Demographic and Regional Trends of Pneumonia Mortality in the United States

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In 2020, pneumonia accounted for over 53,000 deaths and 2.6 million emergency department visits. Further research is needed to study the evolution of country-wide trends and highlight disparities. Methods: Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) was used to identify pneumonia-related deaths occurring within the United States. We extracted data regarding pneumonia-related deaths and population sizes from 1999 to 2020. Data on demographic and regional groups were analyzed, including gender, race/ethnicity, age, urban-rural classification, region, and states. Results: Overall mortality from pneumonia related deaths declined within the study period. Males experienced a larger age-adjusted mortality rate decrease than females. African American and Black people experienced the highest mortality throughout the duration of the study, while American Indian and Native Alaskan had the greatest reduction in mortality. Nursing home deaths decreased over time, and in turn, hospice deaths substantially rose. Deaths in people 85 years and older steadily declined. Finally, several geographical differences were found between urban-rural groups, states, and census regions. Conclusions: Pneumonia-related mortality between 1999–2020 has decreased in the United States. Policies to increase vaccination rates appear to be most promising in continuing the downward trend. Further research is needed to address pneumonia-related mortalities across demographic and geographical disparities. Pneumonia pneumonia-related mortality CDC WONDER pneumococcal vaccine health disparity age-adjusted mortality rate Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Pneumonia is among the leading causes of death in the United States (US). In 2020, pneumonia accounted for over 53,000 deaths and 2.6 million emergency department visits in the US [1] . Pneumonia is not only a cause of high mortality but also a great financial expense. In 2017, influenza infections among elderly patients alone cost the US an estimated $ 34.7 billion [2] . The US healthcare system continually works to improve pneumonia outcomes and decrease the economic burden. From 1999 to 2020, the age-adjusted mortality rate has been 44% lower. This reduction in pneumonia mortality is due to medical advancements, such as the development of influenza and pneumococcal vaccines [3] . From the first pneumococcal conjugate vaccine in 2000 to guidelines recommending routinely vaccinating children and the elderly, the incidence of pneumonia disease has been greatly reduced [4] . Even with these advances in care, pneumonia ranks in the top ten causes of death [5] . Studying how mortality has decreased over the years is pivotal in understanding which medical improvements result in greater outcomes. Despite the vast amount of data analyzing pneumonia mortality across the US, further research is needed to study the evolution of country-wide trends and highlight disparities. This study aims to comprehensively evaluate differences in pneumonia mortality across gender, race, age, and geographical regions. Using the US Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) from 1999 to 2020, trends in mortality were analyzed. Methods Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) was used to identify pneumonia (including that caused by influenza) related deaths occurring within the United States [6] . The Underlying cause of death is a public-use database of death certificate records that list the cause of mortality. It was analyzed to determine pneumonia as the underlying cause of death on nationwide death certificate records. This database has been previously used in several other studies to analyze nationwide trends in influenza mortality and vaccination status [5] . pneumonia-related mortality was identified using the International Classification of Diseases, 10th Revision, Clinical Modification codes J09, J10.0, J10.1, J10.8, J11.0, J11.1, J11.8, J12, J12.1, J12.2, J12.3, J12.8, J12.9, J13, J14, J15.0-15.9, J16.0, J16.8, J18.0, J18.1, J18.2, J18.8, J18.9 in patients ≥ 25 years (Supplemental Table S1 ). This age restriction was selected because we focused on the adult population due to pneumonia-related mortality in patients < 25 years of age being infrequent. The study was exempt from institutional review board approval because the CDC WONDER database contains anonymized, publicly available data. We extracted data regarding pneumonia-related deaths and population sizes from 1999 to 2020. Data on demographic and regional groups were extracted, including gender, race/ethnicity, age, urban-rural classification, region, and states. Racial/ethnicity groups were defined as White, Black/African American, American Indian/Alaskan Native, Asian/Pacific Islander, and Hispanic people as identified on death certificates. Age groups were defined as 25 to 39, 40 to 54, 55 to 69, 70 to 84, and 85 + years of age. For urban-rural classifications, the National Center for Health Statistics Urban-Rural Classification Scheme was used to divide the population into urban (large metropolitan area [population ≥ 1 million], medium/small metropolitan area [population 50,000 to 999,999]) and rural (population < 50,000) counties per the 2013 United States census classification [7] . Regions were classified into Northeast, Midwest, South, and West according to the Census Bureau definitions [6] The Locations of death included medical facilities (outpatient, emergency room, inpatient, death on arrival, or status unknown), homes, hospice, and nursing homes/long-term care. Pneumonia-related crude and age-adjusted mortality rates were calculated. Crude mortality rates were calculated by dividing the number of Pneumonia-related deaths by the corresponding United States population. Age-adjusted mortality rates (AAMR) were standardized using the 2000 United States standard population as previously described [8] . The Joinpoint Regression Program (Joinpoint version 4.9.0.0 available from National Cancer Institute, Bethesda, Maryland) was used to determine trends in mortality within the study period [9,10] . This program identifies significant changes in annual mortality trends over time through Joinpoint regression, which fits models of linear segments where significant temporal variation occurred. Annual percentage change (APC) with 95% confidence intervals (CIs) for the AAMRs were calculated for the line segments linking a Joinpoint using the Monte Carlo permutation test. The weighted average of the APCs was calculated and reported as an average annual percentage change (AAPCs) and corresponding 95% CIs as a summary of the reported mortality trend for the entire study period. APC and AAPCs were considered to increase or decrease if the slope describing the change in mortality over the time interval significantly differed from zero using a 2-tailed t-test. Statistical significance was set at p ≤ 0.05 (represented by asterisk “*” in results, figures, and supplemental file). Results 1. Overall From 1999 to 2020, there were 56,806,341 total deaths in the United States. Of these deaths, 1,243,017 (2.1%) were due to pneumonia (Supplemental Table S2). Overall age-adjusted mortality rates (AAMR) decreased during this period from 35.9 (95% CI 35.7 to 36.2) in 1999 to 19.9 (95% CI 19.7 to 20.1) in 2020, with an average annual percentage change (AAPC) of -3.0* (95% CI -3.8 to -2.2) (Supplemental Table S2). The annual percentage change (APC) in AAMR was − 4.0 (95% CI -9.9 to 3.9) from 1999–2010, which decreased to -1.8 (95% CI -10.5 to 5.3) from 2010–2020 (Fig. 1 ). Overall, AAMR decreased to the lowest point in 2019 at 18.75 (95% CI 18.6 to 18.9) and slightly increased to 19.91 (95% CI 19.7 to 20.1) in 2020. 