The Impact of Living in Rural and Urban Areas: Vitamin D and Medical Costs in Veterans


  • This paper is the result of work supported with resources and the use of facilities at the Mountain Home VAMC. The contents of this paper do not reflect the position of the US Government or the Department of Veterans Affairs. No direct funding supported this project. The authors have no conflicts of interest to declare. For further information, contact: Alan Peiris, MD, PhD, Medicine Service – 111, Mountain Home VAMC, Mountain Home, TN 37684; e-mail


Purpose: 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.

Findings: 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.