Trends and Disparities in Mortality From Pneumonia and Cerebrovascular Disease in the United States (1999–2020)

Abstract

ABSTRACT Background Pneumonia is a frequent and often fatal complication of cerebrovascular disease (CVD). Stroke care has improved considerably since the late 1990s, but national trends in deaths involving both conditions and their distribution across demographic and geographic groups have not been described. Methods We used the Centers for Disease Control and Prevention Wide Ranging Online Data for Epidemiologic Research (CDC WONDER) Multiple Cause of Death files to identify United States decedents aged 55 years and older who died between 1999 and 2020 with pneumonia (ICD‐10 codes J18.0, J18.1, J18.2, J18.8, and J18.9) and CVD (I60–I69), both recorded among the causes of death. Age‐adjusted mortality rates (AAMRs) per 100,000 populations were standardized to the 2000 United States population. Joinpoint regression estimated the annual percent change (APC) and average annual percent change (AAPC) overall and by sex, age group, race and ethnicity, urbanization, and census region. A sensitivity analysis of the overall series used a broader pneumonia definition (J12–J18). Results We identified 316,760 deaths involving both conditions. The overall AAMR fell from 45.4 per 100,000 in 1999 to 9.1 in 2019 (80.0% decrease) and rose to 15.8 in 2020 (73.6% above the 2019 rate); the AAPC for 1999 to 2020 was −5.09% (95% confidence interval [CI] −5.92 to −4.26). Every stratum showed a net decline over the full period and an increase in 2020. Rates were higher throughout in men, in adults aged 75 years, and older and in nonmetropolitan counties and were highest in non‐Hispanic Black adults in every year except 2017. Absolute differences between groups narrowed as overall rates fell. The relative increase in 2020 was largest in non‐Hispanic American Indian or Alaska Native (160%), Hispanic (144%), and non‐Hispanic Black (115%) adults and in adults aged 55–74 years (97%). The broader pneumonia definition added 15,521 deaths (4.9%) and produced the same joinpoints and a similar AAPC (−4.89%). Conclusion Deaths involving pneumonia and CVD fell by about 80% between 1999 and 2019 and rose sharply in 2020, coinciding with the COVID‐19 pandemic. Disparities by sex, age, race and ethnicity and urbanization persisted, and the 2020 increase was proportionally larger in several minority groups. These aggregate certificate data describe patterns but cannot identify their causes. Studies with individual‐level clinical data are needed to test whether dysphagia screening, vaccination, and infection prevention explain the long‐term decline and the disparities.