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New research asks whether federal programs are anywhere near fixing some of the existing health disparities. Jeremy Woodhouse/Getty Images
  • Despite federal health programs, Black adults in rural areas of the United States have a higher mortality rate from several chronic health conditions than white adults.
  • The researchers used data from 1999–2018 to compare mortality rates from diabetes, high blood pressure, heart disease, and stroke in Black people and white people aged 25 years and older.
  • They found that Black adults living in rural locations had the highest rate of mortality from all four conditions in comparison with white adults.

Numerous healthcare-related inequities persist among different racial groups. For example, research has shown that Black people experience lower life expectancy, have higher rates of high blood pressure, and receive fewer flu vaccinations than white people.

Structural inequities in healthcare may have a more significant effect on Black people living in rural locations than those living in urban areas, where healthcare may be more accessible.

To investigate rural and urban trends in health disparities and determine whether the gaps between racial groups are closing, researchers from Beth Israel Deaconess Medical Center (BIDMC) used data from the Centers for Disease Control and Prevention (CDC). Specifically, they used the CDC WONDER databases to compare annual mortality rates between Black adults and white adults.

Their research letter appears in the Journal of the American College of Cardiology.

The investigators looked at age-adjusted mortality rates between 1999 and 2018 in rural and urban areas for both Black and white people aged 25 years and older. They examined the death rates associated with four health conditions: heart disease, diabetes, high blood pressure, and stroke.

Over the 20-year timeframe, the researchers found:

  • Black adults had consistently higher death rates from all four conditions in both rural and urban areas than white adults.
  • The highest mortality rates from each health condition occurred in Black adults residing in rural areas.
  • Mortality rates from diabetes and high blood pressure complications were nearly two and three times higher, respectively, in Black adults than in white adults.
  • For diabetes and high blood pressure, the mortality rate gap between white adults and Black adults narrowed over the past 2 decades in urban areas. This also occurred in rural locations but to a lesser extent.
  • For heart disease, the mortality rate gap between the two racial groups narrowed at a similar rate in rural and urban areas, whereas for deaths due to stroke, the gap narrowed more rapidly in rural areas.

“The persistent racial disparities for diabetes and high blood pressure-related mortality in rural areas may reflect structural inequities that impede access to primary, preventive, and specialist care for rural Black adults.”

– Rahul Aggarwal, M.D., a clinical fellow in the Department of Medicine at BIDMC

Aggarwal also says that the heart disease and stroke mortality gap between Black and white adults may have narrowed in rural areas because of several factors.

These include improvements in emergency services, expansion of referral networks, and the creation of more healthcare facilities specific to stroke and heart care in rural locations.

The reduced length in time from diagnosis to treatment is another factor that the researcher mentions.

The same team of researchers also looked at how federal programs are affecting the existing health disparities, publishing a separate letter on these findings in JAMA.

Although federal agencies have implemented programs in hospitals to help Black adults obtain access to healthcare, it is unknown whether these federally mandated “pay for performance” programs have improved health disparities.

These programs exist in more than 3,000 hospitals across the U.S. They work by rewarding or penalizing healthcare organizations dependent on their patient outcomes.

When looking at the data, the team found that hospitals and healthcare facilities that predominately care for Black adults are more likely to experience a higher number of penalties than rewards. This may reduce their ability to improve the level of healthcare in this population.

Rishi K. Wadhera, M.D., from the Smith Center for Outcomes Research in Cardiology at BIDMC, concludes:

“We know that there are substantial gaps in health outcomes between Black and white adults in the U.S.”

“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.”

Although the results were age-adjusted, it is unclear whether males and females accounted for equal proportions of the deaths from all the examined health conditions.

As risk factors and disease progression patterns for some of these conditions differ between the sexes, dividing the data further into male and female groups could clarify any discrepancies in the results due to sex-specific risk factors.