2. Demographic differences 2.1 Gender stratified. From 1999 to 2020, pneumonia caused 574,872 (46.2%) deaths in males and 668,145 (53.8%) deaths in females in the United States (Supplemental Table S2). The AAMR decreased in males from 43.7 (95% CI 43.1 to 44.2) in 1999 to 24.1 (95% CI 23.8 to 24.4) in 2020, with an AAPC of -3.1 (95% CI -3.7 to -2.6) (Supplemental Table S2). The APC in AAMR was − 4.2* (95% CI -8.9 to -3.1) from 1999–2010, which then decelerated to -2.0 (95% CI -3.2 to 3.6) from 2010–2020 (Fig. 1 ). In females, the AAMR decreased from 31.4 (95% CI 31.1 to 31.7) in 1999 to 16.8 (95% CI 16.6 to 17.0) in 2020, with a steady AAPC of -3.1* (95% CI -3.6 to -2.6) (Supplemental Table S2, Fig. 1 ). 2.2 Race stratified. Black or African American people had the highest AAMR over the years, with 38.5 (95% CI 37.5 to 39.5) in 1999 to 25.1 (95% CI 24.5 to 25.8) in 2020 and an AAPC of -2.7* (95% CI -3.3 to -2.2) (Supplemental Table S4). The APC in AAMR was − 3.8* (95% CI -7.0 to -3.1) from 1999–2012, which reduced to -0.9 (95% CI -2.5 to 5.0) from 2012–2020 (Fig. 2 ). The second highest AAMR was shown among White people, starting at 35.8 (95% CI 35.3 to 36.1) in 1999 and changing to 19.5 (95% CI 19.3 to 19.6) in 2020. The APC from 1999–2010 was − 4.2 (95% CI -8.9 to 6.9) and declined to -1.1 (95% CI -3.8 to 5.4) from 2010 to 2020. American Indian and Native Alaskan people had the most significant reduction in AAMR from 42.5 (95% CI 37.3 to 47.7) in 1999 to 19.8 (95% CI 17.9 to 21.7) in 2020 with an AAPC of -3.7* (95% CI -4.5 to -2.8) (Supplemental Table S3). The APC of Asian and Pacific Islander people was − 2.1 (95% CI -2.6 to 0.4) from 1999–2017 and continued to accelerate at -8.4* (95% CI -15.7 to -3.2) from 2017 to 2020 (Fig. 2 ) with an AAPC of -3.0 (95% CI -3.6 to -2.1) (Supplemental Table S3, Fig. 2 ). 2.3 Age group stratified The population of 85 years and older had the highest overall crude mortality rate, which decreased from 751.8 (95% CI 743.4 to 760.1) in the year 1999 to 273.6 (95% CI 269.7 to 277.6) in the year 2020, with a consistent AAPC of -4.4* (95% CI -5.0 to -3.9) (Supplemental Table S4, Fig. 3 ). The 55–69 age group was the only group to experience a Joinpoint with an increase in mortality. The group experienced a decrease from 1999–2010 with an APC of -1.4 (95% CI -7.1 to 0.0), which increased from 2010 to 2020 with an APC of 2.8* (95% CI 1.2 to 9.4) and AAPC deaths of 0.5 (95% CI − 0.2 to 1.2). The 70–84 age group experienced a constant decline, with an AAPC of − 3.2* (95% CI − 3.8 to − 2.6) throughout the study period. Ages 40–54 experienced an unremarkable increase in overall crude mortality rate from 3.9 (95% CI 3.8 to 4.1) in 1999 to 5.2 (95% CI 5 to 5.4) with an AAPC of 0.8 (95% CI -0.1 to 1.8) (Fig. 3 and Supplemental Table S4). 3. Place of death During the study period, the total number of deaths with a known place of death included 1,215,233 (97.7%). 27.9% occurred outside of medical facilities (20.0% nursing home/long-term care, 2.3% hospice, 5.6% home), 72.1% occurred within medical facilities (3.4% outpatient/ER and 68.7% inpatient). Over this time, deaths in nursing homes decreased from 17,771 to 5,634 (31.7%), while deaths in hospice surged, with a 4,114.5% increase, from 62 in the year 2003 (Hospice deaths started being reported from 2003 onwards) to 2,551 in the year 2020 ( Fig. 4 and Supplemental Table S5). 4. Regional variation 5.1 Rural vs. Urban All regional variations saw an overall decline in AAMRs. When comparing populated regions, AAMRs were consistently highest in rural areas compared to small, medium, and large metropolitan regions. Large metropolitan zones experienced a decrease in APC between 1999–2010 by -4.2* (95% CI -8.9 to -3.3), which changed to -2.1 (95% CI -3.0 to 2.0) from 2010–2020 with an AAPC of -3.2 (95% -3.7 to -2.7). From 1999 through 2010, the APC declined from − 4.1 (95% CI -8.9 to 3.1) for medium/small metropolitan areas and slowed to -1.4 (95% CI -3.6 to 3.2) from 2010–2020 with an AAPC − 2.8 (95% CI -3.7 to -2.1). Rural zones saw AAMRs change from 39.6 (95% CI 38.9 to 40.3) in 1999 to 23.5 (95% CI 23 to 24) in 2020, with a consistent AAPC of -2.5* (95% CI -3.1 to -2.0) (Supplemental Table S6, Fig. 5 ). 5.2 State-level difference The Average AAMR for the duration of the study period varied widely from 36.3 (95% CI 35.7 to 36.9) in Mississippi to 16.1 (95% CI 16 to 16.3) in Florida. States in the greater 90th percentile of pneumonia-related mortality included Mississippi, Tennessee, Arkansas, Kentucky, and New York. Conversely, states in the less than 10th percentile of pneumonia-related mortality included Florida, Vermont, Oregon, Minnesota, and Washington (Supplemental Table S7 and S8, Fig. 6 a and 6 b). Colorado saw the largest decrease in AAMR from 38.8 (95% CI 36.1 to 41.5) to 11 (95% CI 10 to 12), with an average AAMR for study duration of 27.8 (12%) (Supplemental Table S8 and Fig. 6 a and 6 b). In comparison, Arkansas had a similar AAMR in 1999 of 38.8 (95% CI 36 to 41.6), but the AAMR only decreased to 27.4 (95% CI 25.3 to 29.5) in 2020 with an average AAMR of 34.5 (96%) (Supplemental Table S8 and Fig. 6 a and 6 b). California had the smallest decrease from 1999 to 2020, with an average AAMR for study duration of 4.9 (64%). 5.3 Census region-based differences Every census region saw a decrease in AAMR over time, with the South seeing the greatest decrease in AAMR from 34.5 (95% CI 34.1 to 35) in 1999 to 23.1 (95% CI 22.8 to 23.4) in 2020 with a consistent AAPC of -3.1 (95% CI -3.6 to -2.7) (Supplemental Table S9, Fig. 7 ). The West saw three changes in their APC with an increase between 1999 to 2001 of 10.5 (95% CI-3.1 to 27.6), which decreased from 2001–2010 to -6.08 (95% CI -13.2 to -4.3) and finally − 1.9 (95% CI -4.0 to 6.3) from 2010–2020 with an AAPC of -2.6 (95% CI -3.6 to -1.3). The Northeast saw a 1999–2010 APC of -3.9* (95% CI -10 to -2.3), which slowed to -1.2 (95% CI -3.2 to 5.6) for the remainder of the study period and an AAPC of -2.6* (95% CI -3.4 to -1.9). The Midwest saw a decrease in APC of -3.9 (95% CI -11.0 to 3.8) from 1999–2009, with a change to -1.5 (95% CI -11.5 to 6.2) from 2009 to 2020, with an AAPC of -2.7 (95% CI -3.7 to -1.8). On average, within the study period, the AAMR was highest in the West in 2000 at 38.9 (95% CI 38.2 to 39.5), then the following regions in 1999: Northeast at 37.7 (95% CI 37.1 to 38.3), the Midwest at 37.6 (95% CI 37.1 to 38.3), and the South at 36.6 (95% CI 36.1 to 37). AAMRs were the lowest for the Northeast, Midwest, and South in 2019 but not remarkably different from 2020 data. Discussion This study reports several important findings regarding pneumonia-related mortality in the US from 1999 to 2020. While seeing overall mortality rates decrease, males experienced a larger AAMR decrease than females, African American and Black people experienced the highest mortality throughout the duration of the study, and American Indian and Native Alaskan people had the greatest reduction in mortality. Nursing home deaths decreased over time, and in turn, hospice deaths substantially rose. Deaths among people 85 and older steadily declined. Lastly, several geographical differences in AAMR were found between urban-rural groups, states, and census regions. A decrease in pneumonia-related mortality rates reflects improvements made in pneumonia care. Over the past 22 years, we have seen the sophistication of the pneumonia and influenza vaccines and an increase in vaccine utilization. The CDC has issued guidelines for annual influenza and pneumococcal vaccines for vulnerable populations [11] . Between 2005 and 2014, the CDC reported that the number of individuals receiving the influenza vaccine doubled (43.7%) [6,12] . Greater vaccine adherence may be reflected in lower mortality rates, as one study in Brazil found that overall mortality fell by 23.6% among individuals 65 and older who were vaccinated [13] . While vaccines play a vital role in reducing influenza incidence and preventing subsequent pneumonia, other key medical advances include rapid viral testing for early detection and prompt treatment [14] . While both sexes saw a decrease in mortality, AAMR for males decreased more