Multiple-cause mortality in the USA, 2000-2021: Insights from pattern-of-failure life tables

Recent mortality patterns reflect increasingly complex pathophysiological processes in which underlying causes (UCD) capture only part of the disease burden. The multi-cause approach offers an alternative because it allows analysis of diseases appearing in the lethal process both as consequences of the UCD and as contributory causes.

In this paper, we use pattern-of-failure life tables to explicitly account for disease interdependence among all causes reported on the death certificate and remeasure the levels and trends in the disease burden in the U.S. during 2000-2021.

Results show the largest discrepancies between underlying-cause and multiple-cause frameworks for heart disease, followed by other respiratory, mental, and metabolic disorders. Intermediate and immediate roles are dominated by other and acute respiratory conditions, heart disease, and infectious diseases, while contributory roles carry growing burdens from metabolic, mental, and heart conditions. Over the study period, heart disease recorded as the underlying cause declines even as its presence in other positions rises, underscoring its continuing importance in the lethal process. Cohorts born since 1960 exhibit increasing contributions of digestive and infectious diseases to mortality, and during the COVID-19 pandemic (2020-2021) notable distortions in role-specific disease burden are observed.

In conclusion, the analysis provides context for trends based on underlying causes and offers a comprehensive analysis of evolution of mortality patterns by cause of death in the U.S. in the 21st century.