The growing rural-urban divide in US life expectancy: contribution of cardiovascular disease and other major causes of death

Whiteness: A Fundamental Determinant of the Health of Rural White Americans

Because residents of rural areas in the United States experience a persistent disadvantage in life expectancy relative to their urban counterparts, it is critical to consider the structural and social determinants that affect the health of rural populations. White Americans constitute 3 out of every 4 (76%) rural residents, and there is growing evidence that rurality is a predictor of poor health status for White Americans in ways that are not present for racially minoritized populations or nonrural White populations. We offer a framework to describe Whiteness as a fundamental determinant of the health of rural White Americans, which is useful to more precisely characterize and address the heterogeneous yet unique factors that drive their health. While Whiteness is a dynamic system that typically upholds White Americans' social supremacy, we provide examples of intermediate (e.g., rural culture, environment) and intrapersonal (e.g., psychosocial) factors through which Whiteness can harm rural White Americans' health (e.g., chronic disease, mental health). We conclude with a discussion of implications and recommendations that may help to advance research to promote health and well-being among rural White Americans. (Am J Public Health. 2025;115(2):152-160. https://doi.org/10.2105/AJPH.2024.307904).

Health differences between rural and non-rural Texas counties based on 2023 County Health Rankings

BACKGROUND

Place matters for health. In Texas, growing rural populations face a variety of structural, social, and economic disparities that position them for potentially worse health outcomes. The current study contributes to understanding rural health disparities in a state-specific context.

METHODS

Using 2023 County Health Rankings data from the University of Wisconsin Population Health Institute, the study analyzes rural/non-rural county differences in Texas across six composite indexed domains of health outcomes (length of life, quality of life) and health factors (health behavior, clinical care, socioeconomic factors, physical environment) with a chi-square test of significance and logistic regression.

RESULTS

Quartile ranking distributions of the six domains differed between rural and non-rural counties. Rural Texas counties were significantly more likely to fall into the bottom quartile(s) in the domains of length of life and clinical care and less likely to fall into the bottom quartile(s) in the domains of quality of life and physical environment. No differences were found in the domains of health behavior and socioeconomic factors. Findings regarding disparities in length of life and clinical care align with other studies examining disease prevalence and the unavailability of many health services in rural Texas. The lack of significant differences in other domains may relate to indicators that are not present in the dataset, given studies that find disparities relating to other underlying factors.

CONCLUSIONS

Texas County Health Rankings data show differences in health outcomes and factors between rural and non-rural counties. Limitations of findings relate to the study's cross-sectional design and parameters of the secondary data source. Ultimately, results can help state health stakeholders, especially those in community or operational contexts with limited resources or access to more detailed health statistics, to use the CHR dataset to consider more relevant local interventions to address rural health disparities.

The urban-rural gap in older Americans' healthy life expectancy

PURPOSE

Estimate health-quality-adjusted life expectancy (QALE) for Americans nearing retirement age and assess rural-urban disparities in QALE.

METHODS

We used a dynamic microsimulation model based on Health and Retirement Study data to estimate the quantity and health quality of expected future life years for rural and urban Americans ages 59-60 in 2014-2020.

FINDINGS

Cohort life expectancy at age 60 (LE) for urban and rural men was 22.9 and 20.9, respectively; for urban and rural women, LE was 25.6 and 25.0, respectively. Adjusting future life years to quality-adjusted life years, QALE was 17.5 versus 15.7 for urban versus rural men, and 19.3 versus 18.7 for women. Compared to a cohort in 1994-2000, the urban-rural QALE gap in 2014-2020 grew substantially for men; changes for women were smaller. Average QALE masked heterogeneity by race/ethnicity, education, and Census region. Counterfactual scenarios suggested eliminating smoking and managing obesity and prevalent heart conditions would be particularly beneficial for increasing rural QALE and reducing the urban-rural gap.

CONCLUSIONS

Expected health quality, in addition to longevity, is an important factor when assessing rural disparities in older Americans' future life outcomes. Current chronic disease disparities are expected to translate to a widening urban-rural gap in QALE, particularly for men. Interventions earlier in life may be needed to fully address disparities in QALE at older ages.

RNA sequencing comparing centenarian and middle-aged women lymphoblastoid cell lines identifies age-related dysregulated expression of genes encoding selenoproteins, heat shock proteins, CD99, and BID

Women typically live longer than men, and constitute the majority of centenarians. We applied RNA-sequencing (RNA-seq) of blood-derived lymphoblastoid cell lines (LCLs) from women aged 60-80 years and centenarians (100-105 years), validated the RNA-seq findings by real-time PCR, and additionally measured the differentially expressed genes in LCLs from young women aged 20-35 years. Top RNA-seq genes with differential expression between the age groups included three selenoproteins (GPX1, SELENOW, SELENOH) and three heat shock proteins (HSPA6, HSPA1A, HSPA1B), with the highest expression in LCLs from young women, indicating that young women are better protected from oxidative stress. The expression of two additional genes, BID encoding BH3-interacting domain death agonist and CD99 encoding CD99 antigen, showed unique age dependence, with similar expression levels in young and centenarian women while exhibiting higher and lower expression levels, respectively, in LCLs from women aged 60-80 years compared with the two other age groups. This age-related differential expression of BID and CD99 suggests elevated inflammation susceptibility in middle-aged women compared with either young or centenarian women. Our findings, once validated with human peripheral blood mononuclear cells and further cell types, may lead to novel healthy aging diagnostics and therapeutics.