than that of females. Males experience greater midlife mortality than females, with pneumonia being a factor that offsets the decline in life expectancy for both genders [15] . Females have also reported higher vaccination rates than males [12] . Further research on differences in gender and pneumonia-related mortality is needed, as looking at mortality without separating males and females can mask specific trends [15] . African Americans and Blacks had the highest overall mortality during the study. In addition to pneumonia-related mortality, this population experiences higher overall mortality [16] . There are many complex factors contributing to poorer health outcomes in African American and Black patients, which include social determinants of health such as socioeconomic status, insurance, and access to primary care [16,17] . These barriers to care may contribute to differences in vaccine rates as well. Studies have found that vaccine rates are lower amongst the Black population compared to other racial/ethnic groups [2,11] . Social determinants of health create issues surrounding vaccine accessibility, but increasing campaigns and education surrounding vaccinations in the African American and Black population may be an area of improvement [18] . American Indian and Native Alaskan people had the greatest reduction in mortality from pneumonia [19] . Prior studies have highlighted this group as a higher risk for pneumonia complications. One hypothesis for this trend is increased vaccination adherence. The Office of Minority Health, a branch of the US Department of Health and Human Services, reported a vaccination ratio of 0.8 for American Indian and Alaskan people compared to non-Hispanic and White Americans for the 2019–2020 influenza season [20] . As mortality changes among different populations, we have also seen shifts in where pneumonia deaths occur, with utilization of hospice services on the rise. A report from Medicare beneficiaries found that hospice services increased by 28.8% between 2000 and 2015 [21] . Nursing homes also contract with hospice facilities to move patients when their health needs change, leading to a greater number of patients dying in hospice care rather than nursing facilities [22] . Advanced age leads to an increased risk for comorbid illnesses as well. Thus, the 85 and older age group has the greatest risk for complications regarding pneumonia. As medical improvements are made to treat these comorbidities, patients in this age category may have better outcomes regarding pneumonia-related illnesses. Additionally, vaccine efforts to target high-risk groups and patients over 65 years of age have helped reduce the spread of influenza and pneumonia [23,24] . Vaccine rates are highest among the 65 and older population [6,12] . In 2014, 58.7 percent of elderly adults reported receiving at least one kind of pneumococcal vaccine [6,12] . With greater improvements in decreasing mortality and higher vaccination rates, this outcome may support a larger effort to increase vaccinations among other age categories. Another population comprised of older individuals is rural communities [25] . Rural areas had higher mortality rates and worse health outcomes due to increased distance from healthcare institutions, higher rates of poverty, and greater comorbidities due to lack of consistent care [25,26] . Another explanation for the improvement in mortality among population-dense areas is a greater concentration of college-educated people [27] . Vaccine campaigns have been shown to be successful in cities, especially when targeting high-risk populations [18,28,29] . On a statewide level, there were several trends. States with the highest rates of pneumonia-related mortality were predominantly located in the South, except for New York, which was also among the states with the highest death rate from pneumonia. When comparing by regions, the South had the greatest decrease in AAMR. Studies have found that overall mortality, especially in the rural South, is greater than in other geographical regions for proposed reasons of improved overall health outcomes and increased population density, leading to fewer rural southern communities [25,26] . Colorado was the state that saw the greatest change in AAMR. Compared to Arkansas, which had a similar AAMR in 1999, Colorado decreased its AAMR by over 27.8 and Arkansas by 11.4. This significant decrease in mortality compared to other states is an interesting finding, and understanding the factors that played a role in this improvement could be applied across the USA. A 2019 study by Woolf focused on life expectancy rather than pneumonia-related mortality and found that Colorado's life expectancy difference increased between Colorado and Kansas from 1990 to 2016 [27] . This study hypothesized that outcome changes may reflect policy choices considering differences in demography and economies between the two states were low [27] . A 2004–2006 report from the CDC found Colorado to have the highest influenza vaccination and pneumococcal rates amongst their 65 and older population, at 76.5% and 71.4%, respectively, contributing positively to their lower AAMR [30] . While California’s vaccination rates from the same study were middle to lower in ranking, they saw the smallest decrease in AAMR over the study duration (20). Considering vaccination rates, factors resulting in consistent mortality outcomes may be related to lower overall mortality rates. Life expectancy in California ranks among the top five states [31] . This could be related to policies and projects such as the Healthy Cities and Communities Program, the oldest WHO campaign in the US to promote healthier lifestyles, focusing on social determinants of health [32,33] . This study has several limitations to be mindful of. First, the CDC WONDER database is based on death certificates for US residents. Any errors in these certificates could affect data points in the study. Mortality data is coded by death certificates in the state where the deaths took place and may inaccurately represent deaths from patients who traveled for care. We only used the mortality data for pneumonia as the underlying cause of death, which does not consider the deaths where pneumonia might have contributed indirectly to mortality or acted as a secondary cause. Conclusion Pneumonia-related mortality in the US decreased between 1999 and 2020. Differences in mortality exist across gender, race, and geographic regions. Improvements in health care and increased utilization of pneumococcal and influenza vaccines have lowered mortality. Further research is needed to delineate why certain groups and regions have improved health outcomes. Policies to increase vaccination rates appear to be the most promising way to continue the downward trend, and further targeted efforts are needed to reduce demographic and geographical disparities. Declarations Not applicable Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Competing interests: The authors declare that they have no competing interests Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution EH analyzed and interpreted the data and was a major contributor in writing the manuscript. AJ completed the data analyses and was a major contributor in writing the manuscript. MA was a contributor to writing and editing the manuscript. NA was a contributor to writing and editing the manuscript. KM was a contributor to writing and editing the manuscript. MM contributed editing the manuscript. AT contributed editing the manuscript. All authors read and approved the final manuscript. Acknowledgements: Not applicable Availability of data and materials: The datasets generated and analyzed during the current study are available on the CDC WONDER repository Underlying Cause of Death 1999–2020, https://wonder.cdc.gov/ucd-icd10.html References Cairns, C., & Kang, K. (2022). National Hospital Ambulatory Medical Care Survey: 2020 Emergency Department Summary Tables . National Center for Health Statistics (U.S.). https://doi.org/10.15620/cdc:121911 Rothman, T. (2017). The Cost of Influenza Disease Burden in U.S Population. International Journal of Economics & Management Sciences , 06 (04). https://doi.org/10.4172/2162-6359.1000443 Simonsen, L., Taylor, R. J., Young-Xu, Y., Haber, M., May, L., & Klugman, K. P. (2011). 