CDC WONDER Research Articles

Mortality Trends and Causes of Death in Individuals with Thalassemia: A Population-Based Retrospective Study in the United States from 1999 to 2020

Background Thalassemia is a hereditary hemoglobinopathy that results in ineffective erythropoiesis. Patients with thalassemia have varying degrees of severity ranging from mild anemia to severe complications due to iron overload. Despite its clinical significance, the study on the mortality rate among patients with thalassemia in the United States (US) remains scarce. Objective This study aimed to analyze the trends in thalassemia-related mortality rate and the underlying causes of death among individuals with thalassemia. Methods We queried the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database and performed serial cross-sectional analyses of national death certificate data for thalassemia-related mortality among patients of all ages. Thalassemia (International Classification of Diseases, Tenth Revision [ICD-10] D56) was listed as the contributing cause of death. We calculated age-adjusted mortality rates (AAMRs) per 1,000,000 individuals and examined the trends over time by estimating the average annual percent change (AAPC) using the Joinpoint Regression Program. Subgroup analyses were performed by sex, age, race, census region, and urbanization level. Results From 1999 to 2020, there were 2,797 deaths related to thalassemia. Among these deaths, beta thalassemia accounted for 24.87%, alpha thalassemia accounted for 6.00%, thalassemia trait accounted for 2.52%, dominant thalassemia, hemoglobin C thalassemia, mixed thalassemia, or thalassemia with other hemoglobinopathies accounted for 1.92%, and unspecified thalassemia accounted for 64.37%. The baseline demographics of patients who met the inclusion criteria are shown in Table 1. Thalassemia-related mortality rate showed an overall decline in trend from 0.50 (95% CI, 0.41 - 0.58) per 1,000,000 individuals in 1999 to 0.34 (95% CI, 0.28 - 0.40) per 1,000,000 individuals in 2019, but increased to 0.48 (95% CI, 0.41 - 0.55) per 1,000,000 individuals in 2020 (Figure 1). The highest AAMR was observed among Asians (1.34 [95% CI, 1.20 - 1.47] per 1,000,000 individuals), followed by non-Hispanic Blacks (0.65 [95% CI, 0.59 - 0.71] per 1,000,000 individuals), non-Hispanic Whites (0.32 [95% CI, 0.30 - 0.33] per 1,000,000 individuals), and Hispanics (0.11 [95% CI, 0.08 - 0.14] per 1,000,000 individuals). The most common underlying causes of death among individuals with thalassemia were cardiovascular causes (26.0%), followed by hematological causes (20.7%), malignancy (17.8%), endocrine disorders (6.3%), respiratory causes (6.2%), disorders of the nervous system (5.0%), gastrointestinal diseases (4.9%), psychiatric disorders (3.3%), infection (3.0%), and other causes (6.7%). Among the cardiovascular causes, ischemic heart disease (11.0%) was the most common cause, followed by hypertensive disease (3.0%), cerebrovascular disease (1.7%), aortic valve disease (1.1%), cardiomyopathy (0.79%), and atrial fibrillation and flutter (0.79%). The urban population had a higher AAMR compared to the rural population (0.43 [95% CI, 0.41 - 0.45] per 1,000,000 individuals vs. 0.29 [95% CI, 0.26 - 0.32] per 1,000,000 individuals). Nevertheless, the rural areas exhibited an increasing trend in the AAMR (+6.90%) while the urban areas exhibited a decreasing trend in the AAMR (-11.36%) during the study period. Conclusion While there has been an overall decline in the thalassemia-related mortality rate, variations exist among different races, geographic regions, and urbanization levels. Our study emphasizes the need for targeted interventions to address these disparities.

Rural-urban disparities in lung cancer-related mortality in the United States.

