CVD Mortality Rates Among Rural Black Adults Remain High | Nutrition Fit

Black adults who live in rural areas of the United States have the highest rates of death from diabetes, hypertension, heart disease, and stroke in the country, surpassing those of both rural and urban White adults, and also urban-dwelling Black adults.

A survey that compared mortality rates from these four common conditions showed that although Black adults have higher mortality overall, such inequities are magnified in rural areas, where Black adults have markedly higher death rates from these conditions.

Hypertension and diabetes-related death rates were found to be up to three times higher among Black than White adults living in rural parts of the United States, a finding that troubles senior author Rishi K. Wadhera, MD, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston.

“There has been growing concern about racial health inequities in the US for quite some time, and we know that specific minority groups, and in particular Black adults, have a higher burden of cardiovascular comorbidities and worse cardiovascular outcomes,” Wadhera told theheart.org | Medscape Cardiology.

“What’s really concerning is our finding that these striking racial disparities have not meaningfully improved in rural areas over the last 2 decades, and that’s because, since the early 2000s, diabetes-related death rates have not changed, while hypertension-related deaths have worsened for Black adults in the rural US,” he said.

The findings are published in the March 23 issue of the Journal of the American College of Cardiology.

Wadhera and colleagues used data from the Centers for Disease Control and Prevention Wonder Database to analyze age-adjusted death rates from diabetes, hypertension, heart disease, and stroke for the period from 1999 to 2018.

Mortality rates were compared among Black and White adults 25 years and older who were stratified by rural or urban status.

Over the 2 decades, annual age-adjusted mortality rates in rural areas were substantially higher for Black adults than for White adults for all conditions.

Mortality Per 100,000 Among Black and White Adults in All Areas
	Average Mortality Rate
Cause	Black Adults (%, SE)	White Adults (%, SE)	P Value
Diabetes	76.2 (0.42)	37.2 (0.07)	<.001
Hypertension	31.3 (0.27)	10.9 (0.04)	<.001
Heart disease	425.0 (0.99)	331.7 (0.22)	<.001
Stroke	112.6 (0.51)	73.9 (0.10)	<.001

But urban Black adults also had higher average age-adjusted mortality rates than urban White adults.

Mortality Per 100,000 Among Black and White Adults in Urban Areas
	Average Mortality Rate
Cause	Black Adults (%, SE)	White Adults (%, SE)	P Value
Diabetes	63.0 (0.14)	30.7 (0.03)	<.001
Hypertension	25.3 (0.09)	10.9 (0.02)	<.001
Heart disease	371.0 (0.34)	291.8 (0.10)	<.001

In addition, the data showed that the gap between Black and White adults narrowed more rapidly in urban than in rural areas for diabetes and hypertension, but the gap for heart disease declined at a similar rate in both areas.

Rural areas in the United States have seen many hospitals and medical centers disappear in recent years, and access to healthcare might not be as easy to come by in many communities, Wadhera said.

“Rural areas have experienced a decline in primary care providers and specialist providers, and increasing closures of rural hospitals over the last 15 years. I think limited access to primary and preventative care services likely explains some of these patterns, such as the worsening of hypertension related deaths in the US,” he said.

“We need to focus on some of the key issues that may be driving these trends, such as income inequality, inadequate access to healthcare services, and structural racism, all of which contribute to practices and social constructs that disadvantage certain groups — in this case, Black Americans.”

Letter Adds Important Data

“This was a provocative discussion about rural–urban disparities — a topic that is especially relevant today with all the current discussion about health equity and access to care,” said Dipti Itchhaporia, MD, program director, Jeffrey M. Carlton Heart & Vascular Institute, Newport Beach, California, who is chair of the American College of Cardiology’s Health Equity Task Force.

The Letter provides additional data that will help the task force hone in on particular or persistent problem areas where inequities remain, Itchhaporia told theheart.org | Medscape Cardiology.

“It’s interesting that there were persistent racial disparities for diabetes and hypertension in rural areas, but that that racial disparities had narrowed for heart disease and stroke mortality in rural areas. I thought that finding was promising, and probably speaks to the fact that these changes may reflect improvements in emergency services and expansion of referral networks and new therapies for stroke that have occurred over the 2 decades. I thought that, at least, was promising. But it seems like we’re not doing as well with chronic disease, and chronic disease management is much harder,” she said.

“I would like to see a drill down to what is, specifically, the reason for that,” Itchhaporia added. “Is it because they’re not getting primary care? Not being screened for hypertension? No access to care? If they have access, are they getting poor care?”

Right now, physicians and other health professionals can encourage healthy eating habits, physical activity, and promote more smoking cessation, she added.

“We’ve always had decreasing health disparities as part of our strategic plan, but now we are actually taking that and putting that front and center. Papers such as this give us data that we can use to help us further our goals, which are to create a culture of health equity in cardiovascular medicine and eliminate disparities by insuring equitable cardiovascular care for all,” she said.

The current climate supports the move to finally achieve those goals, Itchhaporia said.

“In the past, there was a lot of discussion, but I think we finally are starting to see a ground swell of action now. Our Health Equity Task force has great members on it. For some of the members, their life work has centered around this issue, so for them to actually see this moving forward is inspiring,” she added. “We feel that we are going to do something meaningful. Maybe now is our moment.”

Wadhera and Itchhaporia report no relevant financial relationships.

J Am Coll Cardiol .2021;2021;77:1480-1481. Letter