Urban-Rural Differences in Mental and Physical Health among Primary Care Patients with Multiple Chronic Conditions: A Secondary Analysis from a Randomized Clinical Trial.

ABSTRACT

PURPOSE: Rural health disparities are largely attributable to access to healthcare, socioeconomic status, and health behaviors. Little is known about the persistence of these disparities when differences in access to care are eliminated. We sought to investigate urban-rural differences in physical and mental health in primary care patients with demonstrated access to primary care. METHODS: We obtained cross-sectional survey responses from a multicenter randomized controlled trial on 2726 adult primary care patients with multiple chronic medical or behavioral conditions from 42 primary care practices in 13 states. Study outcomes include measures of mental health including The Patient-Reported Outcomes Measurement Information System (PROMIS-29®), General Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9), as well as physical health including the PROMIS-29® and the Duke Activity Status Index (DASI). Urban-rural residence was indicated by census-tract Rural Urban Commuting Areas of the participant's home address. Differences in mental and physical health outcomes attributable to rurality were assessed using multilevel models with a random intercept for census-tract. RESULTS: After adjustment for demographic and neighborhood characteristics, urban residents had significantly worse generalized anxiety disorder (GAD-7) (ß = 0.7; 95% CI = 0.1, 1.3; p = 0.027), depression (PHQ-9) (ß = 0.7; 95% CI = 0.1, 1.4; p = 0.024), and functional capacity (DASI) (ß = -0.4; 95% CI = -0.5, -0.2; p < 0.001) compared to rural residents. Urban residents also had significantly worse anxiety and depression as measured by the PROMIS-29® compared to their rural counterparts. There were no urban-rural differences in the other PROMIS-29® subdomains. CONCLUSIONS: Among adults with demonstrated access to care and multiple diagnosed chronic conditions, rural residents had better mental health and functional capacity than their urban counterparts. This finding is not consistent with prior research documenting rural health disparities and should be confirmed.