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

ImportanceThe US has higher mortality rates than other wealthy nations. ObjectiveTo 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. DesignRepeat cross-sectional study, 1999 to 2020. SettingUnited States and 12 other wealthy nations. ParticipantsAll residents. ExposuresResiding in the US versus other wealthy nations. Main outcome and measuresExcess 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. Results10,856,851 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. Conclusions and RelevanceThe 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. KEY POINTSO_ST_ABSQuestionC_ST_ABSWhat causes of death are responsible for the survival gap between the US and other wealthy nations? FindingsBetween 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. MeaningThe causes of death responsible for the US survival gap suggest areas for policy intervention.