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High Clinical Burden of Influenza Disease in Adults Aged ≥ 65 Years: Can We Do Better? A Systematic Literature Review. Advances in Therapy , 40 (4), 1601–1627. https://doi.org/10.1007/s12325-023-02432-1 Nagata, J. M., Hernández-Ramos, I., Kurup, A. S., Albrecht, D., Vivas-Torrealba, C., & Franco-Paredes, C. (2013). Social determinants of health and seasonal influenza vaccination in adults ≥65 years: A systematic review of qualitative and quantitative data. BMC Public Health , 13 (1), 388. https://doi.org/10.1186/1471-2458-13-388 Centers for Disease Control and Prevention. (2023). About rural health . https://www.cdc.gov/ruralhealth/about.html#:~:text=Rural%20Americans%20are%20more%20likely,stroke%20than%20their%20urban%20counterparts Miller, C. E., & Vasan, R. S. (2021). The southern rural health and mortality penalty: A review of regional health inequities in the United States. Social Science & Medicine , 268 , 113443. https://doi.org/10.1016/j.socscimed.2020.113443 Woolf, S. H., & Schoomaker, H. (2019). Life Expectancy and Mortality Rates in the United States, 1959-2017. JAMA , 322 (20), 1996. https://doi.org/10.1001/jama.2019.16932 City of San Antonio. (2020). Immunization Program . https://www.sanantonio.gov/Health/HealthServices/Immunizations. 23., C. of L. A. P. H. (2020). Immunization Coalition of Los Angeles County . . http://publichealth.lacounty.gov/ip/ICLAC/index.htm Gorina, Y., Kelly, T., Lubitz, J., & Hines, Z. (2008). Trends in influenza and pneumonia among older persons in the United States. Aging Trends (Hyattsville, Md.) , 8 , 1–11. Kochanek, K., Murphy, S., Xu, J., & Arias, E. (n.d.). Deaths: Final Data for 2020. National Vital Statistics Reports: From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System , 72 (10), 63. Twiss, J. M., Duma, S., Look, V., Shaffer, G. S., & Watkins, A. C. (2000). Twelve years and counting: California’s experience with a statewide Healthy Cities and Community program. Public Health Reports (Washington, D.C.: 1974) , 115 (2–3), 125–133. https://doi.org/10.1093/phr/115.2.125 Aronson, R., Norton, B., & Kegler, M. (n.d.). Achieving a “Broad View of Health”: Findings From the California Healthy Cities and Communities Evaluation. Health Education & Behavior , 34 (3), 441–452. Additional Declarations No competing interests reported. Supplementary Files FINALPneumoniaSupplemental.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4732500","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":335966309,"identity":"007f5ce5-604f-4195-955b-cf80321bd744","order_by":0,"name":"Eva 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Abdul","lastName":"Jabbar","suffix":""},{"id":335966311,"identity":"1fa56af6-fbc8-4ddb-82ba-844210a8068f","order_by":2,"name":"Muhammad Sohaib Asghar","email":"","orcid":"","institution":"Advent Health","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Sohaib","lastName":"Asghar","suffix":""},{"id":335966312,"identity":"2bf71228-7aa7-40a9-846e-b52878fd704d","order_by":3,"name":"Noureen Asghar","email":"","orcid":"","institution":"Creighton University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Noureen","middleName":"","lastName":"Asghar","suffix":""},{"id":335966313,"identity":"e4da2981-4ba3-4c18-828a-15c9d0edb8ad","order_by":4,"name":"Karishma Mistry","email":"","orcid":"","institution":"Creighton University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Karishma","middleName":"","lastName":"Mistry","suffix":""},{"id":335966314,"identity":"5702b7cd-ba5d-4d5d-a986-f4fe6da88092","order_by":5,"name":"Mohsin Mirza","email":"","orcid":"","institution":"Creighton University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Mohsin","middleName":"","lastName":"Mirza","suffix":""},{"id":335966315,"identity":"f345045b-6d05-4f4a-832e-1a478a8988b5","order_by":6,"name":"Abubakar Tauseef","email":"","orcid":"","institution":"Creighton University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Abubakar","middleName":"","lastName":"Tauseef","suffix":""}],"badges":[],"createdAt":"2024-07-12 20:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4732500/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4732500/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62078082,"identity":"c7cf3019-8d09-48bc-ac6c-bbc37268dd82","added_by":"auto","created_at":"2024-08-09 04:48:35","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45542,"visible":true,"origin":"","legend":"\u003cp\u003eOverall and gender‐stratified age adjusted mortality rates in the United States, 1999 to 2020. *Indicates the APC is significantly different from 0.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4732500/v1/ae566b71aec67cf655eced1a.jpg"},{"id":62078568,"identity":"340941e1-717b-4432-93e2-983a146da687","added_by":"auto","created_at":"2024-08-09 04:56:35","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":62736,"visible":true,"origin":"","legend":"\u003cp\u003eAge-adjusted mortality rates stratified by race/ethnicity in the United States, 1999 to 2020. *Indicates the APC is significantly different from 0.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4732500/v1/371e1597759fe07a14e419ea.jpg"},{"id":62077679,"identity":"68437499-9029-4979-a2c8-f666ba5d3365","added_by":"auto","created_at":"2024-08-09 04:40:36","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":42188,"visible":true,"origin":"","legend":"\u003cp\u003eCrude mortality rates per 100,000 people in the United States stratified by age, 1999 to 2020.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4732500/v1/f05ca4c0d8fc6811cde189d2.jpg"},{"id":62077677,"identity":"17bf7d0e-fc40-40b5-9f9f-fea65e134721","added_by":"auto","created_at":"2024-08-09 04:40:35","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":43214,"visible":true,"origin":"","legend":"\u003cp\u003eTrends in age adjusted mortality rate stratified by location of death in the United States, 1999-2020.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4732500/v1/6cc397c9189227526a200ddc.jpg"},{"id":62077680,"identity":"83ee3ba6-dec7-41de-ba13-144f50a101dd","added_by":"auto","created_at":"2024-08-09 04:40:36","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":39659,"visible":true,"origin":"","legend":"\u003cp\u003eAge adjusted mortality rates stratified by Urban-Rural classification in the United States, 1999 to 2020.\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4732500/v1/0a99a805282281d6664933f3.jpg"},{"id":62078080,"identity":"2c6d1372-5068-4e29-b72e-9f04ba6d8222","added_by":"auto","created_at":"2024-08-09 04:48:35","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":39414,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 6a\u003c/strong\u003e: Map of age-adjusted mortality rates per 100,000 across the United States of America from 1999-2020.\u003c/p\u003e","description":"","filename":"6a.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4732500/v1/049cfad97c19d641301eec78.jpg"},{"id":62077672,"identity":"49275bd2-7403-4224-b634-20a021cb02fd","added_by":"auto","created_at":"2024-08-09 04:40:35","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":88209,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 6b:\u003c/strong\u003e Change in the State‐level age‐adjusted mortality rates per 100,000 people in the United States from 1999 to 2020.\u003c/p\u003e","description":"","filename":"6b.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4732500/v1/029bf327073b8f1387e9946c.jpg"},{"id":62078084,"identity":"45fb1072-c8bf-441f-8918-5722231b2e5b","added_by":"auto","created_at":"2024-08-09 04:48:35","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":64276,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 7: \u003c/strong\u003ePneumonia-related mortality stratified by region in the United States, 1999-2020.