BACKGROUND
Mortality related to alcohol-associated liver disease (ALD) has been increasing over the past two decades, with greater rises seen in underserved population including those living in rural areas and racial/ethnic minorities. However, the interaction between rurality and race/ethnicity is unclear. We examined the rural-urban disparities in ALD-related mortality across race/ethnicity in US adults.

METHODS
This cross-sectional study extracted data from the Underlying Cause of Death database of CDC Wide-Ranging Online Database for Epidemiological Research (WONDER) (1999-2020). We estimated the age-adjusted mortality rates (AAMRs) for ALD among adults 25 years and older. We created rurality classification based on the 2013 National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme: large metropolitan (≥1 million), small- or medium-sized metropolitan (50,000-999,999), and rural areas (<50,000). We examined temporal trends in mortality from 1999 to 2020 by rurality and race/ethnicity and calculated the average annual percentage change (AAPC) using the Joinpoint regression program.

RESULTS
There were 372,900 deaths due to ALD among adults 25 years and older in the US from 1999 to 2020. Age-adjusted ALD mortality rates increased from 1999 through 2020 across rurality. Rural areas saw the steepest increase in AAMR (AAPC, 4.1%), whereas the mildest increase was seen in large metropolitan areas (AAPC, 2.0%). The absolute difference in AAMRs between rural areas and large metropolitan areas increased from 0.1 to 4.7 per 100,000 population. NHWs and AI/ANs experienced increasingly greater ALD mortality burden in rural areas (AAMR₁₉₉₉ to AAMR₂₀₂₀, 5.7 to 13.9 per 100,000 population in NHWs; 37.9 to 93.3 per 100,000 population in AI/ANs) compared with large metropolitan areas (AAMR₁₉₉₉ to AAMR₂₀₂₀, 6.2 to 11.7 per 100,000 population in NHWs; 24.6 to 41.9 per 100,000 population in AI/ANs) from 1999 to 2020, as evidenced by greater AAPCs seen in rural areas (rural vs urban AAPC, 4.4% vs 3.0% in NHWs; 5.1% vs 3.3% in AI/ANs). Hispanics who lived in rural areas had greater AAPC (rural vs urban AAPC, 4.4% vs 3.0%) and increasingly higher AAMRs over time (AAMR₁₉₉₉ to AAMR₂₀₂₀, 11.8 to 16.0 per 100,000 population) whereas those who lived in large metropolitan areas had stable AAMRs (AAMR₁₉₉₉ to AAMR₂₀₂₀, 11.2 to 12.8 per 100,000 population). NHBs had a nonsignificant decline in AAMR over the study period (AAPC, -0.5%).

CONCLUSION
Early 21st century saw widening rural-urban differences in ALD-related mortality over time in NHWs, AI/ANs, and Hispanics. This may be the result of differences in risk factors, health-related behaviors, and barriers in access to healthcare services. Resources and effort should be allocated to address high and increasing ALD-related mortality in these racial/ethnic groups living in rural areas.

Figure 1. Trends in ALD-related mortality by rurality and race/ethnicity in the US

Vignan Manne

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