, there are implementation barriers in rural areas where there aren't enough providers or specialists to care for the local population.

The pandemic's acceleration of telemedicine efforts could be useful in addressing these care gaps. Other technology, such as remote monitoring devices, could also aid in the effort. At that same time, it's important to note that these steps require equitable access to the Internet and payment parity for providers.

Some of the approaches used in disseminating the COVID-19 vaccine in isolated rural areas could also be helpful in informing future health outreach efforts to address chronic diseases in those locales. These efforts include mobile clinics, vaccination efforts for homebound individuals, and using trusted community members to spread public health information.

Case studies in addressing chronic condition inequities

Those seeking to address disparities in chronic conditions may also benefit from observing integrative care models such as the Center to Improve Chronic Disease Outcomes. This newly-funded New York City center aims to address health inequities for chronic diseases.

The center, which is funded by a grant from the National Institute for Minority Health Disparities, connects researchers from distinct disciplines. The goal is to work together to address the root causes of chronic diseases and other health inequities.

Using a multi-faceted approach to address health and well being

“Reducing health disparities in chronic diseases requires multi-faceted approaches that intervene on structural, community, family and individual level determinants of health and wellbeing," according to a news release.

Indeed, efforts to address these long-standing disparities in chronic disease will require integration and innovation.

RTI Health Advance can help payers and providers address chronic disease inequities

Learn more about RTI Health Advance services that can support rural healthcare initiatives aimed at addressing at reducing these chronic disease inequities. Our experts can support programs and interventions designed to address health equity, digital health, and population health.