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Background:
Recent data suggest that the United States is in the midst of an epidemiologic transition in the leading cause of death.
Objective:
To examine county-level sociodemographic differences in the transition from heart disease to cancer as the leading cause of death in the United States.
Design:
Observational study.
Setting:
U.S. death records, 2003 to 2015.
Participants:
Decedents aged 25 years or older, classified by racial/ethnic group.
Measurements:
All-cause, heart disease, and cancer mortality stratified by quintiles of county median household income. Age- and sex-adjusted mortality rates and average annual percentage of change were calculated.
Results:
Heart disease was the leading cause of death in 79% of counties in 2003 and 59% in 2015. Cancer was the leading cause of death in 21% of counties in 2003 and 41% in 2015. The shift to cancer as the leading cause of death was greatest in the highest-income counties. Overall, heart disease mortality rates decreased by 28% (30% in high-income counties vs. 22% in low-income counties) from 2003 to 2015, and cancer mortality rates decreased by 16% (18% in high-income counties vs. 11% in low-income counties). In the lowest-income counties, heart disease remained the leading cause of death among all racial/ethnic groups, and improvements were smaller for both heart disease and cancer.
Limitation:
Use of county median household income as a proxy for socioeconomic status.
Conclusion:
Data show that heart disease is more likely to be the leading cause of death in low-income counties. Low-income counties have not experienced the same decrease in mortality rates as high-income counties, which suggests a later transition to cancer as the leading cause of death in low-income counties.
Primary Funding Source:
National Institute on Minority Health and Health Disparities.
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Author, Article and Disclosure Information
Acknowledgment: The authors thank the reviewers for their meticulous and comprehensive peer review; Mercedes Carnethon, PhD, for her prepublication review of the manuscript; and staff from the Quantitative Sciences Unit at Stanford University School of Medicine for their thoughtful statistical review and suggestions on this study.
Grant Support: By the National Institute on Minority Health and Health Disparities (R01 MD007012).
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-0796.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Proctor & Gamble, Pfizer, and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Not available. Statistical code: Available from Dr. Boothroyd (e-mail, [email protected]). Data set: Publicly available from the National Center for Health Statistics (www.cdc.gov/nchs/index.htm).
Corresponding Author: Latha Palaniappan, MD, MS, Medical School Office Building, 1265 Welch Road, MC 5475, Stanford, CA 94305; e-mail, [email protected].
Current Author Addresses: Ms. Hastings, Ms. Hu, and Dr. Palaniappan: Division of Primary Care and Population Health, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA 94305.
Dr. Boothroyd and Mr. Kapphahn: Quantitative Sciences Unit, Stanford University School of Medicine, 1070 Arastradero, Suite 300, Palo Alto, CA 94306.
Drs. Rehkopf and Cullen: Center for Population Health Sciences, Stanford University School of Medicine, 1070 Arastradero, Suite 300, Palo Alto, CA 94306.
Author Contributions: Conception and design: K.G. Hastings, D.H. Rehkopf, M.R. Cullen, L. Palaniappan.
Analysis and interpretation of the data: K.G. Hastings, D.B. Boothroyd, K. Kapphahn, J. Hu, M.R. Cullen, L. Palaniappan.
Drafting of the article: K.G. Hastings, D.B. Boothroyd, D.H. Rehkopf, L. Palaniappan.
Critical revision of the article for important intellectual content: K.G. Hastings, D.B. Boothroyd, K. Kapphahn, D.H. Rehkopf, M.R. Cullen, L. Palaniappan.
Final approval of the article: K.G. Hastings, D.B. Boothroyd, K. Kapphahn, J. Hu, D.H. Rehkopf, M.R. Cullen, L. Palaniappan.
Provision of study materials or patients: K.G. Hastings, L. Palaniappan.
Statistical expertise: D.B. Boothroyd, K. Kapphahn, J. Hu, D.H. Rehkopf.
Obtaining of funding: D.H. Rehkopf, M.R. Cullen, L. Palaniappan.
Administrative, technical, or logistic support: K.G. Hastings, L. Palaniappan.
Collection and assembly of data: K.G. Hastings, K. Kapphahn, J. Hu.
This article was published at Annals.org on 13 November 2018.
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