186 Background: Lung cancer survival outcomes have improved substantially over the last two decades, largely due to the advent of immunotherapy and targeted therapy. However, it is still the leading cause of death among all malignancies in the United States (U.S.). It is hence vital to identify the disparities between different population groups to further decrease lung cancer-related mortality. We, therefore, sought to analyze the outcome variances between urban and rural populations. Methods: We retrieved the mortality data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) multiple causes of death database (years: 1999–2020). We analyzed age-adjusted mortality rates (AAMRs) per 100,000 population and assessed temporal trends in the average percent change (APC) of AAMRs by applying the simplest model with a maximum of 3 joinpoints (using the Joinpoint regression program 5.0.2). We conducted nonparallel pairwise comparisons to assess differences in trends between large metropolitan, small/medium metropolitan, and rural areas (per National Center for Health Statistics Urban-Rural Classification Scheme, 2016) using average annual percentage change difference (AAPCD). Results: A total of 5,409,649,211 lung cancer-related deaths were retrieved from CDC Wonder between 1999-2020, amongst which 2,972,877,175 (54.9%) were in the large metropolitan, 1,622,092,262 (30%) were in the small/medium metropolitan, and 814,672,274 (15.1%) were in the rural regions. We noted a decline in the AAMR overall and across large metropolitan, small/medium metropolitan, and rural areas (table). However, the decline in AAMR was significantly higher among large metropolitan areas as compared to small/medium metropolitan (AAPCD -0.5257, 95% CI -0.93, -0.11, p=0.012) and rural areas (AAPCD: -1.2617, 95% CI -1.67, -0.85, p<0.000001). A similar difference was also distinguished when the small/medium metropolitan group was compared with the rural group (AAPCD -0.7360, 95% CI -1.14, -0.32, p=0.0004). Conclusions: We identify discrepancies in the decline in lung cancer AAMR between urban and rural areas. A substantially lower decline in AAMR is eminent in the rural regions, as compared to the urban counterparts. This raises the concern for poor access to cancer care in this population group. Our results, therefore, emphasize the imperative of prioritizing and designing strategies to ensure healthcare equity.[Table: see text]

Association of area-level structural racism with racial disparities in cancer mortality.

172 Background: Structural racism (SR) refers to interactive systems of discrimination that perpetuate advantage for one racial group over others. Single-variable SR measures, such as residential segregation and historical red-lining, are associated with cancer disparities but do not represent all aspects of SR. We aimed to develop a composite measure of SR for cancer research and examine the association of county-level SR with disparities in cancer mortality. Methods: Adapting methods from obesity and public safety research, we developed a SR composite score (SRCS) by calculating the ratio of Black to White performance on eight county-level variables across five domains (housing, education, employment, income and healthcare) using race-stratified census data from 2006-2020. Using North Carolina as a test set, we rank-ordered counties on a min-max scale 1-100 for each domain and averaged scores across domains to create the SRCS, where higher SRCS suggests greater SR. Outcomes were county age-standardized mortality rates (per 100k) for all cancers combined, breast, prostate, colorectal and lung cancers, extracted from CDC Wonder for non-Hispanic Blacks and Whites (2000-2020). We used generalized estimating equations to regress mortality rates on SRCS, race, and their interaction. Results: County-level SRCS was positively associated with county-level racial disparities in all-cancer mortality; for each 10-unit increase in SRCS, Black-White difference in rates increased by 15.3/100k (p<0.001). For individual cancers, a 10 unit rise in county SRCS was associated with a 1.93/100k increase in the colorectal cancer mortality gap (p=0.003) and a 6.18/100k increase in the lung cancer mortality gap (p<0.001). SRCS was not associated with mortality disparities for breast and prostate cancers, although these disparities were large. For all-cancer mortality and all tumor types except breast cancer, mortality rates of Whites significantly decreased as SRCS increased, while mortality rates for Blacks remained roughly stable with rising SRCS. Adjustment for county-level measures of social deprivation, unemployment, primary care provider ratio, and severe housing problems did not attenuate the relationship of SRCS with mortality. Conclusions: A composite measure of SR is associated with racial disparities in overall cancer mortality and mortality of specific solid tumors. Continued research is needed to further understand the role of area-level social determinants, ecologic fallacy, and differences in the relationship of SRCS to mortality across cancers. Nevertheless, increased SR is associated with lower county-level cancer mortality among Whites, suggesting that SR may perpetuate cancer mortality disparities via relative advantage to White residents rather than direct disadvantage to Black residents.

Trends in CV mortality among patients with known mental and behavioral disorders in the US between 1999 and 2020.