Reprint of: Examining U.S. disparities in smoking among rural versus urban women of reproductive age: 2002-2019

OBJECTIVE

This study is part of a programmatic investigation of rural disparities in cigarette smoking examining disparities in smoking prevalence and for the first-time quit ratios among adult women of reproductive age (18-44 years), a highly vulnerable population due to risk for multigenerational adverse effects.

METHODS

Data came from 18 years (2002-2019) of the U.S. National Survey on Drug Use and Health (NSDUH) among women (n = 280,626) categorized by rural-urban residence, pregnancy status, using weighted logistic regression models testing time trends and controlling for well-established sociodemographic predictors of smoking (race/ethnicity, education, income). Concerns regarding changes in survey methods used before 2002 and after 2019 precluded inclusion of earlier and more recent survey years in the present study.

RESULTS

Overall smoking prevalence across years was greater in rural than urban residents (adjusted odds ratio [AOR] = 1.11; 95%CI, 1.07-1.15; P < .001) including those not-pregnant (AOR = 1.10; 1.07-1.14; P < .001) and pregnant (AOR = 1.29; 1.09-1.52; P < .001). Overall quit ratios across years were lower in rural than urban residents (AOR = 0.93; 0.87-0.99; P < .001) including those not-pregnant (AOR = 0.93; 0.88-1.00, P = .035) and pregnant (AOR = 0.78; 0.62-0.99; P = .039). Interactions of rural versus urban residence with study years for prevalence and quit ratios overall and by pregnancy status are detailed in the main text.

CONCLUSIONS

These results support a longstanding and robust rural disparity in smoking prevalence among women of reproductive age including those currently pregnant and provides novel evidence that differences in smoking cessation contribute to this disparity further underscoring a need for greater access to evidence-based tobacco control and regulatory interventions in rural regions.

How rural is All of Us? Comparing characteristics of rural participants in the National Institute of Health's All of Us Research Program to other national data sources

PURPOSE

The National Institute of Health's All of Us Research Program represents a national effort to develop a database to advance health research, especially among individuals historically underrepresented in research, including rural populations. The purpose of this study was to describe the rural populations identified in the All of Us Research Program using the only proxy measure currently available in the dataset.

METHODS

Currently, the All of Us Research Program provides a proxy measure of rurality that identifies participants who self-reported delaying care due to far travel distances associated with living in rural areas. Using the All of Us Controlled Tier Dataset v6, we compared sociodemographic and health characteristics of All of Us rural participants identified via this proxy to rural US residents from nationally representative data sources using chi-squared tests.

RESULTS

3.1% of 160,880 All of Us participants were rural, compared to 15%-20% of US residents based on commonly accepted rural definitions. Proportionally more rural All of Us participants reported fair or poor health status, history of cancer, and history of heart disease (P<.01).

CONCLUSIONS

The All of Us measure may capture a subset of underserved participants who live in rural areas and experience health care access barriers due to distance. Researchers who use this proxy measure to characterize rurality should interpret their findings with caution due to differences in population and health characteristics using this proxy measure rural compared to other commonly used rural definitions.

Examining U.S. disparities in smoking among rural versus urban women of reproductive age: 2002-2019

OBJECTIVE

This study is part of a programmatic investigation of rural disparities in cigarette smoking examining disparities in smoking prevalence and for the first-time quit ratios among adult women of reproductive age (18-44 years), a highly vulnerable population due to risk for multigenerational adverse effects.

METHODS

Data came from 18 years (2002-2019) of the U.S. National Survey on Drug Use and Health (NSDUH) among women (n = 280,626) categorized by rural-urban residence, pregnancy status, using weighted logistic regression models testing time trends and controlling for well-established sociodemographic predictors of smoking (race/ethnicity, education, income). Concerns regarding changes in survey methods used before 2002 and after 2019 precluded inclusion of earlier and more recent survey years in the present study.

RESULTS

Overall smoking prevalence across years was greater in rural than urban residents (adjusted odds ratio [AOR] = 1.11; 95%CI, 1.07-1.15; P < .001) including those not-pregnant (AOR = 1.10; 1.07-1.14; P < .001) and pregnant (AOR = 1.29; 1.09-1.52; P < .001). Overall quit ratios across years were lower in rural than urban residents (AOR = 0.93; 0.87-0.99; P < .001) including those not-pregnant (AOR = 0.93; 0.88-1.00, P = .035) and pregnant (AOR = 0.78; 0.62-0.99; P = .039). Interactions of rural versus urban residence with study years for prevalence and quit ratios overall and by pregnancy status are detailed in the main text.

