Premature mortality from all causes and drug poisonings in the USA according to socioeconomic status and rurality: an analysis of death certificate data by county from 2000-15

Abstract

Background: Increasing premature mortality among some groups of Americans has been largely driven by increases in drug poisoning deaths. However, to our knowledge, a formal descriptive study by race and ethnicity, socioeconomic status, rurality, and geography has not been done. In this study, we examined US trends in premature all-cause and drug poisoning mortality between 2000 and 2015 at the county level among white, black, and Latino people.

Methods: We used US mortality data for the period Jan 1, 2000, to Dec 31, 2015, including underlying cause of death and demographic data, collected from death certificates by the Centers for Disease Control and Prevention National Center for Health Statistics, and ascertained county attributes from the 2011-15 Census American Community Survey. We categorised counties into quintiles on the basis of the percentage of people unemployed, the percentage of people with a bachelor's degree, median income, and rurality. We estimated premature (ie, deaths in those aged 25-64 years) age-standardised mortality for all causes (by race and ethnicity) and drug poisoning, by county, for the periods of 2000-03 and 2012-15. We estimated annual percentage changes in mortality (2000-15) by county-level characteristics.

Findings: Premature mortality declined from 2000-03 to 2012-15 among black and Latino people, but increased among white people in many US counties. Drug poisoning mortality increased in counties throughout the country. Significant increases between 2000 and 2015 occurred across low and high socioeconomic status and urban and rural counties among white people aged 25-64 years (annual percentage change range 4·56% per year [95% CI 3·56-5·57] to 11·51% per year [9·41-13·65]), black people aged 50-64 years (2·27% per year [0·42-4·16] to 9·46% per year [7·02-11·96]), Latino women aged 25-49 years (2·43% per year [1·18-3·71] to 5·01% per year [3·80-6·23]), and Latino men aged 50-64 years (2·42% per year [0·53-4·34] to 5·96% per year [3·86-8·11]). Although drug poisoning mortality increased rapidly in counties with the lowest socioeconomic status and in rural counties, most deaths during 2012-15 occurred in the largest metropolitan counties (121 395 [76%] in metropolitan counties with ≥250 000 people vs 2175 [1%] in the most rural counties), reflecting population size.

Interpretation: Premature mortality has declined among black and Latino people in the USA, and increased among white people, particularly in less affluent and rural counties. Increasing drug poisoning mortality was not limited to poor white people in rural areas. Rapid increases have occurred in communities throughout the USA regardless of race and ethnicity, socioeconomic status, or rurality. Widespread public health interventions are needed to addess this public health emergency.

Funding: National Institutes of Health.

Figure 1:. Age-standardised all-cause premature mortality and rate ratios comparing 2012–15 with 2000–03 by US county and race and ethnicity

Data represent those aged 25–64 years. All rates are expressed per 100 000 person-years and data are not included for counties with less than 10 deaths.

Figure 2:. County-level age-standardised all-cause mortality and annual percentage change in mortality

(A) Age-standardised all-cause mortality, 2012–15 and (B) annual percentage changes in mortality, 2000–15, by age, sex, race and ethnicity, and county attributes.

Figure 3:. Age-standardised drug poisoning premature mortality and rate ratios comparing 2012–15 with 2000–03 by US county

Data represent those aged 25–64 years. All rates are expressed per 100 000 person-years and data are not included for counties with less than ten deaths.

Figure 4:. County-level age-standardised drug poisoning mortality and annual percentage change in mortality

Age-standardised drug poisoning mortality, 2012–15 and (B) annual percentage changes in drug poisoning mortality, 2000–15, by age group, sex, race and ethnicity, and county attributes. Annual percentage changes were not estimable in groups with at least one calendar year with no deaths.

Figure 5:. Age-standardised drug poisoning mortality and number of drug poisoning deaths

(A) Age-standardised drug poisoning mortality and (B) number of drug poisoning deaths.