Patients with mental disorders are at increased risk of cardiovascular events. We aimed to assess the cardiovascular mortality trends over the last two decades among patients with mental and behavioral co-morbidities in the US. We performed a retrospective, observational study using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) Multiple Cause of Death dataset. We determined national trends in age-standardized mortality rates attributed to cardiovascular diseases in patients with and without mental and behavioral disorders, from 1999 to 2020, stratified by mental and behavioral disorders subtype [ICD10 codes F], age, gender, race, and place of residence. Among more than 18.7 million cardiovascular deaths in the United States (US), 13.5% [2.53 million] were patients with a concomitant mental and behavioral disorder. During the study period, among patients with mental and behavioral disorders, the age-adjusted mortality rate increased by 113.9% Vs a 44.8% decline in patients with no mental disorder (both p<0.05). In patients with mental and behavioral disorders, the age-adjusted mortality rate increased more significantly among patients whose mental and behavioral disorder was secondary to substance abuse (+532.6%, p<0.05) than among those with organic mental disorders, such as dementia or delirium (+6.2%, P- nonsignificant). Male patients (+163.6%) and residents of more rural areas (+128-162%) experienced a more prominent increase in age-adjusted cardiovascular mortality. While there was an overall reduction in cardiovascular mortality in the US in the past two decades, we demonstrated an overall increase in cardiovascular mortality among patients with mental disorders.

Rural-urban disparities in breast cancer-related mortality in the United States (1999-2020).

181 Background: Breast cancer is the most commonly diagnosed cancer and the second most common cause of cancer death among women in the United States (U.S.). While racial and ethnic disparities in outcomes are known, large population-based data on rural and urban disparities in breast cancer-related mortality are lacking. Methods: We retrieved de-identified data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) multiple causes of death database (years: 1999–2020) for females (aged 15 years and upwards) with “malignant neoplasm of breast” (ICD-10 C50) listed as “underlying cause of death”. We analyzed age-adjusted mortality rates (AAMRs) per 100,000 population and assessed temporal trends in the average percent change (APC) of AAMRs applying the simplest model with a maximum of 3 joinpoints (using Joinpoint regression program 4.9.1.0). We conducted nonparallel pairwise comparisons to assess differences in trends between large metropolitan, medium to small metropolitan and rural areas (per National Center for Health Statistics Urban-Rural Classification Scheme, 2016) using average annual percentage change difference (AAPCD). Results: A total of 909,467 breast-cancer related deaths were analyzed between 1999-2020. We noted a decline in breast cancer related AAMR overall and across large metropolitan, small to medium metropolitan and rural areas (table). However, the decline in AAMR was significantly higher among large metropolitan areas as compared to small to medium metropolitan (AAPCD -0.3371, 95% CI -0.61, -2.4187, p=0.02) and rural areas (AAPCD: -0.48, 95% CI -0.79, -3.12, p=0.002). No significant difference in AAMR trend in small to medium metropolitan and rural areas was noted (AAPCD -0.15, 95% CI -0.37, 0.08, p=0.19). Conclusions: We demonstrate disparities in decline in breast cancer related AAMR between urban and rural areas. A significantly higher decline in AAMR among large metropolitan areas compared to medium to small metropolitan and rural areas suggests discrepancy in access to cancer care among populations. Further work is needed to develop strategies aimed at ensuring equitable cancer care access for all patients with breast cancer regardless of their geographical location.[Table: see text]