CONCLUSIONS

These results support a longstanding and robust rural disparity in smoking prevalence among women of reproductive age including those currently pregnant and provides novel evidence that differences in smoking cessation contribute to this disparity further underscoring a need for greater access to evidence-based tobacco control and regulatory interventions in rural regions.

The Ecology of Economic Distress and Life Expectancy

Objectives

To determine whether life expectancy (LE) changes between 2000 and 2019 were associated with race, rural status, local economic prosperity, and changes in local economic prosperity, at the county level.

Methods

Between 12/1/22 and 2/28/23, we conducted a retrospective analysis of 2000 and 2019 data from 3,123 United States counties. For Total, White, and Black populations, we compared LE changes for counties across the rural-urban continuum, the local economic prosperity continuum, and for counties in which local economic prosperity dramatically improved or declined.

Results

In both years, overall, across the rural-urban continuum, and for all studied populations, LE decreased with each progression from the most to least prosperous quintile (all p < 0.001); improving county prosperity between 2000-2019 was associated with greater LE gains (p < 0.001 for all).

Conclusion

At the county level, race, rurality, and local economic distress were all associated with LE; improvements in local economic conditions were associated with accelerated LE. Policymakers should appreciate the health externalities of investing in areas experiencing poor economic prosperity if their goal is to improve population health.

Equitable Care for Hypertension: Blood Pressure and Patient-Reported Outcomes of the RICH LIFE Cluster Randomized Trial

BACKGROUND

Disparities in hypertension control are well documented but underaddressed.

METHODS

RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) was a 2-arm, cluster randomized trial comparing the effect on blood pressure (BP) control (systolic BP ≤140 mm Hg, diastolic BP ≤90 mm Hg), patient activation, and disparities in BP control of 2 multilevel interventions, standard of care plus (SCP) and collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs. Primary outcomes were BP control and patient activation at 12 months. Generalized estimating equations and mixed-effects regression models with fixed effects of time, intervention, and their interaction compared change in outcomes at 12 months from baseline.

RESULTS

A total of 1820 adults with uncontrolled BP and ≥1 other risk factors enrolled in the study. Their mean age was 60.3 years, and baseline BP was 152.3/85.5 mm Hg; 59.4% were women; 57.4% were Black, 33.2% were White, and 9.4% were Hispanic; 74% had hyperlipidemia; and 45.1% had type 2 diabetes. CC/SC did not improve BP control rates more than SCP. Both groups achieved statistically and clinically significant BP control rates at 12 months (CC/SC: 57.3% [95% CI, 52.7%-62.0%]; SCP: 56.7% [95% CI, 51.9%-61.5%]). Pairwise comparisons between racial and ethnic groups showed overall no significant differences in BP control at 12 months. Patients with coronary heart disease showed greater achievement of BP control in CC/SC than in SCP (64.0% [95% CI, 54.1%-73.9%] versus 50.8% [95% CI, 42.6%-59.0%]; P=0.04), as did patients in rural areas (67.3% [95% CI, 49.8%-84.8%] versus 47.8% [95% CI, 32.4%-63.2%]; P=0.01). Individuals in both arms experienced statistically and clinically significant reductions in mean systolic BP (CC/SC: -13.8 mm Hg [95% CI, -15.2 to -12.5]; SCP: -14.6 mm Hg [95% CI, -15.9 to -13.2]) and diastolic BP (CC/SC: -6.9 mm Hg [95% CI, -7.8 to -6.1]; SCP: -5.5 mm Hg [95% CI, -6.4 to -4.6]) over time. The difference in diastolic BP reduction between CC/SC and SCP over time was statistically significant (-1.4 mm Hg [95% CI, -2.6 to -0.2). Patient activation did not differ between arms. CC/SC showed greater improvements in patient ratings of chronic illness care (Patient Assessment of Chronic Illness Care score) over 12 months (0.12 [95% CI, 0.02-0.22]).

CONCLUSIONS

Adding a collaborative care team to enhanced standard of care did not improve BP control but did improve patient ratings of chronic illness care.

Age, Sex, and Disease-Specific Mortality Contributions to Life Expectancy in Urban and Rural China, 1987-2021

What is already known about this topic?

Over the past several decades, China has experienced substantial improvements in life expectancy (LE), signifying major advancements in public health outcomes.

What is added by this report?

This study offers an in-depth analysis of the contributions made by various diseases and age demographics to the growth of LE in China over the past 35 years, highlighting crucial factors that influence population health.

What are the implications for public health practice?

The results highlight the need for interventions tailored to various disease types and age groups in order to enhance LE and improve public health outcomes. Public health strategies should prioritize disease prevention, control initiatives, and enhancements in healthcare services that are specifically designed to meet the needs of distinct population demographics.

