LAUSR

BackgroundIn 2017 the CDC issued an alert that, after decades of consistent decline, the stroke death rate levelled off in 2013, particularly in younger individuals and without clear origin. The objective of this analysis is to understand whether social determinants of health have influenced trends in stroke mortality.MethodsWe performed a longitudinal analysis of county-level ischemic and hemorrhagic stroke death rate per 100,000 adults, from 1999-2018 using a Bayesian spatiotemporally smoothed CDC dataset stratified by age [35-64 (younger) and ≥65 (older)] and then by county-level social determinants of health. We report stroke death rate by county and the percentage change in stroke death rate in 2014-18 compared to 2009-13.ResultsWe included data from 3,082 counties for younger individuals and 3,019 counties for older individuals. The stroke death rate began to increase for younger individuals in 2013 (p<0.001) and the slope of the decrease in stroke death rate tapered for older individuals (p<0.001). During the twenty-year period of our study, counties with a high Social Deprivation Index and ≥10% Black residents consistently had the highest rates of stroke death in both age groups. Comparing 2014-18 to 2009-13, larger increases in younger individuals' stroke death rate were seen in counties with ≥90% (vs. <90%) non-Hispanic White individuals (3.2% mean death rate change vs. 1.7%, p<0.001), rural (vs. urban) populations (2.6% vs. 2.0%, p=0.019), low (vs. high) proportion of medical insurance coverage (2.9% vs. 1.9%, p=0.002), and high (vs. low) substance abuse and suicide mortality (2.8 vs. 1.9%, p=0.008; 3.3% vs 1.5%, p<0.001). In contrast to the younger individuals, in older individuals the associations with increased death rates were with more traditional social determinants of health such as the Social Deprivation Index, urban location, unemployment rate, and proportion of Black race and Hispanic ethnicity residents.DiscussionImprovements in the United States' stroke death rate are slowing and even reversing in younger individuals and many US counties. County-level increases in stroke death rate were associated with distinct social determinants of health for younger versus older individuals. These findings may inform targeted public health strategies.