Defining rurality: an evaluation of rural definitions and the impact on survival estimates

Abstract

Background: Patients with cancer living in rural areas have inferior cancer outcomes; however, studies examining this association use varying definitions of "rural," complicating comparisons and limiting the utility of the results for policy makers and future researchers.

Methods: Surveillance, Epidemiology, and End Results data (2000-2016) were used to assess risk of cancer mortality and mortality from any cause across 4 definitions of rurality: Urban Influence codes (UIC), National Center for Health Statistics (NCHS), Rural-Urban continuum codes (RUCC), and Index of Relative Rurality. Binary (urban vs rural) and ternary (urban, micropolitan, rural) definitions were evaluated. Multivariable parametric survival models estimated hazards of mortality overall and among 3 cancer groupings: screening related, obesity related, and tobacco related. Definition agreement was also assessed.

Results: Overall, 3 788 273 patients with an incident cancer representing 605 counties were identified. There was little discordance between binary definitions of rural vs urban and moderate agreement at the 3 levels. Adjusted models using binary definitions revealed 15% to 17% greater hazard of cancer mortality in rural compared with urban. At the 3 levels when comparing rural with metropolitan, RUCC and NCHS saw similarly increased hazard ratios; however, Index of Relative Rurality did not. Screening-related cancers saw the highest hazards of mortality and the largest divergence between definitions. Obesity-related and tobacco-related cancers saw similarly increased hazards of mortality at the binary and ternary levels.

Conclusions: Hazard of death is similar across binary definitions; however, this differed when categorized as ternary or continuous, especially among screening-related cancers. Results suggest that study purpose should direct choice of definitions and categorization.

Figure 1.

Agreement between A) binary and B) ternary definitions of rurality using weighted Cohen kappa. The binary Rural-Urban continuum codes (RUCC), National Center for Health Statistics (NCHS), and Urban Influence Codes (UIC) had perfect agreement with each other and substantial agreement with the binary Index of Relative Rurality (IRR; κ = 0.73). Among the ternary definitions, NCHS and UIC had perfect agreement, RUCC and NCHS had the highest agreement (κ = 0.84), and the NCHS and IRR had the lowest agreement (κ = 0.58).

Figure 2.

Proportion rural in each county as defined by the ternary Rural-Urban continuum codes (RUCC) (A), Index of Relative Rurality (IRR) (B), and National Center for Health Statistics (NCHS) (C) definitions of rurality among the US Surveillance, Epidemiology, and End Results (SEER) and non-SEER populations.

Figure 3.

Hazard of cancer-related mortality among the A) overall, B) screening-related, C) obesity-related, and D) tobacco-related groups across ternary definitions of rurality. IRR = Index of Relative Rurality; NCHS = National Center for Health Statistics; RUCC = Rural-Urban Continuum Codes.