Trends in rheumatoid arthritis associated cardiovascular mortality in the United States from 1999 to 2020

INTRODUCTION

Rheumatoid Arthritis (RA) is a risk enhancing factor for cardiovascular diseases (CVD). However, data regarding the magnitude and trends of RA associated CVD-related mortality in the United States (U.S) remains scarce.

METHODS

A retrospective analysis was conducted using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) dataset. We extracted age-adjusted mortality rates (AAMR) per 100,000 persons and calculated the annual percentage change (APC) through Joinpoint regression. The outcomes were stratified to discern temporal, sex-based, racial, and geographic patterns in RA-associated CVD mortality.

RESULTS

Between 1999 and 2020, 128,058 deaths related to CVD in RA patients aged 25 and above were recorded. The AAMR decreased from 3.50 in 1999 to 2.79 in 2020. However, sex disparities persisted, with females consistently experiencing a higher AAMR (3.35) compared to males (1.74). Non-Hispanic (NH) American Indian/Alaska Native had the highest AAMR (4.44) followed by NH White (2.83), NH Black or African American (2.47) and Hispanic or Latino (2.13), while NH Asian/Pacific Islander had the lowest AAMR (1.28). Geographically, the Midwestern region had the highest AAMR (3.12), while the Northeast had the lowest (2.19) with micropolitan (3.47) and nonmetropolitan (3.37) areas exhibiting higher AAMRs compared to large metropolitans (2.28). Notably, states with the highest AAMRs included North Dakota, South Dakota, Vermont, Minnesota and Wyoming.

CONCLUSION

Recent trends reveal an upward incline in RA-associated CVD-related mortality with profound disparities related to sex, race, geography and regions. Redressing these disparities necessitates the implementation of targeted population level interventions.

Impact of Cardiovascular and Cerebrovascular Diseases Mortality on Life Expectancy in Tianjin, 2004 and 2020

This study aimed to analyze the impact of cardiovascular and cerebrovascular diseases (CCVDs) mortality on Tianjin's life expectancy (LE) in 2004 compared with 2020 using Arriaga's decomposition method. The LE increment for Tianjin residents due to the decrease in CCVDs mortality was 1.54 years (38.7%). Males, females, urban residents, and rural residents contributed 1.29 years (36.83%), 1.76 years (40.25%), 2.11 years (44.41%), and 0.71 years (25.06%), respectively. A total of 38.2% of the LE increment was attributed to deaths from CCVDs in people aged ≥65 years. Cerebral infarction, intracerebral hemorrhage, acute myocardial infarction, and other heart diseases contributed positively to the increase in LE (24.8%, 22.68%, 16.66%, and 11.3%). Sequelae of cerebrovascular disease and other coronary heart diseases contributed negatively to the increase in LE (-25.2% and -17.92%). Therefore, we need to control the risk factors of the elderly, males, rural residents, sequelae of cerebrovascular disease, and other coronary heart diseases.

Social infrastructure and health among mid-life and older adults in rural America: An environmental scan of existing data

Growing evidence shows a relationship between social infrastructure (SI) - the physical places where people gather outside of home and work - and health. However, existing data sources for rigorously investigating this relationship are limited, especially for rural areas. Therefore, we conducted an environmental scan of existing data for furthering research on this topic, with a focus on the rural United States (U.S.). A total of 10 datasets met inclusion criteria. Key information was collated from websites and reviewed by data administrators. We summarize key features of these datasets, including available measures of geography/rurality, SI availability and utilization, and physical, mental and social health. We describe analytic strengths and weaknesses of the available data, which is essential for researchers to be able to assess their data options. While the scan focuses on U.S.-based data, the key points will be applicable more broadly, including a need for more data on availability and use of social infrastructure combined with geographic indicators.

Urban-rural disparities in COVID-19 hospitalisations and mortality: A population-based study on national surveillance data from Germany and Italy

PURPOSE

Recent literature has highlighted the overlapping contribution of demographic characteristics and spatial factors to urban-rural disparities in SARS-CoV-2 transmission and outcomes. Yet the interplay between individual characteristics, hospitalisation, and spatial factors for urban-rural disparities in COVID-19 mortality have received limited attention.

METHODS

To fill this gap, we use national surveillance data collected by the European Centre for Disease Prevention and Control and we fit a generalized linear model to estimate the association between COVID-19 mortality and the individuals' age, sex, hospitalisation status, population density, share of the population over the age of 60, and pandemic wave across urban, intermediate and rural territories.

FINDINGS

We find that in what type of territory individuals live (urban-intermediate-rural) accounts for a significant difference in their probability of dying given SARS-COV-2 infection. Hospitalisation has a large and positive effect on the probability of dying given SARS-CoV-2 infection, but with a gradient across urban, intermediate and rural territories. For those living in rural areas, the risk of dying is lower than in urban areas but only if hospitalisation was not needed; while for those who were hospitalised in rural areas the risk of dying was higher than in urban areas.

