Pierce Jacob B, Shah Nilay S, Petito Lucia C, Pool Lindsay, Lloyd-Jones Donald M, Feinglass Joe, Khan Sadiya S
Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America.
Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America.
PLoS One. 2021 Mar 3;16(3):e0246813. doi: 10.1371/journal.pone.0246813. eCollection 2021.
Adults in rural counties in the United States (US) experience higher rates broadly of cardiovascular disease (CVD) compared with adults in urban counties. Mortality rates specifically due to heart failure (HF) have increased since 2011, but estimates of heterogeneity at the county-level in HF-related mortality have not been produced. The objectives of this study were 1) to quantify nationwide trends by rural-urban designation and 2) examine county-level factors associated with rural-urban differences in HF-related mortality rates.
We queried CDC WONDER to identify HF deaths between 2011-2018 defined as CVD (I00-78) as the underlying cause of death and HF (I50) as a contributing cause of death. First, we calculated national 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 demographic and socioeconomic characteristics, risk factor prevalence, and physician density. Between 2011-2018, 162,314 and 580,305 HF-related deaths occurred in rural and urban counties, respectively. AAMRs were consistently higher for residents in rural compared with urban counties (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) with greatest increases in HF-related mortality in those 35-64 years (+6.1%/year). The rural-urban IRR persisted among both younger (1.10 [1.04-1.16]) and older adults (1.04 [1.02-1.07]) after adjustment for county-level factors. Main limitations included lack of individual-level data and county dropout due to low event rates (<20).
Differences in county-level factors may account for a significant amount of the observed variation in HF-related mortality between rural and urban counties. Efforts to reduce the rural-urban disparity in HF-related mortality rates will likely require diverse public health and clinical interventions targeting the underlying causes of this disparity.
与美国城市县的成年人相比，美国农村县的成年人患心血管疾病（CVD）的总体比率更高。自2011年以来，因心力衰竭（HF）导致的死亡率有所上升，但尚未得出县级HF相关死亡率的异质性估计值。本研究的目的是：1）按城乡划分量化全国趋势；2）研究与城乡HF相关死亡率差异相关的县级因素。
我们查询了美国疾病控制与预防中心（CDC）的WONDER数据库，以确定2011年至2018年间将CVD（I00 - 78）作为根本死因且HF（I50）作为促成死因的HF死亡病例。首先，我们计算了全国年龄调整死亡率（AAMR），并按城乡状况（使用2013年国家卫生统计中心城乡分类方案定义）、年龄（35 - 64岁和65 - 84岁）以及每年的种族 - 性别亚组对趋势进行了研究。其次，我们汇总了2011年至2018年的所有死亡病例，并使用多变量负二项回归模型，在对人口统计学和社会经济特征、危险因素患病率以及医生密度进行调整后，估计农村与城市县HF相关死亡率的发病率比值（IRR）。2011年至2018年间，农村和城市县分别发生了162,314例和580,305例与HF相关的死亡。农村居民的AAMR始终高于城市县居民（2018年分别为73.2 [95% CI：72.2 - 74.2] 与57.2 [56.8 - 57.6]）。2018年，农村黑人男性的AAMR最高（131.1 [123.3 - 138.9]），35 - 64岁人群中HF相关死亡率的增幅最大（每年 +6.1%）。在对县级因素进行调整后，城乡IRR在年轻人（1.10 [1.04 - 1.16]）和老年人（1.04 [1.02 - 1.07]）中均持续存在。主要局限性包括缺乏个体层面的数据以及因事件发生率低（<20）导致的县数据缺失。
县级因素的差异可能是农村和城市县之间观察到的HF相关死亡率差异的重要原因。要努力缩小城乡HF相关死亡率的差距，可能需要针对这种差距的根本原因采取多种公共卫生和临床干预措施。
