Comparison of All-Cause Mortality Rates and Inequities Between Black and White Populations Across the 30 Most Populous US Cities

Importance To address elevated mortality rates and historically entrenched racial inequities in mortality rates, the United States needs targeted efforts at all levels of government. However, few or no all-cause mortality data are available at the local level to motivate and guide city-level actions for health equity within the country's biggest cities. Objectives To provide city-level data on all-cause mortality rates and racial inequities within cities and to determine whether these measures changed during the past decade. Design, Setting, and Participants This cross-sectional study used mortality data from the National Vital Statistics System and American Community Survey population estimates to calculate city-level mortality rates for the non-Hispanic Black (Black) population, non-Hispanic White (White) population, and total population from January 2016 to December 2018. Changes from January 2009 to December 2018 were examined with joinpoint regression. Data were analyzed for the United States and the 30 most populous US cities. Data analysis was conducted from February to November 2020. Exposure City of residence. Main Outcomes and Measures Total population and race-specific age-standardized mortality rates using 3-year averages, mortality rate ratios between Black and White populations, excess Black deaths, and annual average percentage change in mortality rates and rate ratios. Results The study included 26 295 827 death records. In 2016 to 2018, all-cause mortality rates ranged from 537 per 100 000 population in San Francisco to 1342 per 100 000 in Las Vegas compared with the overall US rate of 759 per 100 000. The all-cause mortality rate among Black populations was 24% higher than among White populations nationally (rate ratio, 1.236; 95% CI, 1.233 to 1.238), resulting in 74 402 excess Black deaths annually. At the city level, this ranged from 6 excess Black deaths in El Paso to 3804 excess Black deaths every year in Chicago. The US rate remained constant during the study period (average annual percentage change, -0.10%; 95% CI, -0.34% to 0.14%; P = .42). The racial inequities in rates for the US decreased between 2008 and 2019 (annual average percentage change, -0.51%; 95% CI, -0.92% to -0.09%; P =0.02). Only 14 of 30 cities (46.7%) experienced improvements in overall mortality rates during the past decade. Racial inequities increased in more cities (6 [20.0%]) than in which it decreased (2 [6.7%]). Conclusions and Relevance In this study, mortality rates and inequities between Black and White populations varied substantially among the largest US cities. City leaders and other health advocates can use these types of local data on the burden of death and health inequities in their jurisdictions to increase awareness and advocacy related to racial health inequities, to guide the allocation of local resources, to monitor trends over time, and to highlight effective population health strategies. This cross-sectional study examines city-level data from the 30 most populous US cities regarding all-cause mortality rates and racial inequities within cities and seeks to determine whether these measures changed during the past decade. Question How do all-cause mortality rates and racial inequities in rates vary across the 30 most populous US cities? Findings In this cross-sectional study of more than 26 million death records during a 10-year period, city mortality rates differed widely as did inequities between Black and White populations. Overall mortality rates improved in less than half of the 30 cities, and racial inequities worsened in more cities than in which they improved. Meaning Given the substantial variation in city-level mortality rates and racial inequities, cities need data specific to their jurisdiction to inform local health policy.