Causes of excess deaths in the US relative to other wealthy nations, 1999-2020: a population autopsy

Importance The US has higher mortality rates than other wealthy nations.

To determine causes of death responsible for excess mortality in the US compared to other wealthy nations and how the causes involved in this survival gap have changed over time. Design Repeat cross-sectional study, 1999 to 2020. Setting United States and 12 other wealthy nations. Participants All residents. Exposures Residing in the US versus other wealthy nations. Main outcome and measures Excess US mortality in each year due to specific causes of death using data from the World Health Organization Mortality Database. Differences between the US and other wealthy nations were quantified for each cause of death as: (1) the number of excess US deaths (i.e., deaths that would have been averted if US death rates equaled the average rates of other wealthy nations); (2) years of life lost (YLL) resulting from excess US deaths; and (3) the ratio of observed deaths to expected deaths if US mortality rates equaled the average of other wealthy nations.

10,856,851 excess US deaths occurred between 1999 and 2020. In 2019, prior to the COVID-19 pandemic, there were 637,682 excess US deaths, with leading causes including circulatory diseases (41% of total), mental and nervous system disorders (25%), diabetes, renal, and metabolic diseases (15%), drug poisonings, alcohol-related deaths, and suicide (13%), respiratory disease (12%), and transportation accidents (5%). Over two decades, excess US deaths due to drug poisonings, alcohol and suicide increased from -5,937 in 1999 to 109,015 in 2020. In 2019, deaths from drug poisonings were 6.7 times higher in the US than in peer countries. Circulatory mortality accounted for the largest absolute number of excess US deaths in nearly every year. In 2020, one in 5 excess US deaths were attributed to COVID-19.

and Relevance The US had substantially higher death rates than other wealthy nations between 1999 and 2020, despite having similar access to advanced medical technology. Many of these excess US deaths could likely be avoided by adopting health and social policies that have benefited peer countries. Question What causes of death are responsible for the survival gap between the US and other wealthy nations? Findings Between 1999 and 2020, 10,856,851 US deaths would have been averted if the US had mortality rates equal to the average of peer countries. Circulatory diseases were the leading cause of excess deaths, although deaths due to drugs, alcohol, and suicide increased the most during the study period. Mental and nervous system disorders, diabetes, renal, and metabolic diseases, and transportation accidents were also major contributors. Meaning The causes of death responsible for the US survival gap suggest areas for policy intervention. Competing Interest Statement The authors have declared no competing interest. Funding Statement The authors (ACS, JB, RR) acknowledge financial support from the W.K. Kellogg Foundation (P-6007864-2022). Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability All data used in this analysis are publicly available. Study data and analytic code used to generate all estimates are posted in a public data repository.