Leading Causes of Death Among Asian American Compared With Pacific Islander Individuals

Abstract

This cross-sectional study compares the disaggregated mortality rates and leading causes of death among Asian American and Pacific Islander individuals.

Asian American and Pacific Islander individuals comprise 2 distinct, diverse racial groups, with large health differences, that have historically been combined in mortality statistics. In 2018, all states implemented updated death certificate racial classifications, disaggregating recent mortality rates (MRs) for Asian American from Pacific Islander individuals.

Methods

National Center for Health Statistics death certificate data and US Census Bureau population counts were used to calculate age-standardized MRs per 100 000 person-years for all causes and the 5 leading causes of death among Asian American and Pacific Islander adults aged 20 to 84 years, by sex and age (20-44, 45-54, 55-64, 65-74, and 75-84 years) (eMethods in Supplement 1). Mortality rate ratios (MRRs) compared MRs between Asian American and Pacific Islander adults. Race on death certificates was recorded by funeral directors using an informant or observation.¹ The National Institutes of Health institutional review board waived approval and informed consent because the study used publicly available deidentified data. This study followed the STROBE guideline. Data were analyzed using SEER*stat. P < .05 was considered statistically significant.

Results

From 2018 to 2020, 63 338 Asian American women (population = 22 921 028), 85 601 Asian American men (population = 20 300 668), 4116 Pacific Islander women (population = 637 102), and 5512 Pacific Islander men (population = 644 119) died in the US. The all-cause MR among Pacific Islander women (MR, 723.6) was 2.51 (95% CI, 2.43-2.59) times that of Asian American women (MR, 288.7); the all-cause MR among Pacific Islander men (MR, 999.3) was 2.10 (95% CI, 2.04-2.16) times that of Asian American men (MR, 475.4) (Figure 1 and Figure 2). Leading causes of death for Asian American women were cancer, heart disease, stroke, COVID-19, and diabetes; MRs were higher among Pacific Islander than Asian American women (cancer: MRR, 1.94 [95% CI, 1.82-2.06]; heart disease: MRR, 3.18 [95% CI, 2.95-3.42]; stroke: MRR, 2.41 [95% CI, 2.13-2.73]; diabetes: MRR, 4.03 [95% CI, 3.55-4.56]; and COVID-19: MRR, 2.61 [95% CI, 2.25-3.01]). Leading causes of death for Asian American men were cancer, heart disease, COVID-19, stroke, and unintentional deaths; MRs were higher among Pacific Islander than Asian American men (heart disease: MRR, 2.56 [95% CI, 2.42-2.71]; cancer: MRR, 1.52 [95% CI, 1.42-1.62]; diabetes (MRR, 3.14 [95% CI, 2.81-3.50]; unintentional deaths: MRR, 2.60 [95% CI, 2.34-2.88]; and COVID-19 (MRR, 2.04 [95% CI, 1.82-2.27]).

Figure 1. Mortality Rates for 5 Leading Causes of Death Among Asian American and Pacific Islander Individuals.

Mortality rates per 100 000 person-years were calculated from 2018 to 2020 among female and male Asian American and Pacific Islander individuals, overall and by age at death, and rates were age adjusted to the 2000 US standard population. The y-axis range differed based on age group. Cause of death due to COVID-19 was assessed only in 2020. COPD indicates chronic obstructive pulmonary disease and other allied conditions.

Figure 2. Mortality Rate Ratios for Leading Causes of Death Among Pacific Islander Compared With Asian American Individuals.

Mortality rate ratios were calculated from 2018 to 2020 among Pacific Islander women and men compared with Asian American women and men, overall and by age at death, in the US. Cause of death due to COVID-19 was assessed only in 2020. Error bars indicate 95% CIs. Dotted horizontal lines indicate the reference group of Asian American women and men. COPD indicates chronic obstructive pulmonary disease and other allied conditions.

^aIndicates suppressed data due to small number of events (n < 10).

All-cause MR differences between Asian American and Pacific Islander adults were greatest among women aged 75 to 84 years (1522.4 per 100 000 person-years) and men aged 65 to 74 years (1355.5 per 100 000 person-years). Relative mortality differences were largest among those aged 20 to 44 and 45 to 54 years, especially for chronic obstructive pulmonary disease (COPD), COVID-19, diabetes, and heart disease among women (MRR range, 6.30-15.98) and COPD, COVID-19, diabetes, heart disease, and homicide among men (MRR range, 4.22-13.03).

Discussion

Diverging patterns of greater all-cause and cause-specific MRs were found for Pacific Islander compared with Asian American adults. Both Asian American and Pacific Islander populations experience racism, xenophobia, and structural barriers to health; however, our findings emphasize the importance of disaggregating these racial groups to characterize health outcomes. Without policy changes requiring disaggregation, the public health crisis among Pacific Islander populations would be masked.

Mortality disparities for heart disease, COPD, and diabetes are partly associated with higher prevalence of smoking,² obesity,² and alcohol consumption³ among Pacific Islander populations. Structural causes of mortality differences may be related to medical mistrust rooted in historical colonization of Indigenous lands⁴ and uninsurance rates among adults younger than 65 years that are 2 times higher among Pacific Islander adults.⁵ These could negatively affect access to preventive services, quality health care, and timely treatments.

Limitations of death certificate data include potential misclassification of the underlying cause of death and race and ethnicity due to racial bias⁶ and inability to self-report. Consistent disaggregation of Pacific Islander data from Asian American data will break the cycle of historic structural biases embedded in data aggregation and build capacity for tailored health equity–focused community interventions.

Supplement 1.

eMethods.

eReference.

Supplement 2.

Data Sharing Statement