Urban-rural disparities in diabetes-related mortality in the USA 1999-2019

Aims/hypothesis Our study aimed to examine the trends in diabetes-relatedmortality in urban and rural areas in the USA over the past two decades. Methods We examined the trends in diabetes-related mortality (as the underlying or a contributing cause of death) in urban and rural areas in the USA between 1999 and 2019, using the CDC WONDER Multiple Cause of Death database. We estimated the 20 year trends of the age-adjusted mortality rate (AAMR) per 100,000 population in urban vs rural counties. Results The AAMR of diabetes was higher in rural than urban areas across all subgroups. In urban areas, there was a significant decrease in the AAMR of diabetes as the underlying (-16.7%) and contributing (-13.5%) cause of death (p(trend)<0.001), which was not observed in rural areas (+2.6%, +8.9%, respectively). AAMRs of diabetes decreased more significantly in female compared with male individuals, both in rural and urban areas. Among people younger than 55 years old, there was a temporal increase in diabetes-related AAMR (+13.8% to +65.2%). While the diabetes-related AAMRs of American Indian patients decreased in all areas (-19.8% to -40.5%, all p(trend)<0.001), diabetes-related AAMRs of Black and White patients decreased significantly in urban (-26.6% to -28.3% and -10.7% to -15.4%, respectively, all p(trend)<0.001) but not rural areas (-6.5% to +1.8%, +2.4% to +10.6%, respectively, p(trend) NS, NS, NS and <0.001). Conclusions/interpretation The temporal decrease in diabetes-related mortality in the USA has been observed only in urban areas, and mainly among female and older patients. A synchronised effort is needed to improve cardiovascular health indices and healthcare access in rural areas and to decrease diabetes-related mortality.