Health Care Disparities Across the Urban-Rural Divide: A National Study of Individuals with COPD

The burden of chronic obstructive pulmonary disease (COPD) is high in rural America. Few studies, however, have examined urban/rural differences in health care access, or racial/ethnic and income disparities stratified by urban/rural residence, among persons with COPD.

We studied individuals age ≥ 40 years with COPD from the 2018 Behavioral Risk Factor Surveillance System. The primary exposure was "urban" or "rural" county of residence. We examined multiple health and health care access/services outcomes using logistic regressions adjusted for age and sex, and performed analyses stratified by rural/urban county that included additional adjustment for race/ethnicity or income.

Our sample included 34,439 individuals. COPD prevalence was 8.6% in rural counties versus 5.4% in urban counties. Rural residents with COPD were poorer, had less education, worse health, and more disability. Of the rural population with COPD, 12.6% were uninsured, versus 10.4% in urban areas (AOR 1.26; 95% CI: 1.00-1.58). Rural residents with COPD were more likely to have not seen a doctor due to cost (AOR 1.18; 95% CI: 1.02-1.36). Differences in other outcomes were mostly nonsignificant. We observed large access disparities by race/ethnicity and income among individuals in both urban and rural counties, with the highest rates of forgone care among minorities in rural counties.

Patients with COPD in rural areas experience greater morbidity and obstacles to care than those in urban areas. Racial/ethnic minorities and those with low incomes-particularly in rural areas-are also at greater risk of forgoing doctor visits due to cost. Expanded access to health care could address respiratory health inequities.