CONCLUSIONS

Together with individuals' demographic characteristics (notably age), hospitalisation has the largest effect on urban-rural disparities in COVID-19 mortality net of other individual and regional characteristics, including population density and the share of the population over 60.

Shortage of thoracic surgeons in the United States: Implications for treatment and survival for stage I lung cancer patients

OBJECTIVES

To evaluate whether there is a shortage of thoracic surgeons in the United States and whether any potential shortage is impacting lung cancer treatment and outcomes.

DESIGN

Using the US Area Health Resources File and Surveillance Epidemiology End Results database, we assessed the number of cardiothoracic surgeons per 100,000 people and the number of stage I non-small cell lung cancer (NSCLC) diagnoses in the US in 2010 versus 2018. Changes in the percentage of patients diagnosed with stage I NSCLC who underwent surgery and stereotactic body radiotherapy and changes in overall survival of patients with stage I NSCLC from 2010 to 2018 in the National Cancer Database were evaluated using multivariable logistic regression and Cox proportional hazards modeling.

RESULTS

From 2010 to 2018, the number of cardiothoracic surgeons per 100,000 people in the US decreased by 12% (P < .001), while the number of patients diagnosed with stage I NSCLC increased by 40% (P < .001). Over the same period, the percentage of patients who underwent surgery for stage I NSCLC decreased from 81.0% to 72.3% (adjusted odds ratio, 0.59; 95% confidence interval, 0.55-0.63); this decrease was similarly seen in a subgroup of young and otherwise healthy patients. Greater decreases in the percentage of patients who underwent surgery in nonmetropolitan and underserved regions corresponded with worse improvements in survival among patients in these regions from 2010 to 2018.

CONCLUSIONS

Recent declines in the US cardiothoracic surgery workforce may have led to significantly fewer patients undergoing surgery for stage I NSCLC and worsening disparities in survival between different patient populations.

Influence of the food environment on obesity risk in a large cohort of US veterans by community type

OBJECTIVE

The aim of this study was to examine relationships between the food environment and obesity by community type.

METHODS

Using electronic health record data from the US Veterans Administration Diabetes Risk (VADR) cohort, we examined associations between the percentage of supermarkets and fast-food restaurants with obesity prevalence from 2008 to 2018. We constructed multivariable logistic regression models with random effects and interaction terms for year and food environment variables. We stratified models by community type.

RESULTS

Mean age at baseline was 59.8 (SD = 16.1) years; 93.3% identified as men; and 2,102,542 (41.8%) were classified as having obesity. The association between the percentage of fast-food restaurants and obesity was positive in high-density urban areas (odds ratio [OR] = 1.033; 95% CI: 1.028-1.037), with no interaction by time (p = 0.83). The interaction with year was significant in other community types (p < 0.001), with increasing odds of obesity in each follow-up year. The associations between the percentage of supermarkets and obesity were null in high-density and low-density urban areas and positive in suburban (OR = 1.033; 95% CI: 1.027-1.039) and rural (OR = 1.007; 95% CI: 1.002-1.012) areas, with no interactions by time.

CONCLUSIONS

Many healthy eating policies have been passed in urban areas; our results suggest such policies might also mitigate obesity risk in nonurban areas.

Differences in cancer presentation, treatment, and mortality between rural and urban patients diagnosed with kidney cancer in the United States

INTRODUCTION

Rural-urban discrepancies in care and outcomes for kidney cancer (KCa) in the United States remains poorly understood. Our study aims to improve our understanding of the influence of rurality on KCa outcomes in the United States by analyzing differences in presentation, treatment, and mortality between urban areas (UAs) and rural areas (RAs) in the Surveillance, Epidemiology, and End Results (SEERs) database.

METHODS

SEERs data was queried from 2000 to 2019 for KCa patients. Patient counties were classified as UAs, rural adjacent areas (RAAs), or rural nonadjacent areas (RNAs) using Rural Urban Continuum Codes. Demographic, tumor characteristics, and treatment variables were compared. Propensity score matching was performed to create matched UA-RAA and UA-RNA cohorts. Multivariate regression evaluated rural-urban status as a predictor of treatment selection. Multivariate cox regression assessed the predictive value of rural-urban status for overall survival (OS) and cancer-specific survival (CSS). Kaplan-Meier analysis was used to generate survival curves for OS and CSS.

RESULTS

179,509 KCa patients were identified (UA = 87.0%, RAA = 7.7%, RNA = 5.3%). Patients in RAs were more likely to present with tumors of higher grade and stage than UAs. Following multivariate analysis, rural residency predicted undergoing nephrectomy (RAA: OR = 1.177, RNA: OR = 1.210) but was a negative predictor of receiving partial nephrectomy (RAA: OR = 0.744, RNA: OR = 0.717), all P < 0.001. Multivariate cox regression demonstrated that RAA or RNA residency was predictive of overall and cause-specific mortality. After matching, median OS was 151, 124, and 118 months for UA, RAA, and RNA cohorts respectively; mean CSS was 152, 147, and 144 months for UA, RAA, and RNA cohorts, respectively, all P < 0.001. Stage-specific analysis of CSS demonstrated significantly poorer CSS among RNA patients for localized, regionalized, and distant KCa after matching. Only RAA patients with localized KCa experienced significantly lower CSS than UA patients.

