[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 18.207.129.82. Please contact the publisher to request reinstatement.
Original Investigation
February 2, 2021

Association Between County-Level Change in Economic Prosperity and Change in Cardiovascular Mortality Among Middle-aged US Adults

Author Affiliations
  • 1Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 3The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
  • 4Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 5Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 6Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 7Harvard Medical School, Boston, Massachusetts
  • 8Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 9Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 10Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 11Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
JAMA. 2021;325(5):445-453. doi:10.1001/jama.2020.26141
Key Points

Question  Are changes in county-level economic prosperity associated with changes in cardiovascular mortality among middle-aged adults (aged 40-64 years) in the US?

Findings  In this retrospective analysis of county-level mortality data from 3123 US counties from 2010 to 2017, every 10-point greater change in economic prosperity from baseline to follow-up (range, 5 to 92) was significantly associated with a 0.4% lower cardiovascular mortality rate per year among middle-aged adults.

Meaning  In US counties from 2010 to 2017, a relative increase in economic prosperity was associated with a small relative decrease in cardiovascular mortality among middle-aged adults.

Abstract

Importance  After a decline in cardiovascular mortality for nonelderly US adults, recent stagnation has occurred alongside rising income inequality. Whether this is associated with underlying economic trends is unclear.

Objective  To assess the association between changes in economic prosperity and trends in cardiovascular mortality in middle-aged US adults.

Design, Setting, and Participants  Retrospective analysis of the association between change in 7 markers of economic prosperity in 3123 US counties and county-level cardiovascular mortality among 40- to 64-year-old adults (102 660 852 individuals in 2010).

Exposures  Mean rank for change in 7 markers of economic prosperity between 2 time periods (baseline: 2007-2011 and follow-up: 2012-2016). A higher mean rank indicates a greater relative increase or lower relative decrease in prosperity (range, 5 to 92; mean [SD], 50 [14]).

Main Outcomes and Measures  Mean annual percentage change (APC) in age-adjusted cardiovascular mortality rates. Generalized linear mixed-effects models were used to estimate the additional APC associated with a change in prosperity.

Results  Among 102 660 852 residents aged 40 to 64 years living in these counties in 2010 (51% women), 979 228 cardiovascular deaths occurred between 2010 and 2017. Age-adjusted cardiovascular mortality rates did not change significantly between 2010 and 2017 in counties in the lowest tertile for change in economic prosperity (mean [SD], 114.1 [47.9] to 116.1 [52.7] deaths per 100 000 individuals; APC, 0.2% [95% CI, −0.3% to 0.7%]). Mortality decreased significantly in the intermediate tertile (mean [SD], 104.7 [38.8] to 101.9 [41.5] deaths per 100 000 individuals; APC, −0.4% [95% CI, −0.8% to −0.1%]) and highest tertile for change in prosperity (100.0 [37.9] to 95.1 [39.1] deaths per 100 000 individuals; APC, −0.5% [95% CI, −0.9% to −0.1%]). After accounting for baseline prosperity and demographic and health care–related variables, a 10-point higher mean rank for change in economic prosperity was associated with 0.4% (95% CI, 0.2% to 0.6%) additional decrease in mortality per year.

Conclusions and Relevance  In this retrospective study of US county-level mortality data from 2010 to 2017, a relative increase in county-level economic prosperity was significantly associated with a small relative decrease in cardiovascular mortality among middle-aged adults. Individual-level inferences are limited by the ecological nature of the study.

×