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The Reversal of Fortunes: Trends in County Mortality and Cross-County Mortality Disparities in the United States

机译:命运的逆转:美国县级死亡率和跨县级死亡率差异的趋势

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摘要

Background: Counties are the smallest unit for which mortality data are routinely available, allowing consistent and comparable long-term analysis of trends in health disparities. Average life expectancy has steadily increased in the United States but there is limited information on long-term mortality trends in the US counties This study aimed to investigate trends in county mortality and cross-county mortality disparities, including the contributions of specific diseases to county level mortality trends.Methods and Findings: We used mortality statistics (from the National Center for Health Statistics [NCHS]) and population (from the US Census) to estimate sex-specific life expectancy for US counties for every year between 1961 and 1999. Data for analyses in subsequent years were not provided to us by the NCHS. We calculated different metrics of cross-county mortality disparity, and also grouped counties on the basis of whether their mortality changed favorably or unfavorably relative to the national average. We estimated the probability of death from specific diseases for counties with above- or below-average mortality performance. We simulated the effect of cross-county migration on each county\u27s life expectancy using a time-based simulation model. Between 1961 and 1999, the standard deviation (SD) of life expectancy across US counties was at its lowest in 1983, at 1.9 and 1.4 y for men and women, respectively. Cross-county life expectancy SD increased to 2.3 and 1.7 y in 1999. Between 1961 and 1983 no counties had a statistically significant increase in mortality; the major cause of mortality decline for both sexes was reduction in cardiovascular mortality. From 1983 to 1999, life expectancy declined significantly in 11 counties for men (by 1.3 y) and in 180 counties for women (by 1.3 y); another 48 (men) and 783 (women) counties had nonsignificant life expectancy decline. Life expectancy decline in both sexes was caused by increased mortality from lung cancer, chronic obstructive pulmonary disease (COPD), diabetes, and a range of other noncommunicable diseases, which were no longer compensated for by the decline in cardiovascular mortality. Higher HIV/AIDS and homicide deaths also contributed substantially to life expectancy decline for men, but not for women. Alternative specifications of the effects of migration showed that the rise in cross-county life expectancy SD was unlikely to be caused by migration.Conclusions: There was a steady increase in mortality inequality across the US counties between 1983 and 1999, resulting from stagnation or increase in mortality among the worst-off segment of the population. Female mortality increased in a large number of counties, primarily because of chronic diseases related to smoking, overweight and obesity, and high blood pressure.
机译:背景:县是常规获得死亡率数据的最小单位,可以对健康差异趋势进行一致且可比较的长期分析。美国的平均预期寿命稳定增长,但有关美国各县长期死亡率趋势的信息有限。该研究旨在调查县死亡率和跨县死亡率差异的趋势,包括特定疾病对县级的贡献死亡率趋势。方法和调查结果:我们使用了死亡率统计数据(来自国家卫生统计中心[NCHS])和人口统计数据(来自美国人口普查)来估计1961年至1999年之间美国各县的按性别划分的预期寿命。 NCHS未向我们提供后续年份的分析数据。我们计算了跨县死亡率差异的不同指标,并根据县的死亡率相对于全国平均水平变化是有利还是不利,对县进行了分组。我们估算了死亡率高于或低于平均水平的县因特定疾病而死亡的可能性。我们使用基于时间的模拟模型模拟了跨县迁移对每个县的预期寿命的影响。在1961年至1999年之间,美国各县的预期寿命标准差(SD)最低,是1983年,男女分别为1.9和1.4年。跨县预期寿命SD在1999年增加到2.3和1.7岁。在1961年至1983年之间,没有县的死亡率有统计学上的显着增加;而在1982年至1983年之间,没有县的死亡率有统计学意义的增加。男女死亡率下降的主要原因是心血管死亡率的降低。从1983年至1999年,男子的11个县的预期寿命显着下降(1.3年),女子的180个县的预期寿命显着下降(1.3年);另外48个(男子)和783个(妇女)县的预期寿命没有明显下降。男女预期寿命的下降是由于肺癌,慢性阻塞性肺疾病(COPD),糖尿病和其他一系列非传染性疾病死亡率增加所致,而心血管疾病死亡率的下降并不能弥补这些死亡率。较高的艾滋病毒/艾滋病和凶杀死亡人数也大大导致了男子的预期寿命下降,而妇女却没有。关于迁移影响的其他说明表明,跨县预期寿命SD的增加不太可能由迁移引起。结论:1983年至1999年,由于停滞或增加,美国各县的死亡率不平等现象持续增加人口中最富裕人群的死亡率下降。在许多县,女性死亡率增加了,主要原因是与吸烟,超重和肥胖以及高血压有关的慢性疾病。

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