Rural versus urban living and COPD: a systematic review

Clinical Snapshot

Key Findings

• P Value: Statistical significance reported for 11/15 prevalence studies

• Effect Size: Not quantified due to narrative synthesis approach

• Primary Outcome: COPD prevalence higher in rural areas in 83% of studies (15/18), with 11/15 showing statistical significance

• Nnt Or Sensitivity: 86% of studies (6/7) demonstrated higher rural mortality; 67% (4/6) showed higher rural symptom burden

• Confidence Interval: Not reported

Clinical Application

Findings support targeted rural COPD interventions including telehealth, mobile services, and enhanced primary care capacity Highly relevant to Australian context given similar rural healthcare challenges. Supports PBS subsidies for rural telehealth, RACGP rural training initiatives, and targeted COPD management programs in rural areas Australian rural and urban COPD populations, particularly relevant given Australia's significant rural-urban healthcare disparities

Abstract

Chronic obstructive pulmonary disease (COPD) is a leading cause of global morbidity and mortality. Emerging evidence suggests disparities in COPD outcomes between rural and urban populations, but no prior review has synthesised these differences globally. Five databases (Medline, Embase, Emcare, CINAHL and Cochrane Central) were searched in May 2025. Eligible peer-reviewed studies directly compared rural and urban populations in at least one of four measures of COPD burden: prevalence, symptom burden, exacerbations or mortality. Study quality was assessed and narrative synthesis was conducted due to heterogeneity in outcome measures. Of 1339 screened studies, 32 met inclusion criteria, spanning 13 countries. COPD prevalence was higher rurally in 83% (15/18) of studies, with 11/15 demonstrating statistical significance. This pattern was consistent across geographical distributions. Total exacerbation rates were higher rurally in 60% (3/5) of studies, although hospitalisations varied significantly. 50% (6/12) of studies reported higher hospitalisation rates in urban areas and 5/12 studies reporting higher rates in rural areas. 86% (6/7) of studies demonstrated higher mortality rurally and symptom burden was higher amongst rural residents in 67% (4/6) of studies; however, the majority of these were conducted in the USA. This review highlights consistent rural-urban inequalities in COPD prevalence and outcomes, reflecting the impact of healthcare inequities, socioeconomic deprivation and environmental exposures on COPD burden in rural areas. Targeted interventions promoting equitable healthcare access, health education, transition to cleaner fuels and rural access to smoking cessation and pulmonary rehabilitation services are essential to mitigate these disparities and improve outcomes in rural populations.

References

1. 1.Patel, S., Marchant, J., Bhatt, S. P., & Hurst, J. R. (2026). Rural versus urban living and COPD: a systematic review. European Respiratory Review, 35(140), Article 0290-2025. https://doi.org/10.1183/16000617.0290-2025