Results

Both in nonmetropolitan and metropolitan counties, the five leading causes of death in the United States during 2010–2017 were heart disease, cancer, unintentional injury, CLRD, and stroke, which accounted for 1.72 million deaths (approximately 61% of all deaths) in 2017 (7). Four of the five leading causes of death were chronic diseases, two of which (heart disease and cancer) accounted for the majority of deaths among persons aged <80 years in 2017 (Figure 3).

National Aggregation

The number of potentially excess deaths in the United States increased during 2010–2017 for unintentional injury (APC: 11.2%), with the quadratic trend suggesting that the increase accelerated in more recent years, primarily as a result of increases in deaths related to drug poisoning, including opioid overdose (Supplementary Figure, https://stacks.cdc.gov/view/cdc/81888). The number of potentially excess deaths attributed to CLRD also increased (APC: 1.7%). Potentially excess deaths decreased for cancer (APC: −9.1%) (Table), with the quadratic trend suggesting that the decrease was more rapid in recent years. Trends for both heart disease and stroke initially decreased and then stabilized (Figure 4).

When death rates were assessed in the six urban-rural county categories, a persistent disparity was identified between the most rural counties (noncore) and the most urban counties (large central metropolitan and large fringe metropolitan) for the study period. Although the number of persons aged <80 years living in nonmetropolitan counties of the United States decreased from 44.3 million in 2010 to 43.9 million in 2017 (an average of 0.1% per year), potentially excess deaths in nonmetropolitan counties (both micropolitan and noncore) increased for heart disease, unintentional injury, and CLRD; decreased for cancer; and exhibited a quadratic trend for stroke in noncore counties (i.e., decreased then increased) (Table) (Figure 5). Similar trends were observed for medium and small metropolitan counties. Large central and large fringe metropolitan counties experienced decreases in the numbers of potentially excess deaths from cancer and CLRD, with quadratic trends for heart disease and stroke (Table).

Potentially excess deaths from unintentional injury increased across most urban-rural county categories, with the highest increases in large central and large fringe metropolitan counties (18% and 17%, respectively) (Figure 5). Among subcategories of unintentional injury deaths for all ages, age-adjusted death rates for poisonings increased 89%, followed by an increase in falls (19%) and an increase in motor vehicle traffic (7%) from 2010–2017 in all urban-rural county classifications (14) (Supplementary Figure, https://stacks.cdc.gov/view/cdc/81888). From 2010 to 2017, age-adjusted death rates from drug poisoning increased by 119.3% in large fringe metropolitan counties but by 30.8% in the most rural (noncore) counties (14). In medium metropolitan counties, age-adjusted death rates from drug poisoning increased by 86.3% and in large central metropolitan counties by 91.0%, approximately 25–30 percentage points lower than in large fringe metropolitan counties.

Noncore counties, which are the most rural counties, had a higher percentage of deaths that were potentially excess from the five the leading causes than the other five urban-rural county categories every year of the study period (Table). In 2017, the percentages of deaths that were potentially excess from the five leading causes of death in noncore counties were 64.1% for unintentional injury, 57.1% for CLRD, 44.9% for heart disease, 21.7% for cancer, and 37.8% for stroke (Figure 6). The lowest percentage of potentially excess deaths from the five leading causes occurred in the most urban counties (large central metropolitan and large fringe metropolitan counties). For example, in 2017, 44.9% of heart disease deaths among persons aged <80 years in noncore counties were potentially excess deaths, compared with 18.5% in large fringe metropolitan counties, which had the lowest percentage of deaths that were potentially excess. A total of 64.1% of deaths among persons aged <80 years from unintentional injury in noncore counties were potentially excess deaths, compared with 47.8% in large central metropolitan counties. The largest disparity in potentially excess deaths between the most rural and most urban counties was from CLRD, for which 57.1% of deaths were potentially excess in noncore counties and 13.0% in large central metropolitan counties.

