{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T13:44:16Z","timestamp":1785851056011,"version":"3.56.0"},"reference-count":50,"publisher":"Oxford University Press (OUP)","issue":"8","license":[{"start":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T00:00:00Z","timestamp":1782432000000},"content-version":"vor","delay-in-days":176,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","award":["R01-AG057801"],"award-info":[{"award-number":["R01-AG057801"]}],"id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","award":["R01-AG066133"],"award-info":[{"award-number":["R01-AG066133"]}],"id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","award":["R01-AG063971"],"award-info":[{"award-number":["R01-AG063971"]}],"id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,7,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background and Objectives<\/jats:title>\n                    <jats:p>The distribution of life expectancy at age 65 (LE65) in the United States is characterized by profound sex- and locality-related disparities. Quantifying the disease-specific drivers of these disparities prior to the coronavirus disease 2019 (COVID-19) pandemic provides a critical baseline for understanding subsequent health shocks.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Using CDC WONDER data (1999-2018) and Pollard\u2019s decomposition method, we analyzed cause-specific contributions to disparities in LE65, establishing a pre-pandemic baseline for trends in years of life lost (YLL) at age 65.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Sex-related disparities (YLLsex) narrowed, particularly in disadvantaged localities, driven by reductions in YLL from macrovascular diseases and lung cancer. Conversely, locality-related disparities (YLLloc) widened, especially for females, due to increasing YLL from Alzheimer\u2019s disease and the persistent impacts of diabetes, chronic lower respiratory diseases, and heart failure. This created a pre-existing landscape of vulnerability concentrated in low-LE states.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion and Implications<\/jats:title>\n                    <jats:p>The 2 decades before COVID-19 saw a critical divergence: progress in reducing sex-based gaps was offset by rapidly widening geographic disparities. The systemic failures that drove the increasing burden of chronic conditions in disadvantaged regions likely predetermined the populations most vulnerable to the pandemic\u2019s shock. Our findings highlight that building future resilience requires targeted investments to address these specific, pre-existing health challenges.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/geroni\/igag065","type":"journal-article","created":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T15:29:15Z","timestamp":1782487755000},"source":"Crossref","is-referenced-by-count":0,"title":["Disease-specific drivers of sex- and locality-related disparities in life expectancy at age 65: two decades of progress before COVID-19"],"prefix":"10.1093","volume":"10","author":[{"given":"Galina","family":"Gorbunova","sequence":"first","affiliation":[{"name":"Social Science Research Institute, Duke University , Durham, North Carolina,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1185-148X","authenticated-orcid":false,"given":"Arseniy P","family":"Yashkin","sequence":"additional","affiliation":[{"name":"Social Science Research Institute, Duke University , Durham, North Carolina,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julia","family":"Kravchenko","sequence":"additional","affiliation":[{"name":"Department of Surgery, Duke University School of Medicine , Durham, North Carolina,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Svetlana","family":"Ukraintseva","sequence":"additional","affiliation":[{"name":"Social Science Research Institute, Duke University , Durham, North Carolina,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric","family":"Stallard","sequence":"additional","affiliation":[{"name":"Social Science Research Institute, Duke University , Durham, North Carolina,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anatoliy","family":"Yashin","sequence":"additional","affiliation":[{"name":"Social Science Research Institute, Duke University , Durham, North Carolina,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Igor","family":"Akushevich","sequence":"additional","affiliation":[{"name":"Social Science Research Institute, Duke University , Durham, North Carolina,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,6,26]]},"reference":[{"key":"2026080408522615400_igag065-B1","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1016\/j.amepre.2005.07.031","article-title":"Eight Americas: new perspectives on US health disparities","volume":"29","author":"Murray","year":"2005","journal-title":"Am J Prev Med."