Abstract
This study analyzes all deaths occurring in the US using the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from 1999-2019 and the National Center for Health Statistics Urban-Rural Classification Scheme to create population categories per the 2013 US Census classification (large, small- or medium-sized, and rural areas).
The economic, social, and political challenges facing rural areas in the US have implications for the entire country. Even though rural-urban disparities in mortality from such diseases as chronic lung disease and cardiovascular disease have been described,1,2 less is known about recent trends in rural-urban differences in age-adjusted mortality rates (AAMRs) overall in the US.
Methods
We analyzed all deaths occurring in the US using the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2019. We used the National Center for Health Statistics Urban-Rural Classification Scheme to create the following population categories per the 2013 US Census classification: large metropolitan area (≥1 million), small- or medium-sized metropolitan area (50 000-999 999), and rural area (<50 000).3
The AAMRs per 100 000 population were calculated by multiplying the age-specific death rate for each age group by the corresponding weight from the 2000 standard US population, summing across all age groups, and then multiplying by 100 000. We stratified the results by age, sex, and race/ethnicity. We also analyzed these subgroups among individuals aged 25 to 64 years.
We estimated the annual percentage change (APC) in AAMR using Poisson regression with log-link and robust standard errors and included an interaction term to test for differences in time trends. We performed all analyses using Stata version 16 (StataCorp), considering a 2-tailed P < .05 as statistically significant. The data were publicly available and deidentified and therefore informed consent was not applicable per HHS regulation 45 CFR 46.101(c).
Results
From 1999 to 2019, rural areas had the highest AAMRs. The overall AAMR in large metropolitan areas decreased from 861.5/100 000 to 664.5/100 000 and in rural areas it decreased from 923.8/100 000 to 834.0/100 000 (P < .001 for time trend) (Figure and Table). The absolute difference in the AAMRs between large metropolitan areas and rural areas increased from 62.3/100 000 (95% CI, 59.2/100 000-65.4/100 000) in 1999 to 169.5/100 000 (95% CI, 167.0/100 000-172.1/100 000) in 2019, which was an increase of 172%.
Figure. Mortality Trends in the US From 1999 to 2019.
Table. Age-Adjusted Mortality Rates (AAMRs) per 100 000 Population per Year in the US, 1999-2019.
| Total (N = 53 422 612) |
Large metropolitan area (n = 26 305 365 [49.6%]) |
Small- or medium-sized metropolitan area (n = 16 825 867 [31.5%]) |
Rural area (n = 10 291 380 [19.3%]) |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| AAMR/100 000 (95% CI) |
APC, % (95% CI) |
AAMR/100 000 (95% CI) |
APC, % (95% CI) |
AAMR/100 000 (95% CI) |