Regional Differences

The percentages of deaths that were potentially excess from the five leading causes varied widely across HHS public health regions and by cause of death (Supplementary Table 1, https://stacks.cdc.gov/view/cdc/81884; Supplementary Table 2, https://stacks.cdc.gov/view/cdc/81885). For cancer, the percentage of excess deaths in noncore counties in 2017 ranged from 31.2% in region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) to 0% in region 9 (Arizona, California, Hawaii, and Nevada). In large central metropolitan counties, the percentage of excess deaths from cancer ranged from 21.8% in region 7 (Iowa, Kansas, Missouri, and Nebraska) to 0% in regions 8 (Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming), 9, and 10 (Alaska, Idaho, Oregon, and Washington). For heart disease, the percentage of excess deaths in noncore counties in 2017 ranged from 55.8% in region 4 to 13% in region 1 (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont). In large central metropolitan counties, the percentage of excess deaths from heart disease ranged from 47.2% in region 7 to 0% in region 10. For unintentional injury, the percentage of excess deaths in noncore counties in 2017 ranged from 71.6% in region 9 to 45.6% in region 2 (New Jersey and New York). In large central metropolitan counties, the percentage of excess deaths from unintentional injury ranged from 69.4% in region 7 to 33.3% in region 9.

State Highlights

Heart Disease

The percentage of potentially excess deaths from heart disease in the United States was 30.1% in 2017 (Table) (Supplementary Table 3, https://stacks.cdc.gov/view/cdc/81886; Supplementary Table 4, https://stacks.cdc.gov/view/cdc/81887). Among the states with reliable trend data, the number of potentially excess deaths in nonmetropolitan counties increased for heart disease in 18 states, whereas in metropolitan counties, 12 states experienced decreases in the number of potentially excess deaths. Decreases in potentially excess deaths from heart disease in metropolitan counties ranged from −33.8% to −0.8%, with two states experiencing APCs of −34% (Massachusetts) and −31% (North Dakota). Increases in potentially excess deaths from heart disease in metropolitan counties ranged from <0.5% (South Carolina) to 48.4% (Vermont). In nonmetropolitan counties, decreases in potentially excess deaths from heart disease ranged from −0.2% (Montana) to −10.8% (Utah). Increases in potentially excess deaths in nonmetropolitan counties ranged from 0.6% (South Carolina) to 8.2% (Oregon and Arizona).

Cancer

The percentage of potentially excess deaths from cancer in the United States was 9.2% in 2017 (Table) (Supplementary Table 3, https://stacks.cdc.gov/view/cdc/81886; Supplementary Table 4, https://stacks.cdc.gov/view/cdc/81887). In metropolitan counties, potentially excess deaths from cancer decreased in all states. Decreases in potentially excess deaths from cancer in metropolitan counties ranged from −76.5% (Colorado) to −2.9% (Oklahoma), with two states (California and New Mexico) experiencing APCs of −42% and −54%, respectively. In nonmetropolitan counties, decreases in potentially excess deaths from cancer ranged from −48.8% (Connecticut) to −0.3% (Georgia), with two states experiencing APCs of −45% and −30%, respectively (Wyoming and Arizona). Massachusetts was the only state to experience an increase in potentially excess deaths from cancer in nonmetropolitan counties (APC: 17.7%).

Unintentional Injury

The percentage of potentially excess deaths from unintentional injury in the United States was 54% in 2017 (Table) (Supplementary Table 3, https://stacks.cdc.gov/view/cdc/81886; Supplementary Table 4, https://stacks.cdc.gov/view/cdc/81887). In metropolitan counties, potentially excess deaths from unintentional injury increased in most states. Increases in potentially excess deaths from unintentional injury in metropolitan counties ranged from 70.8% (Maryland) to 1.3% (Mississippi), with states in the northeast experiencing APCs between 13% (Rhode Island) and 43% (New York). Wyoming was the only state that experienced a decrease in the number of potentially excess deaths from unintentional injury in metropolitan counties. In nonmetropolitan counties, the number of potentially excess deaths from unintentional injury increased in most states, but more slowly than in metropolitan counties. Increases in potentially excess deaths from unintentional injury in nonmetropolitan counties ranged from 27.2% (Massachusetts) to 0.6% (Oklahoma). Several states (i.e., Arkansas, Kentucky, Montana, and Nevada) experienced a decrease in the number of potentially excess deaths from unintentional injury in nonmetropolitan counties. State-level results for potentially excess deaths from CLRD and stroke by metropolitan and nonmetropolitan county categories are available (Supplementary Table 3, https://stacks.cdc.gov/view/cdc/81886; Supplementary Table 4, https://stacks.cdc.gov/view/cdc/81887); (https://tabsoft.co/2BxWUg0external icon).