American Diabetes Association
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Disparities in Acute and Chronic Complications of Diabetes Along the U.S. Rural-Urban Continuum

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posted on 2024-02-22, 22:24 authored by Kyle Steiger, Jeph Herrin, Kavya Sindhu Swarna, Esa M Davis, Rozalina G McCoy

Objective: To determine the relative hazards of acute and chronic diabetes complications among those with diabetes across the U.S. rural-urban continuum.

Research Design and Methods: This retrospective cohort study used OptumLabs® Data Warehouse, a deidentified dataset of U.S. commercial and Medicare Advantage beneficiaries to follow 2,901,563 adults (age>18) with diabetes between January 1, 2012 and December 31, 2021. We compared adjusted hazard ratios of diabetes complications in remote areas (population <2,500), small towns (population 2,500-50,000), and cities (population >50,000).

Results: Compared to residents of cities, residents of remote areas had greater hazards of myocardial infarction (HR 1.06, 95% CI 1.02-1.10) and revascularization (HR 1.04, 1.02-1.06) but lower hazards of hyperglycemia (HR 0.90, 0.83-0.98) and stroke (HR 0.91, 0.88-0.95). Compared to cities, residents of small towns had greater hazards of hyperglycemia (HR 1.06, 1.02-1.10), hypoglycemia (HR 1.15, 1.12-1.18), end-stage kidney disease (HR 1.04, 1.03-1.06), myocardial infarction (HR 1.10, 1.08-1.12), heart failure (HR 1.05, 1.03-1.06), amputation (HR 1.05, 1.02-1.09), other lower extremity complications (HR 1.02, 1.01-1.03), and revascularization (HR 1.05, 95% CI 1.04-1.06) but smaller hazard of stroke (HR 0.95, 0.94-0.97). Compared to small towns, those in remote areas had lower hazard of hyperglycemia (HR 0.85, 0.78-0.93), hypoglycemia (HR 0.92, 0.87-0.97), and heart failure (HR 0.94, 0.91-0.97). Hazards of retinopathy and atrial fibrillation/flutter did not vary geographically.

Conclusions: Adults in small towns were disproportionately impacted by complications of diabetes. Future studies should probe for the reasons underlying these disparities.


This effort was funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institute of Health (NIH) grant K23DK114497. Study contents are the sole responsibility of the authors and do not necessarily represent the official views of NIH.