Objectives: The purpose of this study was to quantify rural and metropolitan trends in premature heart disease (HD) mortality using the most up-to-date data available (through 2013). To our knowledge this is the first study to analyze these geographic disparities for Hispanics (HSP), Asians/Pacific Islanders (API), and American Indians/Alaska Natives (AI/AN).
Methods: Annual age-adjusted HD death rates for adults aged 25-64 years were analyzed for 2000-2013. Rates were calculated for 5 racial/ethnic groups (Non-Hispanic Whites (WNH), Non-Hispanic Blacks (BNH), HSP of any race, Non-Hispanic API, and Non-Hispanic AI/AN). County-level data were aggregated by urbanicity: large central metro (LCM), large fringe metro (LFM), medium/small metro (MSM), and micropolitan/rural (RURAL). Region was defined as South (16 states) and Non-South. All data were obtained from the National Vital Statistics System on CDC WONDER. Average annual percent change (AAPC) was calculated by linear regression of the log-transformed death rates using SAS 9.4.
Results: In 2013, the national population-at-risk predominantly resided in metro areas. However, there were more than 10 million RURAL adults aged 25-64 years in the South (16.2% of the region) and more than 13.4 million in the non-South (12.9% of the region). Nationwide, HD death rates were lowest in the LFM counties. In the South, the rate ratio (RR) for RURAL vs. LFM areas in 2011-2013 was 1.76 (95% CI 1.73 to 1.79) for WNH, 2.00 (95% CI 1.85 to 2.16) for HSP, 1.78 (95%CI 1.71 to 1.82) for BNH, 1.57 (95% CI 1.22 to 2.03) for API, and 3.13 (95% CI 2.47 to 3.96) for NNH. In the non-South, RURAL vs. LFM RRs were smaller, with the exception of API (RR 2.37, 95% CI 2.07 to 2.71). Temporal trend analyses revealed significantly smaller AAPC in RURAL areas (see Table).
Conclusions: Higher death rates coupled with slower declines have resulted in a widening rural disadvantage in premature HD mortality in the United States from 2000 to 2013, particularly for WNH, HSP, BNH, and AI/AN in the South, and WNH in the non-South.