},{"key":"2026080408522615400_igag065-B2","doi-asserted-by":"publisher","first-page":"e260","DOI":"10.1371\/journal.pmed.0030260","article-title":"Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States","volume":"3","author":"Murray","year":"2006","journal-title":"PLoS Med."},{"key":"2026080408522615400_igag065-B3","doi-asserted-by":"publisher","first-page":"565","DOI":"10.1016\/S0140-6736(20)31561-0","article-title":"Sex and gender: modifiers of health, disease, and medicine","volume":"396","author":"Mauvais-Jarvis","year":"2020","journal-title":"Lancet."},{"key":"2026080408522615400_igag065-B4","doi-asserted-by":"publisher","first-page":"1996","DOI":"10.1001\/jama.2019.16932","article-title":"Life expectancy and mortality rates in the United States, 1959-2017","volume":"322","author":"Woolf","year":"2019","journal-title":"JAMA."},{"key":"2026080408522615400_igag065-B5","doi-asserted-by":"publisher","first-page":"e196386","DOI":"10.1001\/jamanetworkopen.2019.6386","article-title":"Trends in health equity in the United States by race\/ethnicity, sex, and income, 1993-2017","volume":"2","author":"Zimmerman","year":"2019","journal-title":"JAMA Netw Open."},{"key":"2026080408522615400_igag065-B6","doi-asserted-by":"publisher","first-page":"1750","DOI":"10.1001\/jama.2016.4226","article-title":"The association between income and life expectancy in the United States, 2001-2014","volume":"315","author":"Chetty","year":"2016","journal-title":"JAMA"},{"key":"2026080408522615400_igag065-B7","doi-asserted-by":"publisher","first-page":"444","DOI":"10.15585\/mmwr.mm6617e1","article-title":"Vital signs: racial disparities in age-specific mortality among Blacks or African Americans\u2014United States, 1999-2015","volume":"66","author":"Cunningham","year":"2017","journal-title":"MMWR Morb Mortal Wkly Rep."},{"key":"2026080408522615400_igag065-B8","doi-asserted-by":"publisher","first-page":"135","DOI":"10.1373\/clinchem.2018.288332","article-title":"Differences between men and women in mortality and the health dimensions of the morbidity process","volume":"65","author":"Crimmins","year":"2019","journal-title":"Clin Chem."},{"key":"2026080408522615400_igag065-B9","doi-asserted-by":"publisher","first-page":"15078","DOI":"10.1073\/pnas.1518393112","article-title":"Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century","volume":"112","author":"Case","year":"2015","journal-title":"Proc Natl Acad Sci USA."},{"key":"2026080408522615400_igag065-B10","author":"Social Security Administration","year":"2022"},{"key":"2026080408522615400_igag065-B11","doi-asserted-by":"publisher","first-page":"1003","DOI":"10.1001\/jamainternmed.2017.0918","article-title":"Inequalities in life expectancy among US counties, 1980 to 2014: temporal trends and key drivers","volume":"177","author":"Dwyer-Lindgren","year":"2017","journal-title":"JAMA Intern Med."},{"key":"2026080408522615400_igag065-B12","doi-asserted-by":"publisher","first-page":"771","DOI":"10.1001\/jama.2013.91","article-title":"The US health disadvantage relative to other high-income countries: findings from a National Research Council\/Institute of Medicine report","volume":"309","author":"Woolf","year":"2013","journal-title":"JAMA."},{"key":"2026080408522615400_igag065-B13","doi-asserted-by":"publisher","first-page":"1297","DOI":"10.1016\/S0140-6736(11)60781-2","article-title":"Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies","volume":"378","author":"Huxley","year":"2011","journal-title":"Lancet."},{"key":"2026080408522615400_igag065-B14","doi-asserted-by":"publisher","first-page":"2707","DOI":"10.1002\/alz.12662","article-title":"Consideration of sex and gender in Alzheimer\u2019s disease and related disorders from a global perspective","volume":"18","author":"Mielke","year":"2022","journal-title":"Alzheimers Dement."},{"key":"2026080408522615400_igag065-B15","doi-asserted-by":"publisher","first-page":"101459","DOI":"10.1016\/j.arr.2021.101459","article-title":"Female specific risk factors for the development of Alzheimer\u2019s disease neuropathology and cognitive impairment: call for a precision medicine approach","volume":"71","author":"Udeh-Momoh","year":"2021","journal-title":"Ageing Res Rev."},{"key":"2026080408522615400_igag065-B16","doi-asserted-by":"publisher","first-page":"1136","DOI":"10.1001\/jama.2017.11747","article-title":"Trends and patterns of differences in chronic respiratory disease mortality among US counties, 1980-2014","volume":"318","author":"Dwyer-Lindgren","year":"2017","journal-title":"JAMA."