Research Brief
Mortality by Education Before and During the COVID-19 Pandemic, U.S., 2017–2020

https://doi.org/10.1016/j.amepre.2022.08.015Get rights and content

Introduction

Mortality disparities by SES, including education, have steadily increased in the U.S. over the past decades. This study examined whether these disparities overall and for 7 major causes of death were exacerbated in 2020, coincident with the emergence of the COVID-19 pandemic.

Methods

Using data on 7,123,254 U.S. deaths from 2017 to 2020, age-standardized death rates and mortality rate differences per 100,000 population and rate ratios comparing least with most educated were calculated by sex and race/ethnicity.

Results

All-cause death rates were approximately 2 times higher among adults with least than among those with most education. Disparities in all-cause mortality by educational attainment slightly increased from 2017 (rate ratio=1.97; 95% CI=1.95, 1.98; rate difference=739.9) to 2019 (rate ratio=2.04; 95% CI=2.03, 2.06; rate difference=761.3) and then greatly increased in 2020 overall (rate ratio=2.32; 95% CI=2.30, 2.33; rate difference=1,042.9) and when excluding COVID-19 deaths (rate ratio=2.27; 95% CI=2.25, 2.28; rate difference=912.3). Similar patterns occurred across race/ethnicity and sex, although Hispanic individuals had the greatest relative increase in disparities for all-cause mortality from 2019 (rate ratio=1.47; 95% CI=1.43, 1.51; rate difference=282.4) to 2020 overall (rate ratio=2.00; 95% CI=1.94, 2.06; rate difference=652.3) and when excluding COVID-19 deaths (rate ratio=1.84; 95% CI=1.79, 1.90; rate difference=458.7). Disparities in cause-specific mortality by education were generally stable from 2017 to 2019, followed by a considerable increase from 2019 to 2020 for heart disease, cancer, cerebrovascular disease, and unintentional injury. Among these causes of death, the relative increase in rate ratio from 2019 to 2020 was greatest for unintentional injury (24.8%; from 3.41 [95% CI=3.23, 3.60] to 4.26 [95% CI=3.99, 4.53]).

Conclusions

Mortality disparities by education widened in the U.S. in 2020, during the COVID-19 pandemic. Further research is warranted to understand the reasons for these widened disparities.

Section snippets

INTRODUCTION

Previous studies have reported steadily increasing SES mortality disparities in the U.S. over the past few decades.1, 2, 3 The emergence of the coronavirus disease 2019 (COVID-19) pandemic heightened the awareness of widening health disparities.4,5 The pandemic created an immense disturbance to the U.S. health system, including impacts on delivery of care and outcomes for other conditions. A study comparing provisional data from March through August 2020 with data from the same months in 2019

METHODS

U.S. population9 and mortality10 data in 2017–2020 by age group (25–39, 40–54, 55–64, 65–74, and ≥75 years), sex, race/ethnicity (non-Hispanic White [White], non-Hispanic Black [Black], non-Hispanic Asian [Asian], or Hispanic), and educational attainment were obtained from the National Center for Health Statistics. Analyses were restricted to adults aged ≥25 years to allow adequate time for complete educational attainment, categorized as high school graduate or less (least educated), some

RESULTS

After excluding deaths with missing age (n=1,188; 0.02%) or educational attainment (n=224,043; 3.1%), this analysis included 7,123,254 deaths at age ≥25 years from 2017 to 2020. All-cause death rates were approximately 2 times higher among adults with the least education than among adults with the most education, with a slight annual increase in disparity during 2017–2019 that was accentuated in 2020 (Table 1). The rate ratio slightly increased from 1.97 (95% CI=1.95, 1.98; RD=739.9) in 2017 to

DISCUSSION

In this study using nationwide data from 2017 to 2020, widening educational attainment disparities in overall and cause-specific mortality were exacerbated in 2020, coincident with the emergence of the COVID-19 pandemic. Disparities in cause-specific mortality by educational attainment were particularly heightened in heart disease-, cancer-, cerebrovascular-, and unintentional injury-related deaths. Similar patterns were observed across race/ethnicity and sex, although Hispanic individuals had

CONCLUSIONS

Mortality disparities by educational attainment substantially widened in the U.S. in 2020. Further research is warranted to fully understand the contributing factors to the widening disparities and to plan mitigation strategies in anticipation of future healthcare crises.

ACKNOWLEDGMENTS

The funders of the study had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

This study was supported by the Surveillance & Health Equity Science Department of the American Cancer Society (grant number not applicable).

All authors are employed by the American Cancer Society, which receives grants from private and corporate

CRediT AUTHOR STATEMENT

Emily C. Marlow: Conceptualization, Data curation, Formal analysis, Methodology, Visualization, Writing – original draft. Ahmedin Jemal: Conceptualization, Writing – review and editing. Blake Thomson: Writing – review and editing. Daniel Wiese: Writing – review and editing. Jingxuan Zhao: Writing – review and editing. Rebecca L. Siegel: Writing – review and editing. Farhad Islami: Conceptualization, Methodology, Supervision, Visualization, Writing – review and editing.

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