Trends in Cardiovascular Disease Mortality in US Women Veterans vs Civilians

Cardiovascular disease (CVD) remains the leading cause of death in the US. Women veterans have higher rates of CVD compared with civilian US women; however, analyses of recent trends in mortality from cardiac disease for women veterans are lacking. To investigate trends in cardiac disease mortality among women veterans over approximately the past 2 decades and compare rates with those for civilian women. In this retrospective longitudinal cohort study, US Veterans Health Administration (VHA) electronic health record data, linked with the National Death Index, were analyzed for CVD trends and rates of cardiac disease mortality among women veterans (aged 18 years or older) with VHA health care encounters from January 1, 2000, to December 31, 2017. These data were compared with a national cohort of civilian women (aged 15 years or older) in the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database, which provides cause-of-death data using death certificates for all US residents. The data analysis was performed between March 10, 2021, and November 28, 2022. Cardiac disease mortality among women veterans and civilian women. Cardiac disease mortality was based on International Classification of Diseases, Tenth Revision diagnostic codes (I00-I09, I11, I13, and I20-I51 as defined by CDC WONDER). For women veterans and civilian women, crude and age-adjusted cardiac disease mortality rates (per 100 000 life-years) and 95% CIs were calculated, with the 2000 US general population as the reference for age-adjusted rates. From 2000 to 2017, 817 912 women veterans engaged with VHA health care (mean [SD] age, 45.7 [17.1] years), and 19 022 cardiac disease deaths were identified (22.4% of total deaths). The crude and age-adjusted cardiac disease mortality rates, respectively, per 100 000 life-years were 200.2 (95% CI, 181.0-221.0) and 197.6 (95% CI, 175.2-222.0) in 2000 and 196.0 (95% CI, 186.1-206.4) and 208.1 (95% CI, 196.4-220.4) in 2017, reflecting stable crude rates and a 5.3% increase in age-adjusted rates. For civilian women, the crude and age-adjusted rates decreased over time from 320.7 (95% CI, 319.7-321.8) and 268.1 (95% CI, 267.3-269.0) in 2000 to 220.9 (95% CI, 220.1-221.7) and 164.7 (95% CI, 164.1-165.3) in 2017. In this cohort study comparing women veterans and civilian women, cardiac disease mortality rates for women veterans did not exhibit the improvements seen for civilian women during the nearly 2-decade study period. Further research and actionable clinical interventions are warranted to improve cardiovascular care for women veterans, who represent the fastest growing group of patients within the VHA health care system.

Joint effects of US area-level social mobility &amp; income inequality on mortality: an ecological study

Abstract Background Income inequality and its relationship with health has been extensively studied. Intergenerational income mobility (IGIM) has received less attention, but may be an important independent mechanism explaining health inequalities. Methods We conducted ecological analyses of the effects of IGIM and income inequality on mortality across commuting zones (CZ) in the US. IGIM was measured using rank-rank slope, i.e. the correlation between household income rank at age 15-19 and own income rank at age 29-30. We used CZ-level IGIM data from the Opportunity Insights project, Gini index of inequality from the American Community Survey, and mortality rates from CDC WONDER. Cross-sectional and longitudinal (CZ fixed effects) regression models were fitted adjusting for mean income and weighted by population. Results CZs with higher IGIM between 1995-2001 and 2011-12 had lower age-standardised mortality in 2009-2013, with 53.9 (95% CI: 48.9-58.9) fewer deaths per 100,000 for a standard deviation (SD) increase in IGIM (adjusting for mean income and Gini index in 2009-2013). This equates to 778 (773-783) deaths at the lower quartile vs. 710 (705-715) at the upper. Income inequality had a negligible association at 1.1 (-5.0, 7.3) deaths per SD increase. Longitudinal analysis across three 5-year periods confirmed that within-CZ changes in infant mortality were predicted by changes in IGIM (32.0 [12.7-51.2] fewer deaths per SD increase) but not income inequality (4.5 [-12.0, 20.9] deaths per SD increase). Conclusions Preliminary evidence suggests IGIM is a more important indicator for population health than income inequality. European researchers and public health bodies should further research and monitor IGIM, which may require improved availability of intergenerationally linked income data. Policy measures that improve social mobility, such as education and early-years interventions, may have greater health effects than policies only aiming at resource redistribution. Key messages • Differences in intergenerational income mobility accounted for substantial differences in mortality across US commuting zones, while income inequality appeared relatively unimportant. • European policymakers should put greater emphasis on social mobility as an economic determinant of health, and facilitate research using intergenerationally linked income data.

Suicide and Self-Harm in Adolescents During the COVID-19 Pandemic: A U.S. Virtual Pediatric Systems, LLC, Database Study of PICU Admissions, 2016-2021.

