Introduction
Mortality rates due to heart failure (HF) have increased since 2011, but estimates
of heterogeneity at the county-level in HF-related mortality are not known. Differences
between rural and urban counties and the impact of county-level factors on HF-related
mortality are needed to inform public health strategies.
Hypotheses
Substantial variation in HF-related mortality trends between 2011-2018 exists by rural-urban
designation. In addition, county-level factors account for a large proportion rural-urban
differences in HF-related mortality rates.
Methods
We queried CDC WONDER to identify HF deaths between 2011-2018 defined as any mention
of HF (I50) on the death certificate and cardiovascular disease (I00-78) as the underlying
cause of death. First, we calculated age-adjusted mortality rates (AAMR) and examined
trends stratified by rural-urban status (defined using 2013 NCHS Urban-Rural Classification
Scheme), age (35-64 and 65-84 years), and race-sex subgroups per year. Second, we
combined all deaths from 2011-2018 and estimated incidence rate ratios (IRR) in HF-related
mortality for rural versus urban counties using multivariable negative binomial regression
models with adjustment for sociodemographic factors, risk factor prevalence, and physician
density.
Results
Between 2011-2018, AAMRs were consistently higher for rural compared with urban counties
(e.g., 73.2 [95% CI: 72.2-74.2] vs. 57.2 [56.8-57.6] in 2018, respectively). The highest
AAMR was observed in rural black men (131.1 [123.3-138.9] in 2018), and the greatest
increases in HF-related mortality occurred in rural black men, age 35-64 years (+6.1%/year).
Unadjusted models demonstrated significantly higher HF-related mortality in rural
versus urban counties across the entire study period (IRR = 1.67 [95% CI: 1.57-1.78]
and 1.16 [95% CI: 1.13-1.18] for younger and older adults, respectively). The rural-urban
IRR was significantly attenuated after adjustment for county-level factors among both
younger (1.10 [1.04-1.16]) and older adults (1.04 [1.02-1.07]).
Conclusions
Differences in county-level factors account for a significant amount of the observed
variation in HF-related mortality between rural and urban counties.
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Identification
Copyright
© 2020 Published by Elsevier Inc.