APC, % (95% CI) |
AAMR/100 000 (95% CI) |
APC, % (95% CI) |
|||||
| 1999 | 2019 | 1999-2019 | 1999 | 2019 | 1999-2019 | 1999 | 2019 | 1999-2019 | 1999 | 2019 | 1999-2019 | |
| Overall | 875.6 (874.5 to 876.7) | 715.2 (714.4 to 716.1) | −1.1 (−1.2 to −0.1)a | 861.5 (860.0 to 863.1) | 664.5 (664.5 to 665.6) | −1.4 (−1.6 to −1.2)a | 871.3 (869.2 to 873.3) | 744.8 (743.3 to 746.4) | −0.9 (−1.0 to −0.7)a | 923.8 (921.2 to 936.5) | 834.0 (831.7 to 836.3) | −0.5 (−0.7 to −0.4)a |
| Age group, y | ||||||||||||
| <25 | 72.9 (72.4 to 73.4) | 58.1 (57.7 to 58.6) | −1.3 (−1.5 to −1.1)a | 69.8 (69.1 to 70.5) | 54.2 (53.6 to 54.8) | −1.5 (−1.7 to −1.3)a | 71.5 (70.5 to 72.5) | 59.9 (59.0 to 60.7) | −1.1 (−1.3 to −0.9)a | 86.4 (85.0 to 87.9) | 70.9 (69.5 to 72.3) | −1.2 (−1.4 to −1.0)a |
| 25-64 | 365.4 (364.4 to 366.4) | 345.6 (344.8 to 346.5) | −0.4 (−0.6 to −0.2)a | 356.0 (354.7 to 357.3) | 304.1 (303.1 to 305.2) | −0.9 (−1.2 to −0.7)a | 364.2 (362.4 to 366.0) | 378.5 (376.8 to 380.1) | 0.1 (−0.1 to 0.3)b | 398.7 (396.1 to 401.2) | 447.0 (444.4 to 449.6) | 0.6 (0.4 to 0.7)a |
| ≥65 | 5220.1 (5212.5 to 5227.7) | 4073.8 (4068.3 to 4079.4) | −1.3 (−1.4 to −1.2)a | 5155.9 (5145.2 to 5166.7) | 3854.2 (3846.7 to 3861.7) | −1.5 (−1.7 to −1.4)a | 5194.5 (5180.7 to 5208.3) | 4167.8 (4157.9 to 4177.7) | −1.2 (−1.3 to −1.1)a | 5426.8 (5409.2 to 5444.5) | 4560.2 (4546.1 to 4574.4) | −0.9 (−1.0 to −0.8)a |
| Sex | ||||||||||||
| Male | 1067.0 (1065.1 to 1069.0) | 846.7 (845.3 to 848.1) | −1.2 (−1.4 to −1.1)a | 1044.6 (1041.9 to 1047.4) | 789.6 (787.7 to 791.4) | −1.5 (−1.7 to −1.3)a | 1059.9 (1056.4 to 1063.5) | 879.0 (876.4 to 881.5) | −1.0 (−1.2 to −0.8)a | 1140.4 (1135.7 to 1145.0) | 977.3 (973.6 to 981.0) | −0.8 (−1.0 to −0.6)a |
| Female | 734.0 (732.7 to 735.3) | 602.7 (601.7 to 603.8) | −1.1 (−1.2 to −0.9)a | 727.3 (725.5 to 729.2) | 560.0 (558.7 to 561.4) | −1.4 (−1.5 to −1.3)a | 730.7 (728.3 to 733.1) | 628.5 (626.5 to 630.4) | −0.8 (−0.9 to −0.7)a | 760.2 (757.1 to 763.4) | 704.5 (701.7 to 707.4) | −0.4 (−0.5 to −0.3)a |
| Race/ethnicityc | ||||||||||||
| Non-Hispanic White | 859.8 (858.6 to 861.0) | 736.8 (735.7 to 737.8) | −0.8 (−0.9 to −0.7)a | 845.3 (843.6 to 847.0) | 688.3 (686.9 to 689.7) | −1.1 (−1.2 to −0.9)a | 856.8 (854.6 to 858.9) | 753.0 (751.2 to 754.8) | −0.7 (−0.8 to −0.6)a | 900.5 (897.8 to 903.3) | 833.2 (830.6 to 835.7) | −0.4 (−0.5 to −0.3)a |
| Non-Hispanic Black | 1150.1 (1145.7 to 1154.4) | 870.7 (867.8 to 873.7) | −1.6 (−1.8 to −1.4)a | 1138.2 (1132.7 to 1143.6) | 837.8 (834.3 to 841.4) | −1.8 (−2.0 to −1.6)a | 1158.8 (1149.8 to 1167.7) | 997.2 (911.6 to 924.0) | −1.4 (−1.6 to −1.2)a | 1199.1 (1186.8 to 1211.3) | 978.9 (968.9 to 988.8) | −1.2 (−1.3 to −1.0)a |
| Asian or Pacific Islander | 519.7 (513.7 to 525.6) | 383.5 (380.8 to 386.2) | −1.5 (−1.7 to −1.4)a | 490.9 (484.1 to 497.7) | 366.0 (363.0 to 369.0) | −1.5 (−1.6 to −1.3)a | 576.1 (563.5 to 588.7) | 444.3 (437.7 to 450.9) | −1.4 (−1.5 to −1.2)a | 772.3 (733.7 to 811.0) | 452.1 (435.7 to 468.5) | −2.0 (−2.7 to −1.3)a |