To characterize the epidemiology of suicide and self-harm among adolescents admitted to PICUs during the first 2 years of the COVID-19 pandemic in the United States. Descriptive analysis of a large, multicenter, quality-controlled database (Virtual Pediatric Systems [VPS]), and of a national public health dataset (U.S. Centers for Disease Control and Prevention web-based Wide-ranging ONline Data for Epidemiology Research [CDC WONDER]). The 69 PICUs participating in the VPS database that contributed data for the entire the study period, January 1, 2016, to December 31, 2021. Adolescents older than 12 years to younger than 18 years old admitted to a participating PICU during the study period with a diagnosis involving self-harm or a suicide attempt (VPS sample), or adolescent suicide deaths over the same period (CDC WONDER sample). None. We identified 10,239 suicide deaths and 7,692 PICU admissions for self-harm, including 5,414 admissions in the pre-pandemic period (Q1-2016 to Q1-2020) and 2,278 in the pandemic period (Q2-2020 to Q4-2021). Compared with the pre-pandemic period, there was no increase in the median (interquartile range) number of suicide deaths per quarter (429 [399-453] vs. 416 [390-482]) or PICU admissions for self-harm per quarter (315 [289-353] vs. 310 [286-387]) during the pandemic period, respectively. There was an increase in the ratio of self-harm PICU admissions to all-cause PICU admissions per quarter during the pandemic (1.98 [1.43-2.12]) compared with the pre-pandemic period per quarter (1.59 [1.46-1.74]). We also observed a significant decrease in all-cause PICU admissions per quarter early in the pandemic compared with the pre-pandemic period (16,026 [13,721-16,297] vs. 19,607 [18,371-20,581]). The number of suicide deaths and PICU admissions per quarter for self-harm remained relatively constant during the pandemic, while the number of all-cause PICU admissions per quarter decreased compared with the pre-pandemic period. The resultant higher ratio of self-harm admissions to all-cause PICU admissions may have contributed to the perception that more adolescents required critical care for mental health-related conditions early in the pandemic.

S1386 Ethnic and Racial Disparities in Alcoholic Liver Disease Related Mortality: Data From CDC Wonder 1999-2020

S1386 Ethnic and Racial Disparities in Alcoholic Liver Disease Related Mortality: Data From CDC Wonder 1999-2020

The Impact of the COVID-19 Pandemic on Cancer Mortality in Pennsylvania: A Retrospective Study with Geospatial Analysis.

We sought to quantify the impact of the COVID-19 pandemic on cancer mortality and identify associated factors in Pennsylvania. The retrospective study analyzed cross-sectional cancer mortality data from CDC WONDER for 2015 through 2020 for Pennsylvania and its 67 counties. The spatial distributions of 2019, 2020, and percentage change in age-adjusted mortality rates by county were analyzed via choropleth maps and spatial autocorrelation. A Wilcoxon Signed Rank Test was used to analyze whether the rates differed between 2019 and 2020. Quasi-Poisson and geographically weighted regression at the county level were used to assess the association between the 2019 rates, sex (percent female), race (percent non-White), ethnicity (percent Hispanic/Latino), rural-urban continuum codes, and socioeconomic status with the 2020 rates. At the state level, the rate in 2020 did not reflect the declining annual trend (-2.7 per 100,000) in the rate since 2015. Twenty-six counties had an increase in the rate in 2020. Of the factors examined, the 2019 rates were positively associated with the 2020 rates, and the impact of sociodemographic and geographic factors on the 2020 rates varied by county. In Pennsylvania, the 2020 cancer mortality rates did not decline as much as reported before the COVID-19 pandemic. The top five cancer types by rate were the same type for 2019 and 2020. Future cancer control efforts may need to address the impact of the COVID-19 pandemic on trends and geospatial distribution in cancer mortality.

Racial disparities in COVID-19 and gastrointestinal diseases–related mortality: analysis from CDC-WONDER databases, 2020–2022

Background The COVID-19 pandemic represents an unprecedented global health challenge. Gastrointestinal diseases (GID) have been shown to increase morbidity and mortality in COVID-19 patients, warranting a comprehensive investigation of their combined impact and racial disparities in mortality rates within the United States. Methods Data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) mortality statistics database were analyzed for the period from January 1, 2020, to December 31, 2022. This study focused on adults, considering all deaths related to COVID-19 and GID. Age-adjusted mortality rates (AAMR) per 100,000 population were reported. Sociodemographic data, including age, sex, race/ethnicity, and region of residence, were collected. Results Among 9,925,729 total deaths in the US between 2020 and 2022, 3.9% were GID related only, 9.6% were COVID-19 related only, and 0.4% were attributed to both COVID-19 and GID as underlying causes of death. AAMR for COVID-19 was 121.3 per 100,000, significantly higher than the AAMR for GID (50.3 per 100,000). Age-wise, elderly individuals had the highest AAMR for both COVID-19 and GID-related deaths. Stratified by race/ethnicity, Hispanics exhibited the highest AAMR, nearly twice that of Non-Hispanic Black patients and substantially higher than Non-Hispanic White and Asian patients. Conclusion Our findings reveal substantial disparities in race/ethnicity-specific AAMR associated with both COVID-19 and GID in the US. Further research is crucial to delve deeper into their root causes and develop targeted interventions to strive for health equity for all.