\u003c/p\u003e","description":"","filename":"7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4732500/v1/abb7a9acf16dbc0fd9799d8a.jpg"},{"id":64066099,"identity":"31c3b422-152e-44f2-ae1e-77f3482aafa2","added_by":"auto","created_at":"2024-09-06 04:34:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":860736,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4732500/v1/064fc282-7d62-46d8-bd37-ba8824675bc9.pdf"},{"id":62077675,"identity":"ede5d2e7-e85f-417d-a5d8-938f481830f2","added_by":"auto","created_at":"2024-08-09 04:40:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":416808,"visible":true,"origin":"","legend":"","description":"","filename":"FINALPneumoniaSupplemental.docx","url":"https://assets-eu.researchsquare.com/files/rs-4732500/v1/eb336093412f8a56bf2edf38.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Demographic and Regional Trends of Pneumonia Mortality in the United States","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePneumonia is among the leading causes of death in the United States (US). In 2020, pneumonia accounted for over 53,000 deaths and 2.6\u0026nbsp;million emergency department visits in the US \u003csup\u003e[1]\u003c/sup\u003e. Pneumonia is not only a cause of high mortality but also a great financial expense. In 2017, influenza infections among elderly patients alone cost the US an estimated \u003cspan\u003e$\u003c/span\u003e34.7 billion\u003csup\u003e[2]\u003c/sup\u003e. The US healthcare system continually works to improve pneumonia outcomes and decrease the economic burden.\u003c/p\u003e \u003cp\u003eFrom 1999 to 2020, the age-adjusted mortality rate has been 44% lower. This reduction in pneumonia mortality is due to medical advancements, such as the development of influenza and pneumococcal vaccines\u003csup\u003e[3]\u003c/sup\u003e. From the first pneumococcal conjugate vaccine in 2000 to guidelines recommending routinely vaccinating children and the elderly, the incidence of pneumonia disease has been greatly reduced\u003csup\u003e[4]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEven with these advances in care, pneumonia ranks in the top ten causes of death\u003csup\u003e[5]\u003c/sup\u003e. Studying how mortality has decreased over the years is pivotal in understanding which medical improvements result in greater outcomes. Despite the vast amount of data analyzing pneumonia mortality across the US, further research is needed to study the evolution of country-wide trends and highlight disparities. This study aims to comprehensively evaluate differences in pneumonia mortality across gender, race, age, and geographical regions. Using the US Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) from 1999 to 2020, trends in mortality were analyzed.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eCenters for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) was used to identify pneumonia (including that caused by influenza) related deaths occurring within the United States\u003csup\u003e[6]\u003c/sup\u003e. The Underlying cause of death is a public-use database of death certificate records that list the cause of mortality. It was analyzed to determine pneumonia as the underlying cause of death on nationwide death certificate records. This database has been previously used in several other studies to analyze nationwide trends in influenza mortality and vaccination status\u003csup\u003e[5]\u003c/sup\u003e. pneumonia-related mortality was identified using the International Classification of Diseases, 10th Revision, Clinical Modification codes J09, J10.0, J10.1, J10.8, J11.0, J11.1, J11.8, J12, J12.1, J12.2, J12.3, J12.8, J12.9, J13, J14, J15.0-15.9, J16.0, J16.8, J18.0, J18.1, J18.2, J18.8, J18.9 in patients\u0026thinsp;\u0026ge;\u0026thinsp;25 years (Supplemental Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). This age restriction was selected because we focused on the adult population due to pneumonia-related mortality in patients\u0026thinsp;\u0026lt;\u0026thinsp;25 years of age being infrequent. The study was exempt from institutional review board approval because the CDC WONDER database contains anonymized, publicly available data.\u003c/p\u003e \u003cp\u003eWe extracted data regarding pneumonia-related deaths and population sizes from 1999 to 2020. Data on demographic and regional groups were extracted, including gender, race/ethnicity, age, urban-rural classification, region, and states. Racial/ethnicity groups were defined as White, Black/African American, American Indian/Alaskan Native, Asian/Pacific Islander, and Hispanic people as identified on death certificates. Age groups were defined as 25 to 39, 40 to 54, 55 to 69, 70 to 84, and 85\u0026thinsp;+\u0026thinsp;years of age. For urban-rural classifications, the National Center for Health Statistics Urban-Rural Classification Scheme was used to divide the population into urban (large metropolitan area [population\u0026thinsp;\u0026ge;\u0026thinsp;1 million], medium/small metropolitan area [population 50,000 to 999,999]) and rural (population\u0026thinsp;\u0026lt;\u0026thinsp;50,000) counties per the 2013 United States census classification\u003csup\u003e[7]\u003c/sup\u003e. Regions were classified into Northeast, Midwest, South, and West according to the Census Bureau definitions\u003csup\u003e[6]\u003c/sup\u003eThe Locations of death included medical facilities (outpatient, emergency room, inpatient, death on arrival, or status unknown), homes, hospice, and nursing homes/long-term care.\u003c/p\u003e \u003cp\u003ePneumonia-related crude and age-adjusted mortality rates were calculated. Crude mortality rates were calculated by dividing the number of Pneumonia-related deaths by the corresponding United States population. Age-adjusted mortality rates (AAMR) were standardized using the 2000 United States standard population as previously described\u003csup\u003e[8]\u003c/sup\u003e. The Joinpoint Regression Program (Joinpoint version 4.9.0.0 available from National Cancer Institute, Bethesda, Maryland) was used to determine trends in mortality within the study period\u003csup\u003e[9,10]\u003c/sup\u003e. This program identifies significant changes in annual mortality trends over time through Joinpoint regression, which fits models of linear segments where significant temporal variation occurred. Annual percentage change (APC) with 95% confidence intervals (CIs) for the AAMRs were calculated for the line segments linking a Joinpoint using the Monte Carlo permutation test. The weighted average of the APCs was calculated and reported as an average annual percentage change (AAPCs) and corresponding 95% CIs as a summary of the reported mortality trend for the entire study period. APC and AAPCs were considered to increase or decrease if the slope describing the change in mortality over the time interval significantly differed from zero using a 2-tailed t-test. Statistical significance was set at p\u0026thinsp;\u0026le;\u0026thinsp;0.05 (represented by asterisk \u0026ldquo;*\u0026rdquo; in results, figures, and supplemental file).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1. Overall\u003c/h2\u003e \u003cp\u003eFrom 1999 to 2020, there were 56,806,341 total deaths in the United States. Of these deaths, 1,243,017 (2.1%) were due to pneumonia (Supplemental Table S2). Overall age-adjusted mortality rates (AAMR) decreased during this period from 35.9 (95% CI 35.7 to 36.2) in 1999 to 19.9 (95% CI 19.7 to 20.1) in 2020, with an average annual percentage change (AAPC) of -3.0* (95% CI -3.8 to -2.2) (Supplemental Table S2). The annual percentage change (APC) in AAMR was \u0026minus;\u0026thinsp;4.0 (95% CI -9.9 to 3.9) from 1999\u0026ndash;2010, which decreased to -1.8 (95% CI -10.5 to 5.3) from 2010\u0026ndash;2020 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Overall, AAMR decreased to the lowest point in 2019 at 18.75 (95% CI 18.6 to 18.9) and slightly increased to 19.91 (95% CI 19.7 to 20.1) in 2020.