},{"key":"2026080408522615400_igag065-B17","doi-asserted-by":"publisher","first-page":"470","DOI":"10.1093\/pubmed\/fdu059","article-title":"Differences in healthy life expectancy for the US population by sex, race\/ethnicity and geographic region: 2008","volume":"37","author":"Chang","year":"2015","journal-title":"J Public Health (Oxf)"},{"key":"2026080408522615400_igag065-B18","doi-asserted-by":"publisher","first-page":"624","DOI":"10.1111\/jrh.12465","article-title":"Decomposing urban and rural disparities of preventable ED visits among patients with Alzheimer\u2019s disease and related dementias: evidence of the availability of health care resources","volume":"37","author":"Wang","year":"2021","journal-title":"J Rural Health."},{"key":"2026080408522615400_igag065-B19","doi-asserted-by":"publisher","first-page":"e19","DOI":"10.1016\/j.amepre.2013.10.017","article-title":"Widening rural-urban disparities in life expectancy, US, 1969-2009","volume":"46","author":"Singh","year":"2014","journal-title":"Am J Prev Med."},{"key":"2026080408522615400_igag065-B20","doi-asserted-by":"publisher","first-page":"351","DOI":"10.1215\/00703370-10609710","article-title":"Understanding geographic disparities in mortality","volume":"60","author":"Fletcher","year":"2022","journal-title":"Demography"},{"key":"2026080408522615400_igag065-B21","doi-asserted-by":"publisher","first-page":"851","DOI":"10.3233\/JAD-200491","article-title":"Geographic disparities in county-level prevalence of Alzheimer\u2019s disease across the United States","volume":"4","author":"Fowler","year":"2020","journal-title":"Innov Aging"},{"key":"2026080408522615400_igag065-B22","volume-title":"International Differences in Mortality at Older Ages: Dimensions and Sources","author":"Crimmins","year":"2010"},{"key":"2026080408522615400_igag065-B23","doi-asserted-by":"publisher","first-page":"553","DOI":"10.1146\/annurev-soc-070308-115929","article-title":"Social class differentials in health and mortality: patterns and explanations in comparative perspective","volume":"35","author":"Elo","year":"2009","journal-title":"Annu Rev Sociol"},{"key":"2026080408522615400_igag065-B24","doi-asserted-by":"publisher","first-page":"e2114520","DOI":"10.1001\/jamanetworkopen.2021.14520","article-title":"Association of the COVID-19 pandemic with estimated life expectancy by race\/ethnicity in the United States, 2020","volume":"4","author":"Andrasfay","year":"2021","journal-title":"JAMA Netw Open."},{"key":"2026080408522615400_igag065-B25","doi-asserted-by":"publisher","first-page":"101012","DOI":"10.1016\/j.ssmph.2021.101012","article-title":"The unequal burden of the COVID-19 pandemic: capturing racial\/ethnic disparities in US cause-specific mortality","volume":"17","author":"Luck","year":"2022","journal-title":"SSM Popul Health."},{"key":"2026080408522615400_igag065-B26","doi-asserted-by":"publisher","first-page":"418","DOI":"10.1093\/ije\/dyab267","article-title":"County-level socio-economic disparities in COVID-19 mortality in the USA","volume":"51","author":"Dukhovnov","year":"2022","journal-title":"Int J Epidemiol."},{"key":"2026080408522615400_igag065-B27","author":"Centers for Disease Control and Prevention, National Center for Health Statistics","year":"2022"},{"key":"2026080408522615400_igag065-B28","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.tpb.2023.05.001","article-title":"Decomposition of disparities in life expectancy with applications to administrative health claims and registry data","volume":"152","author":"Akushevich","year":"2023","journal-title":"Theor Popul Biol."},{"key":"2026080408522615400_igag065-B29","doi-asserted-by":"publisher","first-page":"2192","DOI":"10.1001\/jama.2020.7197","article-title":"Variation in COVID-19 hospitalizations and deaths across New York City boroughs","volume":"323","author":"Wadhera","year":"2020","journal-title":"JAMA."},{"key":"2026080408522615400_igag065-B30","doi-asserted-by":"publisher","first-page":"e620","DOI":"10.1016\/j.wneu.2024.02.094","article-title":"Trends in demographic and geographic disparities in stroke mortality among older adults in the United States","volume":"185","author":"McCandless","year":"2024","journal-title":"World Neurosurg."},{"key":"2026080408522615400_igag065-B31","doi-asserted-by":"publisher","first-page":"A4134768","DOI":"10.1161\/circ.150.suppl_1.4134768","article-title":"Geographic, gender, and racial trends in mortality due to heart failure in coronary artery disease among adults aged 65 and older in the United States, 1999-2020: a CDC WONDER database analysis","volume":"150","author":"Naveed","year":"2024","journal-title":"Circulation"},{"key":"2026080408522615400_igag065-B32","doi-asserted-by":"publisher","first-page":"2542","DOI":"10.1001\/jama.2018.19232","article-title":"Association of the hospital readmissions reduction program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia","volume":"320","author":"Wadhera","year":"2018","journal-title":"JAMA."