Despite targeted efforts, racial disparities persist in rural areas

In the last 20 years, Black adults living in rural areas of the United States have experienced high mortality rates due to diabetes, high blood pressure, heart disease, and stroke compared to white adults.

In a research letter written by colleagues at Beth Israel Deaconess Medical Center (BIDMC) and published in the Journal of the American College of Cardiology, the authors report racial disparities improved only minimally in rural areas over the last two decades, with larger improvements occurring in urban areas.

"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, a cardiologist, and researcher in the Smith Center for Outcomes Research in Cardiology at BIDMC and senior author of the letter.

"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. Given that these conditions are preventable and treatable, targeted public health and policy efforts are needed to address structural inequities that contribute to racial disparities in rural health."

Using data from the CDC Wonder Database, researchers assessed age-adjusted mortality rates for Black and white adults 25 years and older, stratified by rural or urban areas, between 1999 and 2018.

They then compared mortality rates among Black and white individuals for each condition -- diabetes, high blood pressure, heart disease, and stroke -- and whether they were different in rural and urban areas during the timeframe.

Over the last two decades, Black adults living in rural areas experienced the highest mortality rates from each condition. Black adults die from diabetes and high blood pressure-related complications two to three times as often as white adults.

Over the entire study period, the researchers found mortality rates in rural and urban areas were significantly higher for Black adults compared to white adults for all conditions.

However, between 1999 and 2018, the gap in mortality rates between Black and white adults narrowed more rapidly in urban areas for diabetes and high blood pressure compared to those in rural areas. In contrast, racial disparities in heart disease and stroke mortality narrowed in rural areas.

"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," said Rahul Aggarwal, MD, a clinical fellow in the Department of Medicine at BIDMC, and contributing author of the letter.

"However, the modest improvement in racial disparities for heart 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."

In a second research article published in the Journal of the American Medical Association, Wadhera and colleagues examined how federally-mandated pay-for-performance programs, which financially reward or penalize more than 3,000 hospitals in the United States, affect hospitals that care for a higher percentage of Black adults.

They found that hospitals caring for a high proportion of Black adults were significantly more likely to be penalized by these national programs run by the Centers for Medicare & Medicaid Services, potentially hampering hospitals' ability to improve care for Black populations.

We know that there are substantial gaps in health outcomes between Black and white adults in the United States. Disproportionately penalizing already under-resourced hospitals that care for Black communities makes very little sense, is not going to improve health equity and may, instead, unintentionally widen disparities. We need a more thoughtful approach."

Rishi Wadhera, MD, MPP, MPhil, Cardiologist, Study Senior Author and Researcher, Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center