Data sources

U.S. mortality data for 1990–2015 were based on underlying cause of death and demographic information extracted from all death certificates from the entire population of U.S. residents, as provided by the Centers for Disease Control and Prevention National Center for Health Statistics and extracted using SEER*Stat in single-year increments of age and year at death.¹³ US mortality for 2016 for non-AIAN groups was obtained from CDC Wonder¹⁴. Death certificate data is provided by states to NCHS. This analysis focused on all-cause premature mortality (deaths among 25–64-year-olds, as defined in prior studies^7,15), and the commonest causes of premature death (cancer, heart disease, accidents, suicide, chronic liver disease/cirrhosis)⁷ among white, black, Hispanic, API and AIAN men and women (ICD code groupings and racial/ethnic classification details in Supplemental Methods. Accidental and suicide deaths were mutually exclusive). AIAN estimates were restricted to counties in Contract Health Services Delivery Areas (CHSDA counties);¹⁶ 2016 data were not available for AIANs as CDC WONDER does not provide a restriction to these counties. Estimates and projections of yearly U.S. population by age, sex, and race/ethnicity were obtained from the Census Bureau.¹⁷ Institutional Review Board approval was unnecessary for this study as all data are de-identified and publicly available.