S916 Rural-Urban Disparities in Esophageal Varices Mortality in the United States—1999-2021

Introduction: Esophageal varices are a life-threatening complication of portal hypertension. Despite known disparities in healthcare access, rural-urban differences in esophageal varices mortality have not been thoroughly examined at the national level. This study evaluates temporal trends and geographic disparities in U.S. mortality from esophageal varices between 1999 and 2021. Methods: We analyzed mortality data from the CDC WONDER Multiple Cause of Death database spanning 1999 to 2021. Deaths attributed to esophageal varices (International Classification of Diseases-10: I85.0, I85.9) were extracted and stratified using the 2013 National Center for Health Statistics urban-rural classification system. Counties were categorized as urban (large central metro, large fringe metro, medium metro, and small metro) or rural (micropolitan and noncore). Crude death rates per 100,000 population were calculated annually for each geographic category. Results: A total of 20,871 deaths from esophageal varices were identified over the 23-year period. Mortality rates increased substantially in both urban and rural areas, with rural regions experiencing disproportionately greater increases. The average rural crude death rate rose from 0.094 per 100,000 in 1999-2005 to 0.972 in 2017-2021, representing a 935% increase. Urban rates rose from 0.064 to 0.642 over the same periods, a 908% increase. By the most recent period, rural mortality rates were 1.51 times higher than urban rates. The COVID-19 pandemic revealed pronounced mortality spikes, with peak crude death rates in 2021 reaching 2.06 per 100,000 in rural areas compared to 1.36 in urban settings. Conclusion: Esophageal varices mortality has increased dramatically over the past 2 decades, with persistent and widening rural-urban disparities. Rural populations face significantly higher mortality risk, likely due to geographic barriers to specialized gastroenterology care, limited endoscopic capabilities in rural hospitals, and delays in emergency intervention. These findings highlight critical gaps in rural healthcare infrastructure and underscore the need for targeted efforts to improve access to specialized care for patients with portal hypertension and variceal bleeding in rural communities.