Age adjusted mortality for CKM: From a total of 3243 county and county equivalent regions in the US, we analyzed data from 2857 US counties (88% of the total) over the ten-year study duration (2010-2019). Among studied counties, 934 (33%), 792 (28%), 664 (23%) and 4467 (16%) belonged to SDI groups I, II, III and IV respectively (Figure 1). The median CKM related aaCVM in the US was 60.6 (Interquartile Range [IQR]: 45.4, 82.3)/100 000 residents. Mississippi [98.9 (IQR: 97.6, 100.3)] followed by Oklahoma [91.4 (IQR: 90.3, 92.5)]/ 100 000 residents had the highest CKM related aaCVM rates while Minnesota [32.5 (IQR: 32, 33)]/ 100 000 residents had the lowest rate (Table 1, Figure S1). CKM related aaCVM rates were high in many counties in the South (Figure 2A) The CKM related aaCVM rates increased incrementally across the SDI groups: Group I – 44.6 (IQR: 36.1, 54.8)/100 000 residents, Group II- 61.4 (IQR: 48.9, 77.1) /100 000 residents, Group III- 77.4 (IQR: 61.6, 94.3) /100 000 residents, and Group IV- 85.3 (IQR: 64.6, 107.4) /100 000 residents (Figure 2B). Each subsequent SDI group had significantly higher aaCVM rates than the prior group [p-values: II vs I - <0.001, III vs II: < 0.001, IV vs III: < 0.001] (Table 2; Figure 3A). The CKM related aaCVM was significantly higher for men [84.9 (IQR: 64, 112)] /100 000 residents than women [40.7 (IQR: 28.1, 57.6)] /100 000 residents (p < 0.001). Among men, Mississippi [133.9 ((IQR: 131.7, 136.1) /100 000 residents] followed by Arkansas [120.6 ((IQR: 118.5, 122.6) /100 000 residents] had the highest aaCVM rates while Utah [45.4 ((IQR: 44, 46.2) /100 000 residents] had the lowest rate (Figure S2 - A). Among the 2733 counties that reported results for men, 2149 (78%) counties had median CKM related aaCVM rates that were higher than the national rate (Figure 4A). In fact, among men, very few counties in each US state had CKM related aaCVM rates lower than the national rate. In women, Mississippi [66.6 ((IQR: 65.1, 68.1) /100 000 residents] followed by Oklahoma [63.5 ((IQR: 62.2, 64.8) /100 000 residents] had the highest CKM related aaCVM rates, while Massachusetts [17.7 ((IQR: 17.2, 18.2) /100 000 residents] reported the lowest rate in the nation (Figure S2 – B). Among the 2280 counties that reported data for women, 488 (17%) had median CKM related aaCVM rates above the national rate (Figure 4B). Furthermore, these counties were largely located as a band across the southern US. In both men and women, the aaCVM rates increased across the SDI and the pairwise comparison between all groups in both men and women were statistically significant (Table 2). Additionally, for each SDI group, men had much higher aaCVM rates than women (Figure 3A).
The aaCVM rates In metropolitan counties [1150 counties, median rate 54.3 (IQR: 40.1, 72) /100 000 residents] were lower than in non-metropolitan counties [1707 counties; median rate 60.3 (IQR: 48.9, 89.4) /100 000 residents] (p-value < 0.001). Among metropolitan counties, Mississippi [89.4 ((IQR: 87.5, 91.2) /100 000 residents] followed by Arkansas [84.6 ((IQR: 83.1, 86.2) /100 000 residents] had the highest aaCVM rates, while Minnesota [30.9 ((IQR: 30.3, 31.5) /100 000 residents] reported the lowest rate in the nation (Figure S3 – A). In the 1150 metropolitan counties that reported data, 459 (39%) had median CKM related aaCVM rates above the national rate (Figure 3B; Figure 4C). Most of these metropolitan counties were in the South. Among non-metropolitan counties, Mississippi [107.2 ((IQR: 105.3, 109.1) /100 000 residents] followed by Oklahoma [104.4 ((IQR: 102.3, 106.4) /100 000 residents] had the highest aaCVM rates, while Connecticut [33.5 ((IQR: 30.6, 36.4) /100 000 residents] reported the lowest rate in the nation (Figure S3 – B). Among the 1707 non-metropolitan counties, 976 (57%) reported median CKM related aaCVM rates above the national rate (Figure 3B; Figure 4D). In metropolitan counties, aaCVM rates increased significantly across SDI group I, II and III; however, aaCVM rates between SDI group III and IV were similar (p-value 0.48) (Figure 3B; Table 2). In non-metropolitan counties on the other hand, aaCVM rates increased significantly across the SDI groups (Figure 3B; Table 2).
Overall, in the US, non-Hispanic Black residents [1088 counties, median aaCVM rate 110.1 (IQR: 85.6, 136.5) /100 000 residents] had almost double the rates of aaCVM as non-Hispanic White residents [ 2754 counties, median aaCVM rate 58.8 (IQR: 44.1, 78) /100 000 residents]. Hispanic (median rate 34.2/100 000 residents) and residents of other races (Asian, Alaskan Natives, Pacific Islanders, American Indian) (median rate 35.4/100 000 residents) had low aaCVM rates. However, given the low number of residents belonging to these racial/ethnic minorities in many counties, we only obtained data regarding Hispanic and residents of other races from 437 (13% of all US counties and county equivalent regions) and 336 (10% of all US counties and county equivalent regions) counties respectively. For non-Hispanic White residents, Oklahoma [88.8 ((IQR: 87.5, 90) /100 000 residents] followed by Arkansas [85.2 ((IQR: 83.8, 86.6) /100 000 residents] had the highest aaCVM rates, while the District of Columbia [18.1 ((IQR: 15.9, 20.3) /100 000 residents] reported the lowest rate in the nation. In non-Hispanic Black residents, Oklahoma [147.7 ((IQR: 142.2, 153) /100 000 residents] followed by Michigan [138.8 ((IQR: 136, 140.6) /100 000 residents] had the highest aaCVM rates, while Maine [33.9 ((IQR: 23.3, 47.6) /100 000 residents] reported the lowest rate in the nation. In the 2754 counties that reported data for non-Hispanic White residents, 1295 (45%) had a median CKM related aaCVM rate above the national rate (Figure 3C; Figure 4E). In the 1088 counties that reported data for non-Hispanic Black residents, 1006 (92%) reported a median CKM related aaCVM rate above the national rate (Figure 3C; Figure 4F). In non-Hispanic black residents, aaCVM rates increased significantly across all SDI groups (all pairwise comparison p-values < 0.01), while in non-Hispanic white residents, aaCVM rates in group II > group I, and group III > group II, but rates in groups III and IV were comparable (p-value 0.82) (Figure 3C).