Chronic Disease Death Rates Continue to Reflect Racial Disparities

Black individuals in rural parts of the US have experienced higher chronic disease death rates than whites in the last 20 years, reflecting significant racial disparities and gaps in care.

In a research letter written by a team from Beth Israel Deaconess Medical Center (BIDMC), the group stated that black adults living in rural areas had higher mortality rates due to diabetes, high blood pressure, heart disease, and stroke compared to white adults.

Researchers noted that racial disparities improved only minimally in rural areas over the last 20 years, while there were larger improvements 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."

For the analysis, researchers used data from the CDC Wonder Database. The group analyzed age-adjusted mortality rates for black and white adults 25 years and older, stratified by rural or urban area, between 1999 and 2018.

The team then compared mortality rates among black and white individuals for each condition – diabetes, high blood pressure, heart disease, and stroke – and assessed whether the rates were different in rural and urban areas during the timeframe.

Researchers found that over the past two decades, black adults living in rural areas experienced the highest mortality rate from each chronic condition. Black adults die from diabetes and high blood pressure-related complications two to three times as often as white adults, the team stated.

Over the entire study period, the group found that 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 team stated that the US urgently needs targeted public health initiatives to reduce racial inequities in cardiovascular health in rural parts of the country.

"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, 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 separate research letter published in JAMA, the team analyzed the impact of federal-mandated pay-for-performance programs impact hospitals that care for a higher percentage of black adults. These programs financially reward or penalize more than 3,000 hospitals in the US.

Researchers found that hospitals caring for a high proportion of black adults were significantly more likely to be penalized by these national programs. This could potentially hinder hospitals’ efforts 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," said Wadhera, senior author of the paper.

"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."

The results from both studies mirror findings from a separate analysis recently published in Diabetes Research and Clinical Practice. Researchers examined data at the city level and found that in all 30 of the largest cities of the US, there are significant racial disparities in diabetes mortality rates.

Diabetes mortality rates are higher among black individuals than they are among whites in all 30 cities, and diabetes mortality inequities are four times larger in some cities compared to others.

“The COVID-19 pandemic has increased awareness about racial health disparities in the US,” said Joanna Buscemi, a psychologist of DePaul University and lead author of the study.

“Most studies do look at the US overall, but that can hide these nuances and differences that exist across cities.”