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2. Demographic differences\u003c/h2\u003e \u003cp\u003e \u003cb\u003e2.1 Gender stratified.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFrom 1999 to 2020, pneumonia caused 574,872 (46.2%) deaths in males and 668,145 (53.8%) deaths in females in the United States (Supplemental Table S2).\u003c/p\u003e \u003cp\u003eThe AAMR decreased in males from 43.7 (95% CI 43.1 to 44.2) in 1999 to 24.1 (95% CI 23.8 to 24.4) in 2020, with an AAPC of -3.1 (95% CI -3.7 to -2.6) (Supplemental Table S2). The APC in AAMR was \u0026minus;\u0026thinsp;4.2* (95% CI -8.9 to -3.1) from 1999\u0026ndash;2010, which then decelerated to -2.0 (95% CI -3.2 to 3.6) from 2010\u0026ndash;2020 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn females, the AAMR decreased from 31.4 (95% CI 31.1 to 31.7) in 1999 to 16.8 (95% CI 16.6 to 17.0) in 2020, with a steady AAPC of -3.1* (95% CI -3.6 to -2.6) (Supplemental Table S2, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e2.2 Race stratified.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBlack or African American people had the highest AAMR over the years, with 38.5 (95% CI 37.5 to 39.5) in 1999 to 25.1 (95% CI 24.5 to 25.8) in 2020 and an AAPC of -2.7* (95% CI -3.3 to -2.2) (Supplemental Table S4). The APC in AAMR was \u0026minus;\u0026thinsp;3.8* (95% CI -7.0 to -3.1) from 1999\u0026ndash;2012, which reduced to -0.9 (95% CI -2.5 to 5.0) from 2012\u0026ndash;2020 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The second highest AAMR was shown among White people, starting at 35.8 (95% CI 35.3 to 36.1) in 1999 and changing to 19.5 (95% CI 19.3 to 19.6) in 2020. The APC from 1999\u0026ndash;2010 was \u0026minus;\u0026thinsp;4.2 (95% CI -8.9 to 6.9) and declined to -1.1 (95% CI -3.8 to 5.4) from 2010 to 2020. American Indian and Native Alaskan people had the most significant reduction in AAMR from 42.5 (95% CI 37.3 to 47.7) in 1999 to 19.8 (95% CI 17.9 to 21.7) in 2020 with an AAPC of -3.7* (95% CI -4.5 to -2.8) (Supplemental Table S3). The APC of Asian and Pacific Islander people was \u0026minus;\u0026thinsp;2.1 (95% CI -2.6 to 0.4) from 1999\u0026ndash;2017 and continued to accelerate at -8.4* (95% CI -15.7 to -3.2) from 2017 to 2020 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) with an AAPC of -3.0 (95% CI -3.6 to -2.1) (Supplemental Table S3, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Age group stratified\u003c/h2\u003e \u003cp\u003eThe population of 85 years and older had the highest overall crude mortality rate, which decreased from 751.8 (95% CI 743.4 to 760.1) in the year 1999 to 273.6 (95% CI 269.7 to 277.6) in the year 2020, with a consistent AAPC of -4.4* (95% CI -5.0 to -3.9) (Supplemental Table S4, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The 55\u0026ndash;69 age group was the only group to experience a Joinpoint with an increase in mortality. The group experienced a decrease from 1999\u0026ndash;2010 with an APC of -1.4 (95% CI -7.1 to 0.0), which increased from 2010 to 2020 with an APC of 2.8* (95% CI 1.2 to 9.4) and AAPC deaths of 0.5 (95% CI \u0026minus;\u0026thinsp;0.2 to 1.2). The 70\u0026ndash;84 age group experienced a constant decline, with an AAPC of \u0026minus;\u0026thinsp;3.2* (95% CI \u0026minus;\u0026thinsp;3.8 to \u0026minus;\u0026thinsp;2.6) throughout the study period. Ages 40\u0026ndash;54 experienced an unremarkable increase in overall crude mortality rate from 3.9 (95% CI 3.8 to 4.1) in 1999 to 5.2 (95% CI 5 to 5.4) with an AAPC of 0.8 (95% CI -0.1 to 1.8) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Supplemental Table S4).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3. Place of death\u003c/h2\u003e \u003cp\u003eDuring the study period, the total number of deaths with a known place of death included 1,215,233 (97.7%). 27.9% occurred outside of medical facilities (20.0% nursing home/long-term care, 2.3% hospice, 5.6% home), 72.1% occurred within medical facilities (3.4% outpatient/ER and 68.7% inpatient). Over this time, deaths in nursing homes decreased from 17,771 to 5,634 (31.7%), while deaths in hospice surged, with a 4,114.5% increase, from 62 in the year 2003 (Hospice deaths started being reported from 2003 onwards) to 2,551 in the year 2020 \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Supplemental Table S5).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e4. Regional variation\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e5.1 Rural vs. Urban\u003c/h2\u003e \u003cp\u003eAll regional variations saw an overall decline in AAMRs. When comparing populated regions, AAMRs were consistently highest in rural areas compared to small, medium, and large metropolitan regions. Large metropolitan zones experienced a decrease in APC between 1999\u0026ndash;2010 by -4.2* (95% CI -8.9 to -3.3), which changed to -2.1 (95% CI -3.0 to 2.0) from 2010\u0026ndash;2020 with an AAPC of -3.2 (95% -3.7 to -2.7). From 1999 through 2010, the APC declined from \u0026minus;\u0026thinsp;4.1 (95% CI -8.9 to 3.1) for medium/small metropolitan areas and slowed to -1.4 (95% CI -3.6 to 3.2) from 2010\u0026ndash;2020 with an AAPC \u0026minus;\u0026thinsp;2.8 (95% CI -3.7 to -2.1). Rural zones saw AAMRs change from 39.6 (95% CI 38.9 to 40.3) in 1999 to 23.5 (95% CI 23 to 24) in 2020, with a consistent AAPC of -2.5* (95% CI -3.1 to -2.0) (Supplemental Table S6, Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e5.2 State-level difference\u003c/h2\u003e \u003cp\u003eThe Average AAMR for the duration of the study period varied widely from 36.3 (95% CI 35.7 to 36.9) in Mississippi to 16.1 (95% CI 16 to 16.3) in Florida. States in the greater 90th percentile of pneumonia-related mortality included Mississippi, Tennessee, Arkansas, Kentucky, and New York. Conversely, states in the less than 10th percentile of pneumonia-related mortality included Florida, Vermont, Oregon, Minnesota, and Washington (Supplemental Table S7 and S8, Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003ea and \u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003eb).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eColorado saw the largest decrease in AAMR from 38.8 (95% CI 36.1 to 41.5) to 11 (95% CI 10 to 12), with an average AAMR for study duration of 27.8 (12%) (Supplemental Table S8 and Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003ea and \u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003eb). In comparison, Arkansas had a similar AAMR in 1999 of 38.8 (95% CI 36 to 41.6), but the AAMR only decreased to 27.4 (95% CI 25.3 to 29.5) in 2020 with an average AAMR of 34.5 (96%) (Supplemental Table S8 and Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003ea and \u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e6\u003c/span\u003eb). California had the smallest decrease from 1999 to 2020, with an average AAMR for study duration of 4.9 (64%).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e5.3 Census region-based differences\u003c/h2\u003e \u003cp\u003eEvery census region saw a decrease in AAMR over time, with the South seeing the greatest decrease in AAMR from 34.5 (95% CI 34.1 to 35) in 1999 to 23.1 (95% CI 22.8 to 23.4) in 2020 with a consistent AAPC of -3.1 (95% CI -3.6 to -2.7) (Supplemental Table S9, Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe West saw three changes in their APC with an increase between 1999 to 2001 of 10.5 (95% CI-3.1 to 27.6), which decreased from 2001\u0026ndash;2010 to -6.08 (95% CI -13.2 to -4.3) and finally \u0026minus;\u0026thinsp;1.9 (95% CI -4.0 to 6.3) from 2010\u0026ndash;2020 with an AAPC of -2.6 (95% CI -3.6 to -1.3). The Northeast saw a 1999\u0026ndash;2010 APC of -3.9* (95% CI -10 to -2.3), which slowed to -1.2 (95% CI -3.2 to 5.6) for the remainder of the study period and an AAPC of -2.6* (95% CI -3.4 to -1.9). The Midwest saw a decrease in APC of -3.9 (95% CI -11.0 to 3.8) from 1999\u0026ndash;2009, with a change to -1.5 (95% CI -11.5 to 6.2) from 2009 to 2020, with an AAPC of -2.7 (95% CI -3.7 to -1.8).