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County-Level Disparities in Premature Cardiac Death
Quick Takes
- There is increasing proportions of out‐of‐hospital death among all premature cardiac death (PCD), which appeared to be higher in younger age groups.
- The county‐level disparities in PCD rates were widening during the past two decades, and were associated with demographic composition, socioeconomic features, health care environment, and population health status.
- The slower declines in out‐of‐hospital death rates are of concern and highlights the need for understanding factors that explain disparities in premature cardiac death including inequitable distribution of health resources.
Study Questions:
What is the magnitude of disparities across US counties in premature cardiac death (PCD) rates and county‐level factors related to the disparities?
Methods:
The investigators used US mortality data for cause‐of‐death and demographic data from death certificates and county‐level characteristics data from multiple databases. PCD was defined as any death that occurred at an age between 35 and 74 years with an underlying cause of death caused by cardiac disease based on International Classification of Diseases, Tenth Revision (ICD‐10) codes. Of the 1,598,173 PCDs that occurred during 1999–2017, 60.9% were out of hospital. To assess the geographic disparity and decompose the disparities, the authors conducted the Theil index of county‐level mortality. Hierarchical linear mixed models were used to estimate the associations of factors with state‐specific PCD rates.
Results:
Although the PCD rates declined from 1999–2017, the proportion of out‐of‐hospital PCDs among all cardiac deaths increased from 58.3% to 61.5%. The geographic disparities in PCD rates across counties widened from 1999 (Theil index = 0.10) to 2017 (Theil index = 0.23), and within‐state differences accounted for the majority of disparities (57.4% in 2017). The disparities in out‐of‐hospital PCD rates (and in‐hospital PCD rates) associated with demographic composition were 36.51% (and 37.51%), socioeconomic features were 18.64% (and 18.36%), health care environment were 18.64% (and 13.90%), and population health status were 23.73% (and 30.23%).
Conclusions:
The authors concluded that disparities in PCD rates exist across US counties, which may be related to the decelerated trend of decline in the rates among middle‐aged adults.
Perspective:
This study reports an increasing proportion of out‐of‐hospital death among all PCDs, which appeared to be higher in younger age groups. Furthermore, the county‐level disparities in PCD rates were widening during the past two decades, and were associated with demographic composition, socioeconomic features, health care environment, and population health status. The study has multiple limitations including possible ecological fallacy, inaccuracy of death certificates, and lack of data on time of onset of disease symptoms and exact time of death. Despite these limitations, the slower declines in out‐of‐hospital death rates are of concern and highlight the need for understanding factors that explain disparities in premature cardiac death including inequitable distribution of health resources.
Clinical Topics: Arrhythmias and Clinical EP, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Arrhythmias, Cardiac, Death, Sudden, Cardiac, Healthcare Disparities, Health Resources, Heart Diseases, Middle Aged, Mortality, Premature, Out-of-Hospital Cardiac Arrest, Primary Prevention, Socioeconomic Factors
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