CONCLUSIONS

Patients in RAs are more likely to present with advanced KCa at diagnosis compared to those in UAs and may also experience different treatment options including a lesser likelihood of undergoing partial nephrectomy. Rural patients with KCa also demonstrated significantly worse OS and CSS compared to their urban counterparts. Further patient-level studies are required to better understand the discrepancy in CSS between urban and rural patients diagnosed with KCa.

Rural and Urban Differences in Hypertension Management Through Telehealth Before and During the COVID-19 Pandemic Among Commercially Insured Patients

BACKGROUND

The COVID-19 pandemic prompted a rapid increase in telehealth use. However, limited evidence exists on how rural and urban residents used telehealth and in-person outpatient services to manage hypertension during the pandemic.

METHODS

This longitudinal study analyzed 701,410 US adults (18-64 years) in the MarketScan Commercial Claims Database, who were continuously enrolled from January 2017 through March 2022. We documented monthly numbers of hypertension-related telehealth and in-person outpatient visits (per 100 individuals), and the proportion of telehealth visits among all hypertension-related outpatient visits, from January 2019 through March 2022. We used Welch's two-tail t-test to differentiate monthly estimates by rural-urban status and month-to-month changes.

RESULTS

From February through April 2020, the monthly number of hypertension-related telehealth visits per 100 individuals increased from 0.01 to 6.05 (P < 0.001) for urban residents and from 0.01 to 4.56 (P < 0.001) for rural residents. Hypertension-related in-person visits decreased from 20.12 to 8.30 (P < 0.001) for urban residents and from 20.48 to 10.15 (P < 0.001) for rural residents. The proportion of hypertension-related telehealth visits increased from 0.04% to 42.15% (P < 0.001) for urban residents and from 0.06% to 30.98% (P < 0.001) for rural residents. From March 2020 to March 2022, the monthly average of the proportions of hypertension-related telehealth visits was higher for urban residents than for rural residents (10.19% vs. 6.96%; P < 0.001).

CONCLUSIONS

Data show that rural residents were less likely to use telehealth for hypertension management. Understanding trends in hypertension-related telehealth utilization can highlight disparities in the sustained use of telehealth to advance accessible health care.

Malnutrition-related mortality trends in older adults in the United States from 1999 to 2020

BACKGROUND

Malnutrition mortality in older adults is underrepresented in scientific literature. This obscures any recent changes and hinders needed social change. This study aims to assess malnutrition mortality trends in older adults (≥ 65 years old) from 1999 to 2020 in the United States (U.S.).

METHODS

Mortality data from the Centers for Disease Control and Prevention's (CDC) Wide-Ranging Online Data for Epidemiology Research (WONDER) database were extracted. The ICD-10 Codes E40 - E46 were used to identify malnutrition deaths. Crude mortality rates (CMR) and age-adjusted mortality rates (AAMR) were extracted by gender, age, race, census region, and urban-rural classification. Joinpoint regression analysis was used to calculate annual percentage changes (APC) of AAMR by the permutation test and the parametric method was used to calculate 95% confidence intervals. Average Annual Percentage Changes (AAPC) were calculated as the weighted average of APCs.

RESULTS

Between 1999 and 2020, 93,244 older adults died from malnutrition. Malnutrition AAMR increased from 10.7 per 100,000 in 1999 to 25.0 per 100,000 in 2020. The mortality trend declined from 1999 to 2006 (APC = -8.8; 95% CI: -10.0, -7.5), plateaued till 2013, then began to rise from 2013 to 2020 with an APC of 22.4 (95% CI: 21.3, 23.5) and an overall AAPC of 3.9 (95% CI: 3.1, 4.7). Persons ≥ 85 years of age, females, Non-Hispanic Whites, residents of the West region of the U.S., and urban areas had the highest AAPCs in their respective groups.

CONCLUSION

Despite some initial decrements in malnutrition mortality among older adults in the U.S., the uptrend from 2013 to 2020 nullified all established progress. The end result is that malnutrition mortality rates represent a historical high. The burden of the mortality uptrends disproportionately affected certain demographics, namely persons ≥ 85 years of age, females, Non-Hispanic Whites, those living in the West region of the U.S., and urban areas. Effective interventions are strongly needed. Such interventions should aim to ensure food security and early detection and remedy of malnutrition among older adults through stronger government-funded programs and social support systems, increased funding for nursing homes, and more cohesive patient-centered medical care.

Vaccine promotion strategies in community pharmacy addressing vulnerable populations: a scoping review

CONTEXT

Social determinants of health are drivers of vaccine inequity and lead to higher risks of complications from infectious diseases in under vaccinated communities. In many countries, pharmacists have gained the rights to prescribe and administer vaccines, which contributes to improving vaccination rates. However, little is known on how they define and target vulnerable communities.