Temporal Trends of Semen Quality and Fertility Rates Over the Course of a Decade: Data From King County, Washington

There has been a widely reported decline in both semen quality and fertility rate, however to date these studies have not looked at a decline of both in the same time period within the same geographical area. The objective of this study was to determine if there existed a temporal trend in both semen parameters and fertility rates for the same geographic area (King County, WA) over time. Semen parameters from sperm donors at Seattle sperm bank were obtained from 2008 to 2021. Sperm donations occurred in King County, WA. Donors were from within 50 miles of the donation site. Fertility rates were calculated for King County, WA using census data from SEER to find number of women aged 15-49 and the number of births were found using CDC Wonder data from 2006-2017. There were a total of 76,622 sperm donor semen analyses from King County, WA included in our study from 2008-2021. The fertility rate for King County, WA was calculated from 2006-2017. From 2008-2021, there was a statistically significant decline in semen quality over time for both sperm count (p<0.01), total motile sperm count (p<0.01), sperm concentration (p<.01), and progressive motility (p<.01). Additionally, from 2006-2017 there was a statistically significant decline in fertility rate (p<0.01). We report a statistically significant decline in sperm parameters among donors and a corresponding decline in fertility rates from the same geographic area that warrants further investigation given the serious societal and economic impacts a shrinking population presents. While certainly not the sole contributing factor, declining sperm parameters likely need to be accounted for when accounting for declining fertility rates.

Cystic fibrosis-related mortality in the United States from 1999 to 2020: an observational analysis of time trends and disparities

Cystic fibrosis transmembrane conductance regulator modulators have revolutionized cystic fibrosis (CF) care in the past decade. This study explores the CF-related mortality trends in the US from 1999 to 2020. We extracted CF-related mortality data from the CDC WONDER database. CF age-standardized mortality rates (ASMRs) were identified by ICD-10 code E84 and were stratified by demographic and geographical variables. Temporal trends were analyzed using Joinpoint modeling. CF-related ASMRs decreased from 1.9 to 1.04 per million population (p = 0.013), with a greater reduction in recent years. This trend was replicated in both sexes. The median age of death increased from 24 to 37 years. CF mortality rates decreased across sex, white race, non-Hispanic ethnicity, census regions, and urbanization status. Incongruent trends were reported in non-white races and Hispanic ethnicity. A lower median age of death was observed in women, non-white races, and Hispanic ethnicity. SARS-CoV-2 infection was the primary cause of death in 1.7% of CF decedents in 2020. The national CF-related mortality rates declined and the median age of death among CF decedents increased significantly indicating better survival in the recent years. The changes were relatively slow during the earlier period of the study, followed by a greater decline lately. We observed patterns of sex, ethnic, racial, and geographical disparities associated with the worsening of the gap between ethnicities, narrowing of the gap between races and rural vs. urban counties, and closing of the gap between sexes over the study period.

Changes in cancer-related mortality during the COVID-19 pandemic in the United States.

Few studies have examined cancer-related mortality overall, never mind select cancer types, during the COVID-19 pandemic. Data on cancer-related mortality (any mention in death certificates, multiple causes of death approach) was extracted from the US Centers for Disease Control and Prevention WONDER database. Changes in trends for age-standardized mortality rates through 1999-2021 were assessed by Joinpoint analysis. In total, 1 379 643 cancer-related deaths were registered in 2020-2021, with cancer selected as the underlying cause in 88%. After 2 decades of decline, age-standardized cancer-related mortality increased from 2019 to 2021 for all cancers (annual percentage change = 1.6%, 95% confidence interval = 0.6% to 2.6%), especially for prostate cancer (annual percentage change = 5.1%, 95% confidence interval = 2.2% to 8.2%) and hematologic cancers (annual percentage change = 4.8%, 95% confidence interval = 3.1% to 6.6%). Sharp peaks in cancer-related deaths for many cancer sites were observed during pandemic waves in both 2020 and 2021, mostly attributed to COVID-19 as the underlying cause. Multiple causes of death analyses are warranted to fully assess the impact of the pandemic on cancer-related mortality.