\u003c/p\u003e \u003cp\u003eOn average, within the study period, the AAMR was highest in the West in 2000 at 38.9 (95% CI 38.2 to 39.5), then the following regions in 1999: Northeast at 37.7 (95% CI 37.1 to 38.3), the Midwest at 37.6 (95% CI 37.1 to 38.3), and the South at 36.6 (95% CI 36.1 to 37). AAMRs were the lowest for the Northeast, Midwest, and South in 2019 but not remarkably different from 2020 data.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study reports several important findings regarding pneumonia-related mortality in the US from 1999 to 2020. While seeing overall mortality rates decrease, males experienced a larger AAMR decrease than females, African American and Black people experienced the highest mortality throughout the duration of the study, and American Indian and Native Alaskan people had the greatest reduction in mortality. Nursing home deaths decreased over time, and in turn, hospice deaths substantially rose. Deaths among people 85 and older steadily declined. Lastly, several geographical differences in AAMR were found between urban-rural groups, states, and census regions.\u003c/p\u003e \u003cp\u003eA decrease in pneumonia-related mortality rates reflects improvements made in pneumonia care. Over the past 22 years, we have seen the sophistication of the pneumonia and influenza vaccines and an increase in vaccine utilization. The CDC has issued guidelines for annual influenza and pneumococcal vaccines for vulnerable populations\u003csup\u003e[11]\u003c/sup\u003e. Between 2005 and 2014, the CDC reported that the number of individuals receiving the influenza vaccine doubled (43.7%)\u003csup\u003e[6,12]\u003c/sup\u003e. Greater vaccine adherence may be reflected in lower mortality rates, as one study in Brazil found that overall mortality fell by 23.6% among individuals 65 and older who were vaccinated\u003csup\u003e[13]\u003c/sup\u003e. While vaccines play a vital role in reducing influenza incidence and preventing subsequent pneumonia, other key medical advances include rapid viral testing for early detection and prompt treatment\u003csup\u003e[14]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhile both sexes saw a decrease in mortality, AAMR for males decreased more than that of females. Males experience greater midlife mortality than females, with pneumonia being a factor that offsets the decline in life expectancy for both genders\u003csup\u003e[15]\u003c/sup\u003e. Females have also reported higher vaccination rates than males\u003csup\u003e[12]\u003c/sup\u003e. Further research on differences in gender and pneumonia-related mortality is needed, as looking at mortality without separating males and females can mask specific trends\u003csup\u003e[15]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAfrican Americans and Blacks had the highest overall mortality during the study. In addition to pneumonia-related mortality, this population experiences higher overall mortality\u003csup\u003e[16]\u003c/sup\u003e. There are many complex factors contributing to poorer health outcomes in African American and Black patients, which include social determinants of health such as socioeconomic status, insurance, and access to primary care\u003csup\u003e[16,17]\u003c/sup\u003e. These barriers to care may contribute to differences in vaccine rates as well. Studies have found that vaccine rates are lower amongst the Black population compared to other racial/ethnic groups\u003csup\u003e[2,11]\u003c/sup\u003e. Social determinants of health create issues surrounding vaccine accessibility, but increasing campaigns and education surrounding vaccinations in the African American and Black population may be an area of improvement\u003csup\u003e[18]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAmerican Indian and Native Alaskan people had the greatest reduction in mortality from pneumonia\u003csup\u003e[19]\u003c/sup\u003e. Prior studies have highlighted this group as a higher risk for pneumonia complications. One hypothesis for this trend is increased vaccination adherence. The Office of Minority Health, a branch of the US Department of Health and Human Services, reported a vaccination ratio of 0.8 for American Indian and Alaskan people compared to non-Hispanic and White Americans for the 2019\u0026ndash;2020 influenza season\u003csup\u003e[20]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAs mortality changes among different populations, we have also seen shifts in where pneumonia deaths occur, with utilization of hospice services on the rise. A report from Medicare beneficiaries found that hospice services increased by 28.8% between 2000 and 2015\u003csup\u003e[21]\u003c/sup\u003e. Nursing homes also contract with hospice facilities to move patients when their health needs change, leading to a greater number of patients dying in hospice care rather than nursing facilities\u003csup\u003e[22]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAdvanced age leads to an increased risk for comorbid illnesses as well. Thus, the 85 and older age group has the greatest risk for complications regarding pneumonia. As medical improvements are made to treat these comorbidities, patients in this age category may have better outcomes regarding pneumonia-related illnesses. Additionally, vaccine efforts to target high-risk groups and patients over 65 years of age have helped reduce the spread of influenza and pneumonia\u003csup\u003e[23,24]\u003c/sup\u003e. Vaccine rates are highest among the 65 and older population\u003csup\u003e[6,12]\u003c/sup\u003e. In 2014, 58.7 percent of elderly adults reported receiving at least one kind of pneumococcal vaccine\u003csup\u003e[6,12]\u003c/sup\u003e. With greater improvements in decreasing mortality and higher vaccination rates, this outcome may support a larger effort to increase vaccinations among other age categories.\u003c/p\u003e \u003cp\u003eAnother population comprised of older individuals is rural communities\u003csup\u003e[25]\u003c/sup\u003e. Rural areas had higher mortality rates and worse health outcomes due to increased distance from healthcare institutions, higher rates of poverty, and greater comorbidities due to lack of consistent care\u003csup\u003e[25,26]\u003c/sup\u003e. Another explanation for the improvement in mortality among population-dense areas is a greater concentration of college-educated people\u003csup\u003e[27]\u003c/sup\u003e. Vaccine campaigns have been shown to be successful in cities, especially when targeting high-risk populations\u003csup\u003e[18,28,29]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOn a statewide level, there were several trends. States with the highest rates of pneumonia-related mortality were predominantly located in the South, except for New York, which was also among the states with the highest death rate from pneumonia. When comparing by regions, the South had the greatest decrease in AAMR. Studies have found that overall mortality, especially in the rural South, is greater than in other geographical regions for proposed reasons of improved overall health outcomes and increased population density, leading to fewer rural southern communities\u003csup\u003e[25,26]\u003c/sup\u003e. Colorado was the state that saw the greatest change in AAMR. Compared to Arkansas, which had a similar AAMR in 1999, Colorado decreased its AAMR by over 27.8 and Arkansas by 11.4. This significant decrease in mortality compared to other states is an interesting finding, and understanding the factors that played a role in this improvement could be applied across the USA. A 2019 study by Woolf focused on life expectancy rather than pneumonia-related mortality and found that Colorado's life expectancy difference increased between Colorado and Kansas from 1990 to 2016\u003csup\u003e[27]\u003c/sup\u003e. This study hypothesized that outcome changes may reflect policy choices considering differences in demography and economies between the two states were low\u003csup\u003e[27]\u003c/sup\u003e. A 