OBJECTIVE

The purpose of this study is to describe how vulnerable communities are targeted in community pharmacies.

METHODS

We performed a systematic search of the Embase and MEDLINE database in August 2021 inspired by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols (PRISMA ScR). Articles in English, French or Spanish addressing any vaccine in a community pharmacy context and that target a population defined as vulnerable were screened for inclusion.

RESULTS

A total of 1039 articles were identified through the initial search, and 63 articles met the inclusion criteria. Most of the literature originated from North America (n = 54, 86%) and addressed influenza (n = 29, 46%), pneumococcal (n = 14, 22%), herpes zoster (n = 14, 22%) or human papilloma virus vaccination (n = 14, 22%). Lifecycle vulnerabilities (n = 48, 76%) such as age and pregnancy were most often used to target vulnerable patients followed by clinical factors (n = 18, 29%), socio-economical determinants (n = 16, 25%) and geographical vulnerabilities (n = 7, 11%). The most frequently listed strategy was providing a strong recommendation for vaccination, promotional posters in pharmacy, distributing leaflet/bag stuffers and providing staff training. A total of 24 barriers and 25 facilitators were identified. The main barriers associated to each vulnerable category were associated to effective promotional strategies to overcome them.

CONCLUSION

Pharmacists prioritize lifecycle and clinical vulnerability at the expense of narrowing down the definition of vulnerability. Some vulnerable groups are also under targeted in pharmacies. A wide variety of promotional strategies are available to pharmacies to overcome the specific barriers experienced by various groups.

Age differences in Allostatic Load among adults in the United States by rural-urban residence

•Rural residence is associated with allostatic load levels by age groups.•Allostatic load is higher among rural adults with the exception of the oldest age group.•Evidence of a rural-urban convergence in allostatic load levels among oldest old.•These rural disadvantages remained strong even when accounting for covariates.•The study of allostatic load can improve our understanding of rural disparities.

Contextualizing physical activity in rural adults: Do relationships between income inequality, neighborhood environments, and physical activity exist?

OBJECTIVE

To examine if income inequality, social cohesion, and neighborhood walkability are associated with physical activity among rural adults.

DATA SOURCE

Cross-sectional data came from a telephone survey (August 2020-March 2021) that examined food access, physical activity, and neighborhood environments across rural counties in a southeastern state.

STUDY DESIGN

Multinomial logistic regression models assessed the likelihood of being active versus inactive and insufficiently active versus inactive in this rural population. Coefficients are presented as relative risk ratios (RRRs). Statistical significance was determined using 95% confidence intervals (CIs). All analyses were performed in STATA 16.1.

DATA COLLECTION/EXTRACTION METHODS

Trained university students administered the survey. Students verbally obtained consent, read survey items, and recorded responses into Qualtrics software. Upon survey completion, respondents were mailed a $10 incentive card and printed informed consent form. Eligible participants were ≥18 years old and current residents of included counties.

PRINCIPAL FINDINGS

Respondents in neighborhoods with relatively high social cohesion versus low social cohesion were more likely to be active than inactive (RRR = 2.50, 95% CI: 1.27-4.90, p < 0.01), after accounting for all other variables in the model. Income inequality and neighborhood walkability were not associated with different levels of physical activity in the rural sample.

CONCLUSIONS

Study findings contribute to limited knowledge on the relationship between neighborhood environmental contexts and physical activity among rural populations. The health effects of neighborhood social cohesion warrant more attention in health equity research and consideration when developing multilevel interventions to improve the health of rural populations.

Associations Between Gender Gaps in Life Expectancy, Air Pollution, and Urbanization: A Global Assessment With Bayesian Spatiotemporal Modeling

Objectives: It's evident that women have a longer life expectancy than men. This study investigates the spatiotemporal trends of gender gaps in life expectancy (GGLE). It demonstrates the spatiotemporal difference of the influence factors of population-weighted air pollution (pwPM_2.5) and urbanization on GGLE. Methods: Panel data on GGLE and influencing factors from 134 countries from 1960 to 2018 are collected. The Bayesian spatiotemporal model is performed. Results: The results show an obvious spatial heterogeneity worldwide with a continuously increasing trend of GGLE. Bayesian spatiotemporal regression reveals a significant positive relationship between pwPM_2.5, urbanization, and GGLE with the spatial random effects. Further, the regression coefficients present obvious geographic disparities across space worldwide. Conclusion: In sum, social-economic development and air quality improvement should be considered comprehensively in global policy to make a fair chance for both genders to maximize their health gains.

Conceptualizing rurality: The impact of definitions on the rural mortality penalty

Background

In the U.S., inequality is widespread and still growing at nearly every level conceivable. This is vividly illustrated in the long-standing, well-documented inequalities in outcomes between rural and urban places in the U.S.; namely, the rural mortality penalty of disproportionately higher mortality rates in these areas. But what does the concept of "rural" capture and conjure? How we explain these geographic differences has spanned modes of place measurement and definitions. We employ three county-level rural-urban definitions to (1) analyze how spatially specific and robust rural disparities in mortality are and (2) identify whether mortality outcomes are dependent on different definitions.

