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    Original Investigation
    Health Policy
    February 28, 2020

    Factors Associated With County-Level Variation in Premature Mortality Due to Noncommunicable Chronic Disease in the United States, 1999-2017

    Author Affiliations
    • 1China Center for Health Development Studies, Peking University, Beijing, China
    • 2RTI International, Research Triangle Park, North Carolina
    • 3Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill
    • 4Department of Global Health, Peking University School of Public Health, Beijing, China
    • 5Peking University Institute for Global Health, Beijing, China
    JAMA Netw Open. 2020;3(2):e200241. doi:10.1001/jamanetworkopen.2020.0241
    Key Points español 中文 (chinese)

    Question  How does county-level premature mortality due to noncommunicable chronic disease vary by economic and geographic factors in the United States?

    Findings  In this cross-sectional study of 3109 US counties, the variations in mortality due to noncommunicable chronic disease increased from 1999 to 2017, and within-state differences accounted for most of the inequalities (57.10% in 2017). The mortality variation was associated with demographic composition, socioeconomic features, health care environment, and population health status.

    Meaning  The increasing variations in premature mortality due to noncommunicable chronic disease suggest a need for expanded efforts across multisectoral actions to reduce the differences in socioeconomic characteristics and prevalence of noncommunicable chronic disease risk factors.


    Importance  Progress against premature death due to noncommunicable chronic disease (NCD) has stagnated. In the United States, county-level variation in NCD premature mortality has widened, which has impeded progress toward mortality reduction for the World Health Organization (WHO) 25 × 25 target.

    Objectives  To estimate variations in county-level NCD premature mortality, to investigate factors associated with mortality, and to present the progress toward achieving the WHO 25 × 25 target by analyzing the trends in mortality.

    Design, Setting, and Participants  This cross-sectional study focused on NCD premature mortality and its factors from 3109 counties using US mortality data for cause of death from the Centers for Disease Control and Prevention WONDER databases and county-level characteristics data from multiple databases. Data were collected from January 1, 1999, through December 31, 2017, and analyzed from April 1 through October 28, 2019.

    Exposures  County-level factors, including demographic composition, socioeconomic features, health care environment, and population health status.

    Main Outcomes and Measures  Variations in county-level, age-adjusted NCD mortality in the US residents aged 25 to 64 years and associations between mortality and the 4 sets of county-level factors.

    Results  A total of 6 794 434 deaths due to NCD were recorded during the study period (50.58% women; 16.49% aged 65 years or older). Mortality decreased by 4.30 (95% CI, −4.54 to −4.08) deaths per 100 000 person-years annually from 1999 to 2010 (P < .001) and decreased annually at a rate of 0.90 (95% CI, −1.13 to −0.73) deaths per 100 000 person-years annually from 2010 to 2017 (P < .001). Mortality in the county with the highest mortality was 10.40 times as high as that in the county with the lowest mortality (615.40 vs 59.20 per 100 000 population) in 2017. Geographic inequality was decomposed by between-state and within-state differences, and within-state differences accounted for most inequality (57.10% in 2017). County-level factors were associated with 71.83% variation in NCD mortality. Association with intercounty mortality was 19.51% for demographic features, 23.34% for socioeconomic composition, 16.40% for health care environment, and 40.75% for health-status characteristics.

    Conclusions and Relevance  Given the stagnated trend of decline and increasing variations in NCD premature mortality, these findings suggest that the WHO 25 × 25 target appears to be unattainable, which may be related to broad failure by United Nations members to follow through on commitments of reducing socioeconomic inequalities. The increasing inequalities in mortality are alarming and warrant expanded multisectoral efforts to ameliorate socioeconomic disparities.