Background: Recent data suggest that the United States is in the midst of an epidemiologic transition in the leading cause of death.Objective: To examine county-level sociodemographic differences in the transition from heart disease to cancer as the leading cause of death in the United States.Design: Observational study.Setting: U.S. death records, 2003 to 2015.Participants: Decedents aged 25 years or older, classified by racial/ethnic group.Measurements: All-cause, heart disease, and cancer mortality stratified by quintiles of county median household income. Age- and sex-adjusted mortality rates and average annual percentage of change were calculated.Results: Heart disease was the leading cause of death in 79% of counties in 2003 and 59% in 2015. Cancer was the leading cause of death in 21% of counties in 2003 and 41% in 2015. The shift to cancer as the leading cause of death was greatest in the highest-income counties. Overall, heart disease mortality rates decreased by 28% (30% in high-income counties vs. 22% in low-income counties) from 2003 to 2015, and cancer mortality rates decreased by 16% (18% in high-income counties vs. 11% in low-income counties). In the lowest-income counties, heart disease remained the leading cause of death among all racial/ethnic groups, and improvements were smaller for both heart disease and cancer.Limitation: Use of county median household income as a proxy for socioeconomic status.Conclusion: Data show that heart disease is more likely to be the leading cause of death in low-income counties. Low-income counties have not experienced the same decrease in mortality rates as high-income counties, which suggests a later transition to cancer as the leading cause of death in low-income counties.Primary Funding Source: National Institute on Minority Health and Health Disparities.
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