S2683 Time-Trend Analysis of Rural-Urban Mortality Post-Pandemic in Alcohol-Associated Liver Disease

Introduction: During the COVID-19 pandemic, deaths from alcohol-associated liver disease surged. Given geographic differences in pandemic impact, post-pandemic ALD mortality trends may differ between rural and urban areas. Methods: Using CDC WONDER mortality data for adults aged ≥25 from 2005 to 2023, ALD-related deaths were identified using validated International Classification of Diseases, Tenth Revision (ICD-10) codes (i.e. K70) for underlying cause of death. Rural-urban status was defined by established definitions (rural: micropolitan/noncore; urban: large central metro/large fringe metro/medium/small metro). We calculated age-adjusted mortality rates (AAMR) per 100,000 adults for ALD overall and by sex and age. Trends were assessed using Joinpoint regression to estimate annual percentage change (APC) across detected trend segments, comparing rural and urban areas. Results: In both rural and urban areas, AAMR for ALD peaked in 2021 before declining through 2023. Rural areas had a positive APC of +18.12% (95% CI: +7.7 to +29.5) in 2018-2021, followed by a negative APC of −10.02% (-17.4 to -1.9) in 2021-2023. Urban areas had similar trends (2018-2021: +12.01% [+6.1 to +18.2]; 2021-2023: -7.00% [-11.6 to -2.1]). During 2021-2023, AAMR remained above pre-pandemic levels and higher in rural vs urban areas. In most ALD subgroups, rural-urban trends followed the overall pattern, with a peak in 2021 followed by a negative APC in the 2021-2023 segment among women, men, adults age 25-44, and adults age 45-64 with ALD. However, among adults age ≥65 with ALD, the 2021-2023 segment had a stable APC in rural areas (2021-2023 APC: +0.35% [-10.7 to +12.8]), and no distinct 2021-2023 segment was detected by trend analysis in urban areas (2011-2023 APC: +5.10% [+4.5 to +5.7]). No trend differences by sex or age were observed for MASLD. Conclusion: ALD mortality remains above pre-pandemic levels, with rural rates consistently exceeding urban rates. ALD mortality rose sharply during the pandemic but declined unevenly across age groups from 2021-2023, with older adults in both rural and urban areas remaining particularly vulnerable. Strategies to curtail ALD in the post-pandemic era are an urgent priority, with rural populations and older adults with ALD among the highest risk groups.