Discussion
Rural residents, particularly those in noncore counties, experienced high percentages of preventable premature deaths during the study period. The rural-urban disparities in premature deaths varied by cause of death. However, disparities were not limited to place of residence. Disparities in all-cause premature deaths also were associated with other demographic factors (e.g., sex, race, and ethnicity) (11). For example, the highest rates of premature deaths were observed in rural counties where a majority of the population was Black, African American, American Indian, or Alaska Native (11). To address disparities in preventable premature deaths across rural and urban counties, data on disparities in cause-specific premature deaths from the five leading causes by rural-urban county category, race, and ethnicity are needed to inform interventions and health care policies for specific racial and ethnic groups. A follow-up of this analysis stratified by race and ethnicity will be published in subsequent reports, further contributing evidence to guide existing and new programs and policies.
Cancer
Overall, the decrease in preventable premature deaths from cancer was substantial and was greatest in urban counties where access to preventive services, treatment, survivor care, and specialty care is much higher than in rural counties (19). Large central metropolitan and fringe metropolitan areas achieved the benchmark rates in 2019. This is consistent with overall declines in cancer mortality, which decreased 27% between 2001 and 2020 (20). The decrease in preventable premature deaths likely reflects multiple factors. Increases in recommended screening for the leading causes of deaths from cancer (e.g., lung, colon, cervical, and female breast) have led to earlier detection, when treatment is more effective, and prevention by detecting cellular changes before they turn into cancer, as in the case of colorectal cancer (21). Increases in vaccination rates for cancer-causing viruses and decreases in prevalence of risk factors (e.g., combustible tobacco use) also have driven cancer mortality downward (22). Access to these cancer prevention and early detection strategies was increased with the expansion of Medicaid (23). New cancer treatments and therapies, specifically for lung cancer and melanoma, also have led to longer survival for those with a cancer diagnosis (24). CDC conducted a demonstration project on how to best provide care for persons living in rural areas who had cancer diagnosed (25). Although cancer is categorized as a single disease group in this analysis, each cancer site has different risk factors, has varying treatment methods, and can manifest itself in different ways among groups by sex, age, race, and ethnicity. Preventable premature death might vary depending on the cancer site and might not have decreased for cancers with increasing prevalence of risk factors (e.g., obesity), no recommended screening modalities, or therapies that have not changed. Lung cancer, the leading cause of cancer mortality, accounted for 23% of all cancer deaths in 2020 (20). Geographic differences in combustible tobacco use and use of lung cancer screening likely partially drive differences in lung cancer mortality. Access to lung cancer screening facilities is more limited in rural counties than in urban counties (26). Despite overall reductions in preventable premature deaths from cancer, premature deaths surpass the national average in micropolitan and noncore counties, highlighting the need in rural areas to reduce cancer-related premature deaths. Because more urban areas surpassed the 2010 benchmarks for cancer death rates in 2019, future updates to the cancer-specific benchmarks using more recent years of data might better reflect the lowest achievable death rates.
Unintentional Injury
The worsening and expanding drug overdose epidemic, increases in motor vehicle traffic fatalities, and falls drive the growth in preventable premature deaths from unintentional injury (27). Narrowing rural-urban disparities in the percentage of preventable premature deaths from unintentional injury were driven by worsening rates of preventable mortality in more urban areas, with the percentage more than doubling in large central metropolitan areas over the study period. For drug overdoses, access to medications for opioid use disorder continues to be more limited in rural counties, as evidenced by low buprenorphine dispensing rates and reduced treatment capacity (28). For motor vehicle traffic crashes, rural residents have an increased risk for death and are less likely than urban residents to wear seat belts (29). Evidence-based interventions reduce rural-urban disparities in seat belt use and motor vehicle death rates (30). Many fall risk factors are modifiable, implying that many falls can be prevented (31).
Heart Disease and Stroke
Disparities in preventable premature deaths from heart disease and stroke between rural and urban areas existed across the study period. These gaps increased from 2019 to June 2022, except in large central metropolitan counties where a decrease of three percentage points was observed from 2020 to 2021. Increases in preventable premature deaths from heart disease and stroke in 2020 and 2021 were likely associated with COVID-19–related conditions that contributed to risk-associated increased mortality from heart disease and stroke (32). Increases in systolic and diastolic blood pressure, a leading risk factor for heart disease and stroke, were observed among all age groups when comparing 2020 with 2019 (33). Inequities in control of hypertension (i.e., systolic blood pressure values of ≥130 mm Hg, diastolic blood pressure of >80 mm Hg, or both) were observed during the COVID-19 pandemic and are related to insufficient health care access, medication adherence, and monitoring (34). Patients might have delayed or avoided seeking emergency care when experiencing a life-threatening event during the height of the COVID-19 pandemic (35). Emergency department visits for heart attack and stroke decreased by 20% during the weeks after the declaration of COVID-19 as a national emergency on March 13, 2020, and hospital admissions for heart attack and stroke decreased during the pandemic (35). In addition, COVID-19 was associated with an increased risk for stroke and heart disease (36,37).
Chronic Lower Respiratory Disease
Despite the overall decrease during 2010–2020 (because of decreases observed in larger urban areas), the percentage of preventable premature deaths from CLRD was relatively stable in medium and small urban counties and rural counties during 2010–2015. During 2010–2022, the sharpest decline in preventable premature death from CLRD in urban areas occurred from 2019 through 2021 and could be the result of deaths from COVID-19 that otherwise would have been attributable to CLRD. Persons with CLRD (e.g., chronic obstructive pulmonary disease) are at increased risk for death from COVID-19 (38).