2004\u0026ndash;2006 report from the CDC found Colorado to have the highest influenza vaccination and pneumococcal rates amongst their 65 and older population, at 76.5% and 71.4%, respectively, contributing positively to their lower AAMR\u003csup\u003e[30]\u003c/sup\u003e. While California\u0026rsquo;s vaccination rates from the same study were middle to lower in ranking, they saw the smallest decrease in AAMR over the study duration (20). Considering vaccination rates, factors resulting in consistent mortality outcomes may be related to lower overall mortality rates. Life expectancy in California ranks among the top five states\u003csup\u003e[31]\u003c/sup\u003e. This could be related to policies and projects such as the Healthy Cities and Communities Program, the oldest WHO campaign in the US to promote healthier lifestyles, focusing on social determinants of health\u003csup\u003e[32,33]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study has several limitations to be mindful of. First, the CDC WONDER database is based on death certificates for US residents. Any errors in these certificates could affect data points in the study. Mortality data is coded by death certificates in the state where the deaths took place and may inaccurately represent deaths from patients who traveled for care. We only used the mortality data for pneumonia as the underlying cause of death, which does not consider the deaths where pneumonia might have contributed indirectly to mortality or acted as a secondary cause.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePneumonia-related mortality in the US decreased between 1999 and 2020. Differences in mortality exist across gender, race, and geographic regions. Improvements in health care and increased utilization of pneumococcal and influenza vaccines have lowered mortality. Further research is needed to delineate why certain groups and regions have improved health outcomes. Policies to increase vaccination rates appear to be the most promising way to continue the downward trend, and further targeted efforts are needed to reduce demographic and geographical disparities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eEH analyzed and interpreted the data and was a major contributor in writing the manuscript. AJ completed the data analyses and was a major contributor in writing the manuscript. MA was a contributor to writing and editing the manuscript. NA was a contributor to writing and editing the manuscript. KM was a contributor to writing and editing the manuscript. MM contributed editing the manuscript. AT contributed editing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e \u003cp\u003eThe datasets generated and analyzed during the current study are available on the CDC WONDER repository Underlying Cause of Death 1999\u0026ndash;2020, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://wonder.cdc.gov/ucd-icd10.html\u003c/span\u003e\u003cspan address=\"https://wonder.cdc.gov/ucd-icd10.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCairns, C., \u0026amp; Kang, K. (2022). \u003cem\u003eNational Hospital Ambulatory Medical Care Survey: 2020 Emergency Department Summary Tables\u003c/em\u003e. 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N., \u0026amp; Rosenberg, H. M. (1998). Age standardization of death rates: Implementation of the year 2000 standard. \u003cem\u003eNational Vital Statistics Reports: From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System\u003c/em\u003e, \u003cem\u003e47\u003c/em\u003e(3), 1\u0026ndash;16, 20.\u003c/li\u003e\n\u003cli\u003eKim, H. J., Fay, M. P., Feuer, E. J., \u0026amp; Midthune, D. N. (2000). Permutation tests for joinpoint regression with applications to cancer rates. \u003cem\u003eStatistics in Medicine\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(3), 335\u0026ndash;351. https://doi.org/10.1002/(sici)1097-0258(20000215)19:3\u0026lt;335::aid-sim336\u0026gt;3.0.co;2-z\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eJoinpoint Regression Program, Version 5.0.2\u0026mdash;May 2023\u003c/em\u003e. (n.d.). [National Cancer Institute]. 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Influenza and Pneumonia Mortality Across the 30 Biggest U.S. Cities: Assessment of Overall Trends and Racial Inequities. \u003cem\u003eJournal of Racial and Ethnic Health Disparities\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(4), 1152\u0026ndash;1160. https://doi.org/10.1007/s40615-021-01056-x\u003c/li\u003e\n\u003cli\u003eDoxey, M., Chrzaszcz, L., Dominguez, A., \u0026amp; James, R. D. (2019). A Forgotten Danger: Burden of Influenza Mortality Among American Indians and Alaska Natives, 1999-2016. \u003cem\u003eJournal of Public Health Management and Practice: JPHMP\u003c/em\u003e, \u003cem\u003e25 Suppl 5, Tribal Epidemiology Centers: Advancing Public Health in Indian Country for Over 20 Years\u003c/em\u003e, S7\u0026ndash;S10. https://doi.org/10.1097/PHH.0000000000001062\u003c/li\u003e\n\u003cli\u003eOffice of Minority Health. 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Achieving a \u0026ldquo;Broad View of Health\u0026rdquo;: Findings From the California Healthy Cities and Communities Evaluation. \u003cem\u003eHealth Education \u0026amp; Behavior\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(3), 441\u0026ndash;452.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pneumonia, pneumonia-related mortality, CDC WONDER, pneumococcal vaccine, health disparity, age-adjusted mortality rate","lastPublishedDoi":"10.21203/rs.3.rs-4732500/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4732500/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003ePneumonia is the amongst the leading causes of death in the United States. In 2020, pneumonia accounted for over 53,000 deaths and 2.6\u0026nbsp;million emergency department visits. Further research is needed to study the evolution of country-wide trends and highlight disparities.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eCenters for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) was used to identify pneumonia-related deaths occurring within the United States. We extracted data regarding pneumonia-related deaths and population sizes from 1999 to 2020. Data on demographic and regional groups were analyzed, including gender, race/ethnicity, age, urban-rural classification, region, and states.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eOverall mortality from pneumonia related deaths declined within the study period. Males experienced a larger age-adjusted mortality rate decrease than females. African American and Black people experienced the highest mortality throughout the duration of the study, while American Indian and Native Alaskan had the greatest reduction in mortality. Nursing home deaths decreased over time, and in turn, hospice deaths substantially rose. Deaths in people 85 years and older steadily declined. Finally, several geographical differences were found between urban-rural groups, states, and census regions.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003ePneumonia-related mortality between 1999\u0026ndash;2020 has decreased in the United States. Policies to increase vaccination rates appear to be most promising in continuing the downward trend. Further research is needed to address pneumonia-related mortalities across demographic and geographical disparities.\u003c/p\u003e","manuscriptTitle":"Demographic and Regional Trends of Pneumonia Mortality in the United States","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 04:40:31","doi":"10.21203/rs.3.rs-4732500/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8aa45740-ca7c-43e5-9bc9-e7307cacc618","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-22T04:38:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-09 04:40:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4732500","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4732500","identity":"rs-4732500","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}