Travel distance and social vulnerability index: Impact on liver-related mortality among patients with end-stage liver disease.

The reasons for the geographic disparities in liver-related mortality across the US remain ill-defined. We sought to investigate the impact of travel distance to liver transplantation (LT) programs and social vulnerability on county differences in liver-related mortality. Data on LT registrants were obtained from the Scientific Registry of Transplant Recipients Standard Analytic Files (SRTR SAFs) between 2004 and 2019. Liver-related mortality data were obtained from the Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) platform. Spatial epidemiological clustering of county-level LT registration and liver-related mortality rates was determined using local Moran's I. Comparison analyses assessed social vulnerability index (SVI) and travel distance within various county clusters. Among 151864 LT waitlist registrants who were diagnosed with liver disease due to hepatitis C virus (HCV) or hepatitis B virus (HBV) (n=68479, 45.1%), alcohol (n=38328, 25.2%), non-alcoholic steatohepatitis (NASH) (n=17485, 11.5%), liver tumors (n=16644, 11.0%), and other diseases (n = 10928, 7.2%), median SVI was 59.3 (IQR, 40.1-83.4). SVI (76.2 vs. 24.3, p<.001) was greater in the highest versus lowest liver-related mortality quartiles. The travel distances to LT centers (143.1 miles vs. 107.2 miles, p<.001) was longer in the lowest versus highest LT registration quartiles. Counties with low LT registration rates and high liver-related mortality rates were associated with long travel distances and high SVI. In contrast, while counties with high LT registration rates and high liver-related mortality rates had comparable SVI, travel distance was relatively shorter. Counties with greater SVIs were associated with higher liver-related mortality, with the highest SVI counties having the highest overall liver-related mortality. Longer travel distances were associated with higher liver-related mortality. These findings highlight the impact of social determinants of health (SDOH) on liver disease outcomes.

Trends in cardiovascular mortality in the United States from 1968 to 2019: analysis of the CDC WONDER database.

Trends in cardiovascular mortality in the United States from 1968 to 2019: analysis of the CDC WONDER database.

Years of life lost due to deaths of despair and COVID-19 in the United States in 2020: patterns of excess mortality by gender, race and ethnicity

BackgroundIn 2020 COVID-19 was the third leading cause of death in the United States. Increases in suicides, overdoses, and alcohol related deaths were seen—which make up deaths of despair. How deaths of despair compare to COVID-19 across racial, ethnic, and gender subpopulations is relatively unknown. Preliminary studies showed inequalities in COVID-19 mortality for Black and Hispanic Americans in the pandemic's onset. This study analyzes the racial, ethnic and gender disparities in years of life lost due to COVID-19 and deaths of despair (suicide, overdose, and alcohol deaths) in 2020.MethodsThis cross-sectional study calculated and compared years of life lost (YLL) due to Deaths of Despair and COVID-19 by gender, race, and ethnicity. YLL was calculated using the CDC WONDER database to pull death records based on ICD-10 codes and the Social Security Administration Period Life Table was used to get estimated life expectancy for each subpopulation.ResultsIn 2020, COVID-19 caused 350,831 deaths and 4,405,699 YLL. By contrast, deaths of despair contributed to 178,598 deaths and 6,045,819 YLL. Men had more deaths and YLL than women due to COVID-19 and deaths of despair. Among White Americans and more than one race identification both had greater burden of deaths of despair YLL than COVID-19 YLL. However, for all other racial categories (Native American/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander) COVID-19 caused more YLL than deaths of despair. Also, Hispanic or Latino persons had disproportionately higher mortality across all causes: COVID-19 and all deaths of despair causes.ConclusionsThis study found greater deaths of despair mortality burden and differences in burden across gender, race, and ethnicity in 2020. The results indicate the need to bolster behavioral health research, support mental health workforce development and education, increase access to evidence-based substance use treatment, and address systemic inequities and social determinants of deaths of despair and COVID-19.