},{"key":"2026080408522615400_igag065-B33","doi-asserted-by":"publisher","first-page":"417","DOI":"10.1016\/j.hfc.2017.02.001","article-title":"Epidemiology, pathophysiology, and prognosis of heart failure in older adults","volume":"13","author":"Dharmarajan","year":"2017","journal-title":"Heart Fail Clin."},{"key":"2026080408522615400_igag065-B34","doi-asserted-by":"publisher","first-page":"1280","DOI":"10.1001\/jamacardio.2019.4187","article-title":"Association between aging of the US population and heart disease mortality from 2011 to 2017","volume":"4","author":"Sidney","year":"2019","journal-title":"JAMA Cardiol."},{"key":"2026080408522615400_igag065-B35","doi-asserted-by":"publisher","first-page":"780","DOI":"10.1001\/jama.2019.9161","article-title":"Trends in cardiometabolic mortality in the United States, 1999-2017","volume":"322","author":"Shah","year":"2019","journal-title":"JAMA."},{"key":"2026080408522615400_igag065-B36","doi-asserted-by":"publisher","first-page":"e60308","DOI":"10.1371\/journal.pone.0060308","article-title":"Prevalence, awareness, treatment, and control of hypertension in United States counties, 2001-2009","volume":"8","author":"Olives","year":"2013","journal-title":"PLoS One"},{"key":"2026080408522615400_igag065-B37","doi-asserted-by":"publisher","first-page":"32","DOI":"10.1007\/s10980-024-02039-z","article-title":"Heterogeneous impacts of and vulnerabilities to the COVID-19 pandemic","volume":"40","author":"Li","year":"2025","journal-title":"Landsc Ecol"},{"key":"2026080408522615400_igag065-B38","doi-asserted-by":"publisher","first-page":"e70093","DOI":"10.1111\/jch.70093","article-title":"Hypertension prevalence, awareness, and control in US adults before and after the COVID-19 pandemic","volume":"27","author":"Essa","year":"2025","journal-title":"J Clin Hypertens"},{"key":"2026080408522615400_igag065-B39","doi-asserted-by":"publisher","first-page":"631","DOI":"10.1353\/dem.2006.0037","article-title":"Sex mortality differences in the United States: the role of cohort smoking patterns","volume":"43","author":"Preston","year":"2006","journal-title":"Demography."},{"key":"2026080408522615400_igag065-B40","doi-asserted-by":"publisher","first-page":"684","DOI":"10.7326\/M18-1250","article-title":"Smoking and lung cancer mortality in the United States from 2015 to 2065: a comparative modeling approach","volume":"169","author":"Jeon","year":"2018","journal-title":"Ann Intern Med."},{"key":"2026080408522615400_igag065-B41","doi-asserted-by":"publisher","first-page":"351","DOI":"10.1056\/NEJMsa1211127","article-title":"50-year trends in smoking-related mortality in the United States","volume":"368","author":"Thun","year":"2013","journal-title":"N Engl J Med."},{"key":"2026080408522615400_igag065-B42","doi-asserted-by":"publisher","first-page":"17","DOI":"10.3322\/caac.21763","article-title":"Cancer statistics, 2023","volume":"73","author":"Siegel","year":"2023","journal-title":"CA Cancer J Clin."},{"key":"2026080408522615400_igag065-B43","doi-asserted-by":"publisher","first-page":"327","DOI":"10.1001\/jamaoncol.2019.5358","article-title":"The future of cancer care in the United States\u2014overcoming workforce capacity limitations","volume":"6","author":"Shulman","year":"2020","journal-title":"JAMA Oncol."},{"key":"2026080408522615400_igag065-B44","doi-asserted-by":"publisher","first-page":"149","DOI":"10.1038\/pcan.2015.3","article-title":"Nationally representative trends and geographic variation in treatment of localized prostate cancer: the Urologic Diseases in America project","volume":"18","author":"Cary","year":"2015","journal-title":"Prostate Cancer Prostatic Dis."},{"key":"2026080408522615400_igag065-B45","doi-asserted-by":"publisher","first-page":"258","DOI":"10.1186\/s12885-018-4166-3","article-title":"Temporal and geographic variation in the systemic treatment of advanced prostate cancer","volume":"18","author":"Caram","year":"2018","journal-title":"BMC Cancer."},{"key":"2026080408522615400_igag065-B46","doi-asserted-by":"publisher","first-page":"205","DOI":"10.15585\/mmwr.mm6707a1","article-title":"Urban-rural county and state differences in chronic obstructive pulmonary disease\u2014United States, 2015","volume":"67","author":"Croft","year":"2018","journal-title":"MMWR Morb Mortal Wkly Rep"},{"key":"2026080408522615400_igag065-B47","first-page":"650","article-title":"Prevalence and factors associated with self-reported chronic obstructive pulmonary disease among adults aged 40-79: the National