Safer in the big city: Injury-related deaths more common in rural areas

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1. The most rural areas of the country experience 24 more injury-related deaths per 100,000 than the most urban areas.

2. While unintentional deaths were much more common in rural areas, death by suicide did not vary with rurality and death by homicide was more common in urban areas. 

Evidence Rating Level: 2 (Good)

Study Rundown: Despite a public perception that most injury related deaths (including motor vehicle accidents, suicide, homicide) occur in urban areas, this large study suggests that the heaviest burden of injury-related mortality falls on rural areas in the US. This finding is largely driven by the risk of death by motor vehicle crash, which is two times greater in rural than urban areas. Next steps must focus on which aspects of driving (speed, increased risk taking, adherence to traffic laws) account for these deaths and to implement interventions to address those factors in rural counties. This study also found little change in the rural-urban relationship when “access” to trauma center care was accounted for. However, access to care was determined only by a simple count of trauma centers per county, which did not account for true distances and drive times.  A more sophisticated model is necessary to examine the effect of trauma center access, and to determine how improvements in emergency and trauma care systems in the US may reduce this urban-rural divide in injury mortality.

Click to read the study in Ann Emerg Medicine

Relevant Reading: The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis

In-Depth [cross-sectional analysis]: This study analyzed US injury deaths from 1999 to 2006 in counties across the rural-urban continuum to determine overall injury risk in urban areas compared with suburban and rural areas. Through the Multiple Cause of Death data files from the National Vital Statistics System of the National Center for Health Statistics, 1,295,919 injury deaths were identified in the 3,141 counties analyzed.  These deaths were classified by intent, mechanism, age, and county of occurrence. Counties, in turn, were classified according to a 10-category ordinal variable representing an urban-rural continuum which accounted for both population size and proximity to metropolitan areas.

Overall injury death rate was 56.2 per 100,000 people – with motor vehicle related (14.9 per 100,000) and firearm related (10.4 per 100,000) as the most common mechanisms of injury death. The overall injury death rate increased with increasing rurality; the injury death rate between the most rural and most urban counties differed by 24 per 100,000 (95% CI 16.4 to 31.6 per 100,000). While unintentional injury death rates in US counties varied significantly as a function of rurality (rate ratio 1.42, CI 1.23 to 1.65), suicide injury death did not vary significantly and homicide death rate decreased with rurality (RR 0.44; 95% CI 0.37 to 0.53). Fatal motor vehicle accidents were much more likely to occur in rural areas. Adding proximity to trauma center care as a variable to the model had minimal attenuating effect on the association between injury-related mortality rate and urban-rural nature of the county.

By Elizabeth Kersten and Andrew Bishara

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