09/21/2021 | Press release | Distributed by Public on 09/20/2021 22:31
In the United States, approximately 15% of the population resides in counties located in rural areas (1). Those living in rural areas often face greater public health challenges as they have more limited access to health care, are less likely to be insured, and are more likely to live in poverty (1,2). This report provides the latest national data for trends in age-adjusted death rates for all causes of death among rural and urban areas by sex. Rates for rural and urban areas for the 10 leading causes of death in 2019 are also presented by urban-rural status along with trends in selected causes of death.
Key words: mortality rates, leading causes of death, National Vital Statistics System
The difference in age-adjusted death rates between urban and rural areas increased from 1999 through 2019.
Figure 1. Age-adjusted death rates, by urban-rural classification: United States, 1999-2019
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1Significant decreasing trend from 1999 through 2010; stable trend from 2010 through 2019 (p < 0.05).
2Significant decreasing trend from 1999 through 2019, with different rates of change over time (p < 0.05).
NOTES: Urbanicity of county of residence is based on the 2013 NCHS Urban-Rural Classification Scheme for Counties; see Data source and methods. Access data table for Figure 1pdf icon .
SOURCE: National Center for Health Statistics, National Vital Statistics System, Mortality.
The percentage difference in rural and urban death rates for both males and females widened over the period.
Figure 2. Age-adjusted death rates, by urban-rural classification and sex: United States, 1999-2019
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1Significant decreasing trend from 1999 through 2010; stable trend from 2010 through 2019 (p < 0.05).
2Significant decreasing trend from 1999 through 2019, with different rates of change over time (p < 0.05).
3Stable trend from 1999 through 2002; significant decreasing trend from 2002 through 2019, with different rates of change over time (p < 0.05).
NOTES: Urbanicity of county of residence is based on the 2013 NCHS Urban-Rural Classification Scheme for Counties; see Data source and methods. Access data table for Figure 2pdf icon .
SOURCE: National Center for Health Statistics, National Vital Statistics System, Mortality.
Rates for each of the 10 leading causes of death in 2019 were higher in rural than in urban areas.
Figure 3. Age-adjusted death rates for the 10 leading causes of death, by urban-rural classification: United States, 2019
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NOTES: Urbanicity of county of residence is based on the 2013 NCHS Urban-Rural Classification Scheme for Counties; see Data source and methods. Causes of death are ranked according to the number of deaths for the total population. Rates for all causes in rural areas were significantly higher than rates in urban areas (p < 0.05). Access data table for Figure 3pdf icon .
SOURCE: National Center for Health Statistics, National Vital Statistics System, Mortality.
Differences between rural and urban areas in death rates for heart disease, cancer, and CLRD widened over the period.
Figure 4. Age-adjusted death rates for heart disease, cancer, and chronic lower respiratory disease, by urban-rural classification: United States, 1999-2019
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1Significant decreasing trend from 1999 through 2019, with different rates of change over time (p < 0.05).
2Stable trend from 1999 through 2019 (p < 0.05).
NOTES: Urbanicity of county of residence is based on the 2013 NCHS Urban-Rural Classification Scheme for Counties; see Data source and methods. CLRD is chronic lower respiratory disease. Access data table for Figure 4pdf icon .
SOURCE: National Center for Health Statistics, National Vital Statistics System, Mortality.
Summary
During 1999 through 2019, age-adjusted death rates in rural areas were higher than in urban areas for the entire period, and the difference increased over time. Differences between rural and urban death rates widened over the period for both males and females.
In 2019, rates for the 10 leading causes of death were higher in rural than in urban areas. The greatest differences in rural and urban death rates were for heart disease, cancer, and CLRD. The smallest difference in death rates between rural and urban areas were among those who died of stroke.
The rates for heart disease, cancer, and CLRD were higher in rural than in urban areas over the entire period, but the differences by urban-rural status increased over time. By 2019, the rate in rural areas was 21% higher than the rate in urban areas for heart disease, 15% higher for cancer, and 48% higher for CLRD.
Data source and methods
Mortality and population data are from the National Center for Health Statistics' 1999-2019 underlying cause-of-death mortality files (3). Age-adjusted death rates were calculated using the direct method and the 2000 U.S. standard population (4). Population data for 2000 and 2010 are April 1 bridged-race census counts, for 2001-2009 they are July 1 bridged-race intercensal estimates, and for 2011-2019 they are bridged-race July 1 postcensal estimates based on the 2010 census.
Urbanization level of the decedent's county of residence was categorized using the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties (1). In this scheme, counties are classified into six urbanization levels based primarily on metropolitan-nonmetropolitan status and population distribution. In this report, the urban or rural classification was based on the following groupings: the urban classification contains the four metropolitan groups of large central, large fringe, medium, and small metro; the rural classification contains the two nonmetropolitan groups of micropolitan and noncore.
The 10 leading causes in 2019 by urban and rural classification are presented (Figure 3). Causes of death are classified using International Classification of Diseases, 10th Revision (ICD-10) (5) and are ranked according to the number of deaths assigned to rankable causes for the total population (6). Trends in age-adjusted death rates for heart disease, cancer, and CLRD are presented (Figure 4). These three causes accounted for 51% of all deaths in rural areas and 49% in urban areas in 2019.
Trends in age-adjusted death rates were evaluated using the Joinpoint Regression Program (7). The authors used the Joinpoint software to fit weighted least-squares regression models to the estimated proportions on the logarithmic scale. The default settings allowed for as few as three observed time points in the beginning, ending, and middle line segments, including the joinpoints. Using these settings, the grid search algorithm and permutation test searched for a maximum of three joinpoints, and an overall alpha level of 0.05. Pairwise comparisons between rural and urban areas were tested using the z test statistic at the 0.05 level of significance.
About the authors
Sally C. Curtin is with the Division of Vital Statistics and Merianne Rose Spencer is with the Division of Analysis and Epidemiology, National Center for Health Statistics.
References
Suggested citation
Curtin SC, Spencer MR. Trends in death rates in urban and rural areas: United States, 1999-2019. NCHS Data Brief, no 417. Hyattsville, MD: National Center for Health Statistics. 2021. DOI: https://dx.doi.org/10.15620/cdc:109049external icon .
Copyright information
All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.
National Center for Health Statistics
Brian C. Moyer, Ph.D., Director
Amy M. Branum, Ph.D., Associate Director for Science
Division of Vital Statistics
Steven Schwartz, Ph.D., Director
Andrés A. Berruti, Ph.D., M.A., Associate Director for Science
Division of Analysis and Epidemiology
Irma E. Arispe, Ph.D., Director
Kevin C. Heslin, Ph.D., Associate Director for Science