Methods

We compare place-based all-cause mortality rates using three typologies of "rural" from the literature to assess robustness of mortality rates across these rural and urban distinctions. Results show longitudinal all-cause mortality rate trends from 1968 to 2020 for various categories of urban and rural areas. We then apply this data to rural and urban geography to analyze the similarity in the distribution of spatial clusters and outliers in mortality using spatial autocorrelation methodologies.

Results

The rural disadvantage in mortality is remarkably consistent regardless of which rural-urban classification scheme is utilized, suggesting the overall pattern of rural disadvantage is robust to any definition. Further, the spatial association between rurality and high rates of mortality is statistically significant.

Conclusion

Different definitions yielding strongly similar results suggests robustness of rurality and consequential insights for actionable policy development and implementation.

Does Primary Care Availability Mediate the Relationship Between Rurality and Lower Life Expectancy in the United States?

INTRODUCTION

Rural counties in the United States have lower life expectancy than their urban counterparts and comprise the majority of primary care provider (PCP) shortage areas. We evaluated whether PCP availability mediates the relationship between rurality and lower life expectancy.

METHODS

We performed a mediation analysis on a panel dataset which included county-level estimates (N = 3103) for the years 2010, 2015, and 2017, and on a subset containing only rural counties (N = 1973), with life expectancy as the outcome variable, urbanity as the independent variable, and PCP density as the mediating variable. County-level socio-demographic data were included as covariates.

RESULTS AND CONCLUSIONS

PCP density mediated 10.1% of the relationship between urbanity and life expectancy in rural counties. Increasing PCP density in rural counties with PCP shortages to the threshold of being a non-shortage county (>1 physician/3500 population, as defined by the Health Resources and Services Administration) would be expected to increase mean life expectancy in the county by 26.1 days (95% confidence interval [CI]: 11.4, 49.3) and increasing it to the standards recommended by a Secretarial Negotiated Rulemaking Committee would be expected to increase mean life expectancy by 65.3 days (95% CI: 42.6, 87.5). PCP density is a meaningful mediator of the relationship between urbanity and life expectancy. The mediation effect observed was higher in rural counties compared to all counties. Understanding how PCP density may be increased in rural areas may be of benefit to rural life expectancy.

Higher ATM expression in lymphoblastoid cell lines from centenarian compared with younger women

With increased life expectancies in developed countries, cancer rates are becoming more common among the elderly. Cancer is typically driven by a combination of germline and somatic mutations accumulating during an individual's lifetime. Yet, many centenarians reach exceptionally old age without experiencing cancer. It was suggested that centenarians have more robust DNA repair and mitochondrial function, allowing improved maintenance of DNA stability. In this study, we applied real-time quantitative PCR to examine the expression of ATM in lymphoblastoid cell lines (LCLs) from 15 healthy female centenarians and 24 younger female donors aged 21-88 years. We observed higher ATM mRNA expression of in LCLs from female centenarians compared with both women aged 21-48 years (FD = 2.0, p = .0016) and women aged 56-88 years (FD = 1.8, p = .0094. Positive correlation was found between ATM mRNA expression and donors age (p = .0028). Levels of hsa-miR-181a-5p, which targets ATM, were lower in LCLs from centenarians compared with younger women. Our findings suggest a role for ATM in protection from age-related diseases, possibly reflecting more effective DNA repair, thereby reducing somatic mutation accumulation during aging. Further studies are required for analyzing additional DNA repair pathways in biosamples from centenarians and younger age men and women.

Somatotropic Axis, Pace of Life and Aging

Mice with genetic growth hormone (GH) deficiency or GH resistance live much longer than their normal siblings maintained under identical conditions with unlimited access to food. Extended longevity of these mutants is associated with extension of their healthspan (period of life free of disability and disease) and with delayed and/or slower aging. Importantly, GH and GH-related traits have been linked to the regulation of aging and longevity also in mice that have not been genetically altered and in other mammalian species including humans. Avai+lable evidence indicates that the impact of suppressed GH signaling on aging is mediated by multiple interacting mechanisms and involves trade-offs among growth, reproduction, and longevity. Life history traits of long-lived GH-related mutants include slow postnatal growth, delayed sexual maturation, and reduced fecundity (smaller litter size and increased intervals between the litters). These traits are consistent with a slower pace-of-life, a well-documented characteristic of species of wild animals that are long-lived in their natural environment. Apparently, slower pace-of-life (or at least some of its features) is associated with extended longevity both within and between species. This association is unexpected and may appear counterintuitive, because the relationships between adult body size (a GH-dependent trait) and longevity within and between species are opposite rather than similar. Studies of energy metabolism and nutrient-dependent signaling pathways at different stages of the life course will be needed to elucidate mechanisms of these relationships.