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CME / ABIM MOC / CE

How Do Urban-Rural Disparities Affect Diabetes-Related Death Rates?

  • Authors: News Author: Miriam E. Tucker; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 11/11/2022
  • Valid for credit through: 11/11/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for diabetologists and endocrinologists, family medicine/primary care clinicians, internists, nurses, nurse practitioners, pharmacists, physician assistants, public health and prevention officials, metabolism clinicians, nephrologists, and other members of the health care team for patients with diabetes.

The goal of this activity is for learners, members of the healthcare team to be better able to describe trends in age-adjusted mortality rate in urban and rural areas in the US over the course of the past 2 decades, based on an analysis of Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research.

Upon completion of this activity, participants will:

  • Assess trends in diabetes-related mortality in urban and rural areas in the US from 1999 to 2019, based on an analysis of CDC WONDER
  • Evaluate clinical and public health implications of trends in diabetes-related mortality in urban and rural areas in the US from 1999 to 2019, based on an analysis of CDC WONDER
  • Outline implications for the healthcare team


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News Author

  • Miriam E. Tucker

    Freelance writer, Medscape

    Disclosures

    Miriam E. Tucker has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie Inc.

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Nurse Planner

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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CME / ABIM MOC / CE

How Do Urban-Rural Disparities Affect Diabetes-Related Death Rates?

Authors: News Author: Miriam E. Tucker; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 11/11/2022

Valid for credit through: 11/11/2023

processing....

Clinical Context

Diabetes is a leading cause of mortality worldwide. Diabetes-related deaths have declined recently in the US and other high-income countries, but not in all regions.

A recent analysis from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) Multiple Cause of Death database for US residents describes potential healthcare disparities in patients with diabetes.

Type 2 diabetes risk may be higher among elderly and ethnic minorities more likely to live in rural areas. Patients in rural vs urban communities may experience health care disparities causing age-adjusted mortality rate differences.

Study Synopsis and Perspective

There has been a decline in deaths associated with diabetes in urban, but not rural, areas in the past 2 decades, with the reduction in diabetes-related mortality mainly seen among women and older patients.

Rural areas, in contrast, have seen minimal gains, and there are trends toward worsening rates of diabetes death among men and patients younger than 55 years.

As a result, the mortality gap between rural and urban areas has tripled in the past 3 decades, cardiologist Ofer Kobo, MD, and colleagues report in a short communication published online September 10 in Diabetologia.

"A synchronized effort is required to improve cardiovascular health indices and healthcare access in rural areas and to decrease diabetes-related mortality," say Dr Kobo, from the Hillel Yaffe Medical Centre, Hadera, Israel, and Keele University, UK, and coauthors.

Significant Male–Female Gap

The findings are from the CDC WONDER Multiple Cause of Death database for US residents for 1999 to 2019.

Data were analyzed for 1,572,536 death certificates that list diabetes as the underlying cause, of which 79.8% were in urban counties, and 5,025,745 death certificates with diabetes as a contributing cause of death, of which 79.5% were in urban counties.

In urban areas, the age-adjusted mortality rate of diabetes as underlying and contributing causes of death decreased by 16.7% and 13.5%, respectively, from 1999 to 2019.

But in rural areas, those proportions increased nonsignificantly, by 2.6% and 8.9%, respectively. Rural area residents are at increased risk for diabetes along with higher rates of obesity and metabolic syndrome. Moreover, those individuals are less likely to participate in diabetes self-management education programs and they have higher rates of diabetes-related emergency department use compared with urban residents, the authors say.

"The management of diabetes and its complications requires expertise that may be difficult to access in rural communities. Residents of rural counties are less likely to have usual primary care provided by physicians. Furthermore, there has been a disproportionate closure of hospitals in rural areas," they add.

In both rural and urban areas, the age-adjusted mortality rates of diabetes as underlying and contributing causes of death were higher in males than females. Those rates dropped to a greater degree in females than in males, leaving a significant male-female gap (P trend<.05).

"The fact that male individuals are more likely to be diagnosed with diabetes at an early age may explain the widening male-female diabetes-related mortality gap in both urban and rural areas," Dr Kobo and colleagues say.

Early Onset Type 2 Diabetes More Aggressive

There was a temporal increase in diabetes-associated age-adjusted mortality among people younger than 55 years that was significantly larger in rural than urban areas, both as underlying (59.0% vs 14.7%) and contributing (65.2% vs 13.8%) causes (both P trend<.001).

"The increased mortality among the younger adults may be related to the increasing prevalence of type 2 diabetes in adolescents and young adults. Early onset type 2 diabetes is associated with more aggressive disease and higher rates of premature complications," the authors point out.

In contrast, among those older than 55 years there was a large decrease in diabetes-related age-adjusted mortality in urban areas (by –20.6% and –15.6% for underlying and contributing causes, respectively; both P trend<.001), but not in rural areas (–4.8% and +3.7%, respectively).

Overall, American Indian and Black patients had significantly higher diabetes-related age-adjusted mortality rates than Asian and White patients.

