Reducing Potentially Excess Deaths from the Five Leading Causes of Death in the Rural United States

Abstract

In 2014, the all-cause age-adjusted death rate in the United States reached a historic low of 724.6 per 100,000 population (1). However, mortality in rural (nonmetropolitan) areas of the United States has decreased at a much slower pace, resulting in a widening gap between rural mortality rates (830.5) and urban mortality rates (704.3) (1). During 1999–2014, annual age-adjusted death rates for the five leading causes of death in the United States (heart disease, cancer, unintentional injury, chronic lower respiratory disease (CLRD), and stroke) were higher in rural areas than in urban (metropolitan) areas (Figure 1). In most public health regions (Figure 2), the proportion of deaths among persons aged <80 years (U.S. average life expectancy) (2) from the five leading causes that were potentially excess deaths was higher in rural areas compared with urban areas (Figure 3). Several factors probably influence the rural-urban gap in potentially excess deaths from the five leading causes, many of which are associated with sociodemographic differences between rural and urban areas. Residents of rural areas in the United States tend to be older, poorer, and sicker than their urban counterparts (3). A higher proportion of the rural U.S. population reports limited physical activity because of chronic conditions than urban populations (4). Moreover, social circumstances and behaviors have an impact on mortality and potentially contribute to approximately half of the determining causes of potentially excess deaths (5).

FIGURE 1

Age-adjusted death rates among persons of all ages for five leading causes of death in nonmetropolitan and metropolitan areas,* by year — National Vital Statistics System, United States, 1999–2014 Source: Moy E, García MG, Bastian B, et al. Leading causes of death in nonmetropolitan and metropolitan areas—United States, 1999–2014. MMWR Surveill Summ 2017;66(No. SS-1). * Nonmetropolitan and metropolitan areas were identified using the Office of Management and Budget’s 2013 county-based classification scheme. (Source: Office of Management and Budget, White House. Revised delineations of metropolitan statistical areas, micropolitan statistical areas, and combined statistical areas, and guidance on uses of the delineations of these areas. Washington, DC: Office of Management and Budget; 2013. https://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b13-01.pdf)

FIGURE 2

U.S. Department of Health and Human Services public health regions* Source: Moy E, García MG, Bastian B, et al. Leading causes of death in nonmetropolitan and metropolitan areas—United States, 1999–2014. MMWR Surveill Summ 2017;66(No. SS-1). * 1 = Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont; 2 = New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands (Mortality data for residents of U.S. territories were excluded.); 3 = Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia; 4 = Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee; 5 = Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin; 6 = Arkansas, Louisiana, New Mexico, Oklahoma, and Texas; 7 = Iowa, Kansas, Missouri, and Nebraska; 8 = Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming; 9 = Arizona, California, Hawaii, and Nevada; 10 = Alaska, Idaho, Oregon, and Washington.

FIGURE 3

Percentage of potentially excess deaths* among persons aged <80 years for five leading causes of death in nonmetropolitan and metropolitan areas,† by year and public health region§ — National Vital Statistics System, United States, 2014 Source: Moy E, García MG, Bastian B, et al. Leading causes of death in nonmetropolitan and metropolitan areas—United States, 1999–2014. MMWR Surveill Summ 2017;66(No. SS-1). * For each age group and cause, the death rates of the three states with the lowest rates during 2008−2010 (benchmark states) were averaged to produce benchmark rates. Potentially excess deaths were defined as deaths among persons aged <80 years in excess of the number that would be expected if the age group−specific death rates of the benchmark states occurred across all states. † Nonmetropolitan and metropolitan areas were identified using the Office of Management and Budget’s 2013 county-based classification scheme. (Source: Office of Management and Budget, White House. Revised delineations of metropolitan statistical areas, micropolitan statistical areas, and combined statistical areas, and guidance on uses of the delineations of these areas. Washington, DC: Office of Management and Budget; 2013. https://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b13-01.pdf). § 1 = Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont; 2 = New Jersey and New York; 3 = Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia; 4 = Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee; 5 = Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin; 6 = Arkansas, Louisiana, New Mexico, Oklahoma, and Texas; 7 = Iowa, Kansas, Missouri, and Nebraska; 8 = Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming; 9 = Arizona, California, Hawaii, and Nevada; 10 = Alaska, Idaho, Oregon, and Washington.