In rural America, people suffering stroke have a 30% higher mortality rate than persons in urban and suburban regions. The single most commonly cited risk factor for stroke in rural America is hypertension. Rural residents also have a greater prevalence of diabetes, heart disease, and smoking.29

Among American Indians and Alaska Natives, stroke mortality varies by geographic region, with the highest rates in Alaska and the Northwest. American Indians and Alaska Native groups in rural America have greater rates of obesity, diabetes, alcohol abuse, smoking, and poverty, as well as low rates of education and health literacy.30

Acute stroke management markedly differs in urban vs rural America. Urban areas have tertiary care centers in which acute stroke care typically includes a multidisciplinary team consisting of emergency physicians, stroke neurologists, neuro-interventionists, neurologic nurse specialists, and technologists. Also, time to treatment makes a significant difference in outcome and residual neurological injury.

Recent studies of acute stroke patients found rural regional hospitals could not provide optimal stroke care, and most were not stroke care-qualified facilities, requiring transfer to the nearest stroke center. Inferior emergency medical services and imprudent transport decisions caused delay and excessive time lag, which prevented use of state-of-the-art neurological care.31-33

Cancer Disparities
Cancer incidence and cancer mortality rates are greater in rural regions than in urban and suburban areas. Higher incidence and mortality in rural areas were observed for cervical, colorectal, renal, pulmonary, melanoma, and oropharyngeal cancers.34

Rural communities experience lower rates of cancer screenings, higher incidence of potentially preventable cancers, more advanced stage at cancer diagnosis, treatment that is less concordant with guidelines, low enrollment in clinical trials, and higher mortality rates 11-12, 35-45 Cancer mortality rates are 36% higher in rural Appalachian Kentucky, 15% higher in rural Appalachian Virginia, and 19% higher in areas of West Virginia.46 People in much of rural Appalachia are more likely to die within 3 to 5 years of their diagnoses than those in urban areas across the United States.46-48

Lung Cancer
Lung cancer is the leading cause of cancer death in the United States.49 A review of national, population-based cancer registries (2009-2013 data) indicates that lung cancer incidence and mortality rates are all elevated in rural areas.50 There is greater late-stage lung cancer incidence, in particular, compared with in urban populations.

Higher smoking rates likely contribute to the greater incidence of the disease.51 Rural Americans are less likely to see a PCP regularly for annual exams and have less access to smoking cessation programs.50 In addition, there is less access to low-dose computed tomography screening, which is recommended by the US Preventive Services Task Force for patients at risk.50,52 These factors ultimately contribute to worse outcomes for cancer diagnosis.

Recent advances in lung cancer care, including use of positron emission tomographic scanners, improved techniques for lymph node sampling, stereotactic body radiotherapy, tumor cell genetic analysis, and targeted chemotherapies, are widely available at urban academic medical centers, but not in rural hospitals. This further increases rural-urban disparities in lung cancer mortality.53

Breast Cancer
Limited access to mammography screening and long travel distances to healthcare providers are barriers to access early breast cancer diagnoses and treatment.54,55 Even when women do receive mammography screening, they are less able to access follow-up care for abnormal results.56 Studies of women in Appalachia show that they are commonly diagnosed at a later stage and have a higher risk for treatment complications because they tend to be older and have more comorbidities at diagnosis. This population also has lower 3- and 5-year survival rates than their urban non-Appalachian counterparts.46,57

Prostate Cancer
Men living in rural areas are undertreated for prostate cancer compared with urban residents.58 Black men living in rural regions are particularly inadequately screened and less educated about the risk for prostate cancer.59 Investigators also found that men with prostate cancer in urban areas have a 23% greater chance of treatment compared with men in rural areas. Men who are diagnosed with prostate cancer in rural regions also experience less surgical and radiation treatment, which raises mortality rates.60

Lack of Prenatal and Obstetric Care
Poor access to high-quality maternal healthcare services in rural communities is a major public health concern. As of 2014, fewer than half of all rural counties in the United States had hospital-based obstetric care services.61 Up to 40% of all US counties, most of them rural, lack an obstetricianmidwife, or family physician attending births.62-64

This dearth in services results in a lack of adequate prenatal care, labor and delivery, and clinical postpartum follow-up.65 Lack of prenatal care is associated with increased rates of preterm birth and infant mortality rates.66,67 The rural hospitals and clinics that do provide obstetrics care have provider and staff shortages.16

Most pregnant women in rural regions rely on PCPs for maternal health care.68 However, as a result of a decline in PCP numbers in rural regions,69 pregnant women commonly seek prenatal care later in their pregnancy, which results in more negative health outcomes.16 Women who had to travel >30 miles for prenatal care have fewer prenatal visits and more negative outcomes, including higher rates of postpartum hemorrhage, postpartum depression, maternal mortality, low-birth-weight infants, and premature births.61,67 These obstacles to access disproportionately affect Alaska Natives, American Indians, and non-Hispanic black women.61

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Although infant mortality has declined in the United States, disparities still exist across geographic areas and demographic groups.2 Between 2013 and 2015, rural counties had higher neonatal, infant, and postneonatal mortality rates compared with urban areas.70 Causes of higher infant mortality rates were birth defects, preterm birth, low-birth weight, maternal complications, injuries, and sudden infant death syndrome.71