Yasmin Aziz, MD
Healthy People is a national initiative that sets prevention-based goals for the United States in ten-year increments. Healthy People 2020 (HP2020) had a goal to decrease the mortality of stroke and coronary heart disease (CHD) by at least 20% or more, bringing death rates down to 34.8 per 100,000 in stroke and to 103.4 per 100,000 in CHD. The goal of this study was to see which geographic areas were able to meet the HP2020 death rate goal or decrease their own regional mortality from stroke or CHD by at least 20%. In order to accomplish this, investigators queried the National Vital Statistics System and the National Center for Health Statistics for all counties in the United States in which people died from stroke or CHD, as defined by the International Classification of Diseases codes. Death rates for 2017 were then compared to rates from 2007 and were mapped via a Bayesian spatiotemporal model to assess progress.
For CHD, 26.1% (CI: 25.0, 27.8) of U.S. counties failed to reach the HP2020 goal, nor did they reduce death rates by at least 20%. These counties reduced their death rate by a median 10.2% (IQR: -15.2, -1.7) to a rate of 127.1 per 100,000. For stroke, this number was much higher at 45.8% (CI: 42.9, 48.3), with death rates decreased by a median 12.8% (IQR: -16.6, -7.7), amounting to 42.2 deaths per 100,000. While counties not achieving either milestone for CHD spanned from Appalachia to New Mexico, counties not meeting either metric for stroke were scattered across Appalachia, the Deep South, the Midwest, and the Pacific Coast. Of note, 16.5% (CI 15.4, 17.7) of U.S. counties were still able to reduce local CHD death rates by at least 20% even without meeting the HP2020 target. This is in contrast to the 22.7% (CI: 20.7, 25.0) of counties with similar outcome in stroke.
In summary, while approximately one in every four U.S. counties did not meet the HP2020 death rate target or decrease their regional death rate from CHD between 2007-2017, this number was almost twice as high for stroke. The authors cite potential reasons such as stroke recognition and administration of tissue plasminogen activator as likely causes for this disparity.
While the study is limited by its focus on only mortality rather than morbidity as well, the strength of the study lies in its clear regional delineation of areas that could benefit from focused assistance.