Risk of suicide among stroke survivors in the United States

BackgroundStroke is the largest cause of disability and the 5th leading cause of death in the United States. Suicide is the 12th leading cause of death in the United States. However, little is known about the risk of suicide among people with a prior stroke. ObjectivesUsing Multiple Cause of Death data (1999-2020) from the Centers for Disease Control and Prevention WONDER database, we examined via cross-sectional analysis the risk of suicide among survivors of stroke as compared to the general U.S. population and among subgroups within the United States. MethodsWe assessed disparities in suicide rate among patients with stroke stratified by sex, race, urbanization levels, and census regions using the CDC WONDER multiple cause of death database. Standardized mortality rates were calculated to compare the suicide rate of stroke patients with the rates among demographic-matched cohorts and the general United States population. ResultsAs compared to the general population, stroke survivors had an elevated risk of suicide. Black stroke survivors had a lower rate of suicide as compared to the general population, while White stroke survivors and those in nonmetropolitan areas had an elevated risk compared to the general population. ConclusionThere was a slightly elevated risk of suicide among people with a prior stroke in the United States. This risk may be elevated among White people and among people living in nonmetropolitan areas.

Disparities in testicular cancer incidence, mortality, and place of death trends from 1999 to 2020: A comprehensive cohort study.

Testicular cancer (TC) mortality rates have decreased over time, however it is unclear whether these improvements are consistent across all communities. The aim of this study was to analyze trends in TC incidence, mortality, and place of death (PoD) in the United States between 1999-2020 and identify disparities across race, ethnicity, and geographic location. This cross-sectional study used CDC WONDER and NAACCR, to calculate age-adjusted rates of TC incidence and mortality, respectively. PoD data for individuals who died of TC were collected from CDC WONDER. Using Joinpoint analysis, longitudinal mortality trends were evaluated by age, race, ethnicity, US census region, and urbanization category. TC stage (localized vs metastatic) trends were also evaluated. Univariate and multivariate regression analysis identified demographic disparities for PoD. A total of 8,456 patients died of TC from 1999-2020. Average annual percent change (AAPC) of testicular cancer-specific mortality (TCSM) remained largely stable (AAPC, 0.4; 95% CI -0.2 to 0.9; p = 0.215). Men ages 25-29 experienced a significant increase in TCSM (AAPC, 1.3, p = 0.003), consistent with increased metastatic testicular cancer-specific incidence (TCSI) trend for this age group (AAPC, 1.6; p < 0.01). Mortality increased for Hispanic men (AAPC, 1.7, p < 0.001), with increased metastatic TCSI (AAPC, 2.5; p < 0.001). Finally, younger (<45), single, and Hispanic or Black men were more likely to die in medical facilities (all p < 0.001). The retrospective study design is a limitation. Significant increases in metastatic TC were found for Hispanic men and men aged 25-29 potentially driving increasing testicular cancer specific mortality in these groups. Evidence of racial and ethnic differences in place of death may also highlight treatment disparities.

The impact of COVID-19 on life expectancy among four Asian American subgroups

Background and objectiveTo date, the impact of the COVID-19 pandemic on life expectancy for the Asian American (AA) population has been reported in aggregate. This study provides estimates of life expectancy at birth before and during the pandemic, with a set of demographic, health, and socioeconomic risk factors for the four largest subgroups: Asian Indians, Chinese, Filipinos, and Vietnamese. These estimates are placed in context of the broader U.S. population. MethodsThis study uses age-specific all-cause mortality from CDC WONDER and population counts from the American Community Surveys. We apply methodologies to address variability in population sizes over time (smoothing) and data quality issues at older ages (Brass relational model life table system) to produce three sets of sex-specific life expectancy estimates by subgroup for 2019, 2020, and 2021. ResultsAlmost all estimates show that the four AA subgroups experienced greater losses between 2019 and 2020 than Whites. These losses ranged from 1.1 to 3.9 years, with the largest drops among Chinese women (2.0–2.4) and Filipino men (3.5–3.9). Under all scenarios, losses in life expectancy were considerably smaller in 2021 than in 2020 among the four subgroups – with several subgroups experiencing a modest rebound – but these improvements did not compensate for the large increases in death rates in 2020. Filipino men had the largest decline in life expectancy from 2019 to 2021 among the four subgroups (3.4–4.2 years), and Vietnamese men and women experienced large losses which continued into the second year of the pandemic. ConclusionsDespite high pre-pandemic life expectancies, AAs suffered a large, and rarely acknowledged, increase in mortality during the pandemic, with substantial heterogeneity across subgroups and between women and men. This variability is due in part to the pronounced differences in risk factors for infection and severity which have been documented within the AA population.