Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, MA, USA
Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
BMJ. 2022 Jun 7;377:e069308. doi: 10.1136/bmj-2021-069308.
To assess recent trends in age adjusted mortality rates (AAMRs) in the United States based on county level presidential voting patterns.
Cross sectional study.
USA, 2001-19.
99.8% of the US population.
AAMR per 100 000 population and average annual percentage change (APC).
The Centers for Disease Control and Prevention WONDER database was linked to county level data on US presidential elections. County political environment was classified as either Democratic or Republican for the four years that followed a November presidential election. Additional sensitivity analyses analyzed AAMR trends for counties that voted only for one party throughout the study, and county level gubernatorial election results and state level AAMR trends. Joinpoint analysis was used to assess for an inflection point in APC trends.
The study period covered five presidential elections from 2000 to 2019. From 2001 to 2019, the AAMR per 100 000 population decreased by 22% in Democratic counties, from 850.3 to 664.0 (average APC -1.4%, 95% confidence interval -1.5% to -1.2%), but by only 11% in Republican counties, from 867.0 to 771.1 (average APC -0.7%, -0.9% to -0.5%). The gap in AAMR between Democratic and Republican counties therefore widened from 16.7 (95% confidence interval 16.6 to 16.8) to 107.1 (106.5 to 107.7). Statistically significant inflection points in APC occurred for Democratic counties between periods 2001-09 (APC -2.1%, -2.3% to -1.9%) and 2009-19 (APC -0.8%, -1.0% to -0.6%). For Republican counties between 2001 and 2008 the APC was -1.4% (-1.8% to -1.0%), slowing to near zero between 2008 and 2019 (APC -0.2%, -0.4% to 0.0%). Male and female residents of Democratic counties experienced both lower AAMR and twice the relative decrease in AAMR than did those in Republican counties. Black Americans experienced largely similar improvement in AAMR in both Democratic and Republican counties. However, the AAMR gap between white residents in Democratic versus Republican counties increased fourfold, from 24.7 (95% confidence interval 24.6 to 24.8) to 101.3 (101.0 to 101.6). Rural Republican counties experienced the highest AAMR and the least improvement. All trends were similar when comparing counties that did not switch political environment throughout the period and when gubernatorial election results were used. The greatest contributors to the widening AAMR gap between Republican and Democratic counties were heart disease (difference in AAMRs 27.6), cancer (17.3), and chronic lower respiratory tract diseases (8.3), followed by unintentional injuries (3.3) and suicide (3.0).
The mortality gap in Republican voting counties compared with Democratic voting counties has grown over time, especially for white populations, and that gap began to widen after 2008.
根据县一级总统投票模式评估美国年龄调整死亡率（AAMR）的近期趋势。
横断面研究。
美国，2001-19 年。
99.8%的美国人口。
每 10 万人的 AAMR 和平均年百分比变化（APC）。
疾病控制和预防中心的 WONDER 数据库与美国总统选举的县一级数据相关联。在 11 月总统选举后的四年内，县一级政治环境被归类为民主党或共和党。此外，敏感性分析还分析了整个研究期间只投票给一方的县的 AAMR 趋势，以及县一级州长选举结果和州一级 AAMR 趋势。使用 Joinpoint 分析评估 APC 趋势的拐点。
研究期间涵盖了 2000 年至 2019 年的五次总统选举。从 2001 年到 2019 年，民主党县的每 10 万人死亡率下降了 22%，从 850.3 降至 664.0（APC 平均为-1.4%，95%置信区间为-1.5%至-1.2%），而共和党县的死亡率仅下降了 11%，从 867.0 降至 771.1（APC 平均为-0.7%，-0.9%至-0.5%）。因此，民主和共和两党县之间的 AAMR 差距从 16.7（95%置信区间 16.6 至 16.8）扩大到 107.1（106.5 至 107.7）。民主党县的 APC 在 2001-09 年（APC-2.1%，-2.3%至-1.9%）和 2009-19 年（APC-0.8%，-1.0%至-0.6%）期间出现了统计学上显著的拐点。2001 年至 2008 年，共和党县的 APC 为-1.4%（-1.8%至-1.0%），2008 年至 2019 年期间放缓至接近零（APC-0.2%，-0.4%至 0.0%）。民主党的男性和女性居民死亡率都较低，AAMR 的相对降幅是共和党的两倍。非裔美国人在民主和共和两党县的 AAMR 都有了很大的改善。然而，白人和共和党县居民之间的 AAMR 差距增加了四倍，从 24.7（95%置信区间 24.6 至 24.8）增加到 101.3（101.0 至 101.6）。农村共和党县的死亡率最高，改善最小。当比较整个时期政治环境没有变化的县以及使用州长选举结果时，所有趋势都是相似的。导致共和党和民主党县之间 AAMR 差距扩大的最大因素是心脏病（AAMR 差异 27.6）、癌症（17.3）和慢性下呼吸道疾病（8.3），其次是意外伤害（3.3）和自杀（3.0）。
与投票给民主党的县相比，共和党投票的县的死亡率差距随着时间的推移而扩大，尤其是对白人人口而言，自 2008 年以来，这一差距开始扩大。