| Native American/Alaska Native | 780.9 (764.8 to 796.9) | 561.2 (553.3 to 569.2) | −1.5 (−1.7 to −1.3)a | 507.3 (484.5 to 530.2) | 331.6 (321.6 to 341.6) | −2.2 (−2.5 to −2.0)a | 698.6 (670.7 to 726.6) | 565.9 (551.4 to 580.5) | −0.9 (−1.1 to −0.8)a | 1092.1 (1061.7 to 1122.5) | 870.7 (853.0 to 888.4) | −0.8 (−1.1 to −0.5)a |
| Hispanic | 676.4 (671.9 to 680.9) | 523.8 (521.5 to 526.1) | −1.5 (−1.7 to −1.3)a | 652.1 (646.8 to 657.5) | 502.4 (499.6) to 505.1) | −1.5 (−1.7 to −1.4)a | 703.7 (694.2 to 713.2) | 568.1 (563.3 to 572.9) | −1.3 (−1.5 to −1.1)a | 818.7 (800.1 to 837.2) | 579.1 (569.7 to 588.6) | −1.6 (−1.9 to −1.3)a |
| Aged 25-64 y by race/ethnicity | ||||||||||||
| Non-Hispanic White | 338.9 (337.8 to 339.9) | 354.4 (353.3 to 355.5) | 0.2 (0.1 to 0.4)d | 323.7 (322.2 to 325.3) | 307.6 (306.2 to 309.1) | 0.3 (−0.5 to −0.1)d | 343.2 (341.3 to 345.2) | 380.3 (378.3 to 382.3) | 0.5 (0.4 to 0.7)a | 371.3 (368.7 to 374.0) | 439.1 (436.2 to 442.1) | 0.8 (0.7 to 1.0)a |
| Non-Hispanic Black | 656.1 (652.0 to 660.2) | 515.4 (512.5 to 518.3) | −1.6 (−1.9 to −1.2)a | 649.8 (644.9 to 654.8) | 488.8 (485.4 to 492.3) | −1.8 (−2.2 to −1.5)a | 647.0 (638.6 to 655.4) | 551.4 (545.3 to 557.6) | −1.1 (−1.4 to −0.7)a | 715.4 (702.4 to 728.5) | 617.0 (606.3 to 627.8) | −0.9 (−1.3 to −0.6)a |
| Asian or Pacific Islander | 177.1 (173.6 to 180.7) | 145.6 (143.5 to 147.7) | 1.1 (−1.4 to −0.8)a | 163.1 (159.2 to 167.0) | 132.2 (129.9 to 134.4) | −1.2 (−1.6 to −0.9)a | 213.8 (205.0 to 222.6) | 192.0 (186.3 to 197.7) | −0.6 (−1.0 to −0.2)d | 301.5 (274.3 to 328.6) | 217.5 (202.3 to 232.7) | −1.1 (−2.0 to −0.2)d |
| Native American/Alaska Native | 385.5 (374.3 to 396.7) | 369.6 (362.0 to 377.3) | −0.2 (−0.5 to 0.1)b | 250.6 (235.5 to 265.6) | 193.6 (185.2 to 201.9) | −1.4 (−1.9 to −1.0)a | 361.3 (341.6 to 381.1) | 379.4 (365.2 to 393.6) | 0.4 (0.1 to 0.6)d | 562.1 (538.7 to 585.6) | 656.8 (636.5 to 677.0) | 0.8 (0.6 to 1.1)a |
| Hispanic | 284.3 (281.2 to 287.3) | 240.3 (238.5 to 242.0) | −1.2 (−1.5 to −0.8)a | 275.1 (271.5 to 278.8) | 223.4 (221.3 to 225.4) | −1.4 (−1.8 to −1.1)a | 295.6 (289.1 to 302.1) | 276.6 (272.7 to 280.4) | −0.7 (−1.0 to −0.4)a | 341.3 (328.3 to 354.4) | 283.7 (276.0 to 291.4) | −0.7 (−1.0 to −0.4)a |
| Aged 25-64 y by sex | ||||||||||||
| Male | 464.2 (462.6 to 465.8) | 439.9 (438.5 to 441.3) | −0.4 (−0.6 to −0.2)d | 452.0 (449.8 to 454.1) | 390.8 (389.1 to 392.5) | −0.9 (−1.2 to −0.7)a | 462.8 (459.8 to 465.7) | 480.3 (477.7 to 483.0) | 0.1 (−0.1 to 0.3)b | 505.5 (501.5 to 509.6) | 552.7 (548.6 to 556.8) | 0.4 (0.2 to 0.6)a |
| Female | 271.1 (270.0 to 272.3) | 254.2 (253.2 to 255.2) | −0.4 (−0.5 to −0.2)a | 265.4 (263.8 to 267.0) | 220.7 (219.5 to 222.0) | −1.0 (−1.2 to −0.8)a | 270.0 (267.8 to 272.2) | 280.1 (278.1 to 282.1) | 0.2 (−0 to 0.3)b | 293.1 (290.0 to 296.1) | 339.9 (336.6 to 343.1) | 0.8 (0.7 to 0.9)a |
Abbreviation: APC, annual percentage change.