However, those rates did drop for both groups, in all areas for American Indians and in urban but not rural areas for Black patients. Those rates also dropped significantly in both urban and rural areas among White patients.

"The role of socioeconomic deprivation and structural racism in the incidence of cardiovascular risk factors, progression of diabetes, and survival rates must also be considered, particularly in American Indian and Black individuals," Dr Kobo and colleagues write.

They also note that cardiometabolic risk varies across ethnic groups and areas, and "is inextricably linked with social determinants of health, including education, economic resources, psychological stress and access to preventive healthcare." 

Approaches that could mitigate some of the urban-rural disparity include healthcare equity, expansion of Medicaid, and telemedicine initiatives that extend access to specialty care, they suggest.

However, "the ultimate solutions may lie in economic and policy interventions that broaden our focus from treating disease to preventing it."

The authors have reported no relevant financial relationships.

Diabetologia. Published online September 10, 2022.[1]

Study Highlights

  • Using the CDC WONDER Multiple Cause of Death database, the authors estimated 20-year (1999-2019) age-adjusted mortality rate trends per 100,000 population in urban vs rural counties.
  • Of 1,572,536 death certificates listing diabetes as the underlying cause, 79.8% were in urban counties, and of 5,025,745 death certificates with diabetes as a contributing cause of death, 79.5% were in urban counties.
  • Diabetes age-adjusted mortality rates were higher in rural than urban areas across all subgroups.
  • Urban areas had a significant decrease in diabetes age-adjusted mortality rate as the underlying (−16.7%) and contributing (−13.5%) cause of death (Ptrend<.001), but rural areas did not (+2.6% and +8.9%, respectively).
  • In rural and urban areas, age-adjusted mortality rate as underlying and contributing causes of death were higher in males and declined more in females, causing a significant male-female gap (P trend<.05).
  • Among people younger than 55 years, there was a temporal increase in diabetes-related age-adjusted mortality rate (from +13.8% to +65.2%).
  • This was significantly larger in rural than urban areas, both as underlying (59.0% rural vs 14.7% urban) and contributing (65.2% rural vs 13.8% urban; both P trend<.001) causes.
  • Those aged 55 years and older had a large drop in diabetes-related age-adjusted mortality rate in urban areas (by –20.6% and –15.6% for underlying and contributing causes, respectively; both P trend<.001), but not in rural areas (–4.8% and +3.7%, respectively).
  • Diabetes-related age-adjusted mortality rates of American Indians decreased in all areas (from −19.8% to −40.5%; all P trend<.001), whereas diabetes-related age-adjusted mortality rates of Blacks and Whites decreased significantly in urban (from −26.6% to −28.3% and from −10.7% to −15.4%, respectively; all P trend<.001) but not rural (from −6.5% to +1.8% and from +2.4% to +10.6%, respectively; P trend, NS, NS, NS, and <.001) areas.
  • The investigators concluded that diabetes-related mortality decreased in US urban, but not rural, counties over the course of the last 2 decades.
  • During this period, the rural-urban diabetes-related mortality gap has tripled, mainly among males and those younger than 55 years.
  • A synchronized effort is needed to improve cardiovascular health and healthcare access in rural areas and to decrease diabetes-related mortality.
  • Rural area residents have increased risk for diabetes, obesity, and metabolic syndrome; are less likely to participate in diabetes self-management education programs; and have higher rates of diabetes-related emergency department use than urban residents.
  • Management of diabetes and its complications requires expertise that may be less available in rural areas, where residents are less likely to have usual primary care provided by physicians, and where there have been disproportionate hospital closures.
  • The widening male-female diabetes-related mortality gap in urban and rural areas may result from males being more likely to be diagnosed with diabetes at an early age.
  • As early-onset type 2 diabetes is linked to more aggressive disease and higher rates of premature complications, increased mortality among younger persons may be related to increasing type 2 diabetes prevalence in adolescents and young adults.
  • The role of socioeconomic deprivation and structural racism should be considered regarding incidence of cardiovascular risk factors, diabetes progression, and survival, particularly for American Indians and Blacks.
  • Cardiometabolic risk varies with ethnicity and regions, reflecting education, economic resources, psychological stress, access to preventive healthcare, and other social determinants of health. 
  • Strategies to reduce urban–rural disparity in diabetes deaths include healthcare equity, Medicaid expansion, telemedicine initiatives improving specialty care access, and especially economic and policy interventions shifting focus from disease treatment to prevention.
  • Study limitations include those inherent in the CDC WONDER database, inability to adjust for baseline comorbidities or other potentially important confounders, and reliance on place of death to determine urbanization status.

Clinical Implications

  • Diabetes-related age-adjusted mortality rates decreased in US urban, but not rural, counties during the last 2 decades.
  • During this period, the rural-urban diabetes-related mortality gap has tripled in the US, mainly among males and those younger than 55 years.
  • Implications for the Health Care Team: A synchronized effort is needed to improve cardiovascular health and healthcare access in rural areas and to decrease diabetes-related mortality.

 

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