• Katherine G Hastings, Derek B Boothroyd, Kristopher Kapphahn, Jiaqi Hu, David H Rehkopf, Mark R Cullen, and Latha Palaniappan.
• Stanford University School of Medicine, Stanford, California (K.G.H., D.B.B., K.K., J.H., D.H.R., M.R.C., L.P.).
• Ann. Intern. Med. 2018 Dec 18; 169 (12): 836-844.

BackgroundRecent data suggest that the United States is in the midst of an epidemiologic transition in the leading cause of death.ObjectiveTo examine county-level sociodemographic differences in the transition from heart disease to cancer as the leading cause of death in the United States.DesignObservational study.SettingU.S. death records, 2003 to 2015.ParticipantsDecedents aged 25 years or older, classified by racial/ethnic group.MeasurementsAll-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.ResultsHeart 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.LimitationUse of county median household income as a proxy for socioeconomic status.ConclusionData 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 SourceNational Institute on Minority Health and Health Disparities.

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