Statistically significant (P < .001).
Not statistically significant.
Reported by the funeral director as provided by an informant (typically the next of kin) or on the basis of observation in the absence of an informant.
P < .05.
From 1999 to 2019, the AAMRs declined for all ages except for rural residents aged 25 to 64 years, in whom the AAMR increased from 398.7/100 000 to 447.0/100 000 (APC, 0.6%; 95% CI, 0.4%-0.7%). Across areas, men had greater AAMRs than women (P < .001); however, men experienced a greater APC reduction in the AAMRs. Among men, the AAMR in large metropolitan areas decreased from 1044.6/100 000 in 1999 to 789.6/100 000 in 2019 and in rural areas it decreased from 1140.4/100 000 to 977.3/100 000. Among women, the AAMR in large metropolitan areas decreased from 727.3/100 000 in 1999 to 560.0/100 000 in 2019 and in rural areas it decreased from 760.2/100 000 to 704.5/100 000.
Among men, the absolute difference in the AAMRs between large metropolitan areas and rural areas increased from 95.8/100 000 (95% CI, 90.4/100 000-101.2/100 000) in 1999 to 187.7/100 000 (95% CI, 183.6/100 000-191.8/100 000) in 2019. Among women, the absolute difference in the AAMRs between large metropolitan areas and rural areas increased from 32.9/100 000 (95% CI, 29.2/100 000-36.8/100 000) in 1999 to 144.5/100 000 (95% CI, 141.3/100 000-147.7/100 000) in 2019.
Non-Hispanic Black people had greater AAMRs than all other racial/ethnic groups across all 3 US Census–categorized areas (P < .001). However, the racial/ethnic group that experienced the smallest reductions in the AAMRs among all 3 areas was non-Hispanic White people in rural areas, decreasing from 900.5/100 000 in 1999 to 833.2/100 000 in 2019 (APC, −0.4%; 95% CI, −0.5% to −0.3%). Among rural residents aged 25 to 64 years, there were reductions in the AAMRs for non-Hispanic Black people, Asian people, and Hispanic people and increases in the AAMRs for non-Hispanic White people and Native American people.
Discussion
Rural residents experienced greater mortality and the disparity between rural and large metropolitan areas tripled from 1999 to 2019. Even though there were reductions in AAMRs for all ages, there was a 12.1% increase in the AAMR for rural residents aged 25 to 64 years, which was driven by an increasing AAMR among non-Hispanic White people. However, non-Hispanic Black people had greater AAMRs across all 3 US Census–categorized areas than all other racial/ethnic groups. These trends could be further exacerbated by rural hospital closures4 and the COVID-19 pandemic.5
One limitation is that the rural population decreased from 16.0% in 1999 to 14.0% in 2019, although this would not account for the findings. To reverse increasing rural-urban disparities, researchers, funders, and policy makers must understand the factors worsening rural health and design programs and policies accordingly.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
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