In the last 20 years, Black adults living in rural areas of the U.S. have experienced high mortality rates due to diabetes, high blood pressure, cardiovascular disease and stroke compared to white adults. According to a research letter published March 15 in the Journal of the American College of Cardiology, racial disparities improved minimally in rural areas over the last two decades, with larger improvements occurring in urban areas.

Using data from the CDC Wonder Database, Rahul Aggarwal, MD, FACC, et al., assessed age-adjusted mortality rates for Black and white adults 25 years and older, stratified by rural or urban area from 1999 to 2018. They then determined if disparities in Black vs. white mortality rates for each condition – diabetes, high blood pressure, cardiovascular disease and stroke – changed in rural areas compared to urban areas during the timeframe.

Results showed that over the last two decades, mortality rates from each condition have been highest among Black adults living in rural areas – diabetes and high blood pressure-related mortality are two to three times higher for Black adults compared to white adults. Over the entire study period, the researchers found mortality rates in rural and urban areas were higher for Black adults compared to white adults for all conditions. However, between 1999 and 2018 the gap in mortality rates between Black vs. white adults narrowed more rapidly in urban areas for diabetes and high blood pressure compared to those in rural areas. In contrast, racial disparities narrowed for cardiovascular disease and stroke mortality for rural Black adults.

According to the researchers, the persistent racial disparities for diabetes and high blood pressure-related mortality in rural areas may reflect structural inequities that impede access to primary, preventative and specialist care for rural Black adults. However, the modest improvement in racial disparities for cardiovascular disease and stroke mortality in rural areas may reflect improvements in emergency services, the expansion of referral networks, the development of stroke and myocardial infarction care centers, and the implementation of time to procedure metrics such as door-to-balloon.

"While modest gains have been made in reducing racial health inequities in urban areas, large gaps in death rates between Black and white adults persist in rural areas, particularly for diabetes and hypertension. We haven't meaningfully narrowed the racial gap in outcomes for these conditions in rural areas over the last two decades," said Rishi Wadhera, MD, MPP, MPhil, senior author of the study. "Given that diabetes, hypertension, and heart disease are preventable and treatable, targeted public health and policy efforts are needed to address structural inequities that contribute to racial disparities in rural health."

In 2020 the ACC formed a Board of Trustees Task Force on Health Equity, which is charged with coordinating an ACC-wide approach to improving equity for patients and populations, including access to care, addressing systemic racism and exploring social determinants of health. Learn more about ACC's Diversity and Inclusion initiative.

Clinical Topics: Cardiovascular Care Team, Prevention, Hypertension

Keywords: African Americans, Cardiovascular Diseases, Rural Health, Racism, Benchmarking, Public Health, Social Determinants of Health, Diabetes Mellitus, Hypertension, Stroke, Heart Diseases, Myocardial Infarction

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