title: The impact of living in rural and urban areas: vitamin D and medical costs in veterans.
abstract: OBJECTIVE
  Living in a rural region is associated with significant health disparities and increased medical costs. Vitamin D deficiency, which is increasingly common, is also associated with many adverse health outcomes. The purpose of this study was to determine whether rural-urban residence status of veterans was related to vitamin D levels, and to determine if this factor also influenced medical costs/service utilization. Additionally explored was whether vitamin D differences accounted for part of the association between area of residence and medical costs/service utilization.
  
  
  METHODS
  Medical records of 9,396 veterans from 6 Veterans Administration Medical Centers were reviewed for variables of interest including county of residence, vitamin D level, medical costs and service utilization, and background variables. Rurality status was classified as large metropolitan, urban, and rural.
  
  
  RESULTS
  The 3 rurality status groups differed significantly in vitamin D levels, with the highest levels observed for urban residents, followed by rural residents, and the lowest for large metro residents. Compared with urban residents, large metro residents were 49% more likely, while rural residents were 20% more likely, to be vitamin D deficient. Both rural and large metro residents had higher medical costs, and they were significantly more likely to be hospitalized. Vitamin D levels explained a statistically significant amount of the relationship between rurality status and medical costs/service utilization.
  
  
  CONCLUSIONS
  Vitamin D deficiency may be an additional health disparity experienced by both rural and inner-city veterans, and patients residing in these locations should be considered at increased risk for deficiency and routinely tested.
authors.affiliation: Department of Family Medicine, East Tennessee State University, Johnson City, Tennessee 37684, USA. alan.peiris@va.gov
authors.forename: Beth A
authors.initials: BA
authors.lastname: Bailey
authors.forename: Todd
authors.initials: T
authors.lastname: Manning
authors.forename: Alan N
authors.initials: AN
authors.lastname: Peiris
mesh_terms: D000368:Aged; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data*; D054624:Health Status Disparities; D006801:Humans; D008297:Male; D008875:Middle Aged; D012424:Rural Population / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D014505:Urban Population / Q000706:statistics & numerical data*; D014728:Veterans / Q000706:statistics & numerical data*; D014807:Vitamin D / Q000097:blood*; D014808:Vitamin D Deficiency / Q000097:blood / Q000453:epidemiology*
chemical_list: D014807:Vitamin D