The burden of diabetes in rural America

Diabetes is a serious medical condition that affects the health and well-being of more than 30 million American adults. It is the seventh-leading cause of mortality in the United States, causing around 80,000 deaths per year. Complications due to diabetes can lead to decreases in quality of life. Appropriate medical care and self-management techniques can help people with this condition live longer and healthier lives, but for these to be truly effective, we need a better understanding of differences in the way diabetes affects various populations.

To accomplish this, a multidisciplinary research team led by Jane Bolin, JD, PhD, BSN, professor and director of the Texas A&M Southwest Rural Health Research Center, and Alva O. Ferdinand, JD, DrPH, assistant professor and deputy director of the center, used data from existing databases to expand knowledge of diabetes-related health disparities and identify variations in diabetes-related health outcomes among racial and ethnic groups and between rural and urban populations. The findings from this research were outlined in a series of three policy briefs published by the center that dealt with diabetes diagnosis and access to medical care, diabetes mortality rates across the country and diabetes-related hospital deaths nationwide.

The first of these policy briefs focused on changing trends in diabetes diagnosis rates and rates of people foregoing necessary medical care due to cost. Using data from the Behavioral Risk Factor Surveillance System for 2011–2015, the research team found that diabetes diagnoses increased slightly over the study period but that rates of forgone care were slightly lower in 2015 than in 2011. This study also found variations in diabetes diagnoses and forgone care among racial and ethnic groups and between rural and urban populations, with rural Americans being diagnosed with diabetes at higher rates and with more frequent instances of forgone care.

The second policy brief examined diabetes-related mortality between 1999 and 2015, using a U.S. Centers for Disease Control and Prevention database that contains information on health outcomes and causes of death in the United States. The research team broke these data down into categories based on how rural or urban different parts of the country are and found that small rural areas had significantly higher diabetes-related mortality rates than large cities. They also found disparities among racial and ethnic groups, though the rural versus urban divide remained in all groups.

The third paper explored diabetes-related hospital deaths, a subset of all diabetes-related mortality. Using hospital discharge data from the Healthcare Cost and Utilization Project for the years 2009 to 2014, Ferdinand and colleagues identified nearly 1.5 million diabetes-related hospital admissions during the study period, with a yearly average of approximately 38,000 diabetes-related hospital deaths. The majority of these hospital deaths occurred in urban areas, which is to be expected because most Americans live in cities. However, further analysis found that, nationwide, rural residents hospitalized for diabetes-related issues had a 3.4 percent greater chance of dying than city dwellers. Additionally, the research team noted that the South and Midwest had higher diabetes-related hospital death rates than other geographic regions and the country as a whole. Notably, the uninsured and persons on Medicaid also had higher rates of diabetes-related hospital deaths than their commercially insured counterparts.

Taken together, the research done by center investigators on the burden of diabetes in America highlights the role that geography and other factors, such as race, ethnicity and insurance status, play in diabetes-related mortality and forgone medical in the United States. Though the research provides a contemporary picture of the diabetes burden in the country, it is very much a first step in understanding the impact of the disease on health outcomes, particularly in rural areas. With clear discrepancies based on rurality and race, subsequent research should be directed at understanding the causes of these discrepancies and effective strategies for mitigating them. Above all, findings from this study should serve as a call to action for policymakers and other key stakeholders who are interested in narrowing the gap with respect to poor health outcomes that can be overcome with effective outpatient care for rural Americans.

“Diabetes is considered an ambulatory care sensitive condition, which therefore means that sufficient outpatient specialist care should prevent individuals from needing diabetes-related treatment at a hospital and from forgoing care,” Ferdinand said. “Since rural residents have higher rates of diabetes-related mortality, this indicates that access to health care continues to be a great challenge for them.”

Adequately funding efforts to target improved health access and, in turn, diabetes-related health outcomes in rural areas will be important to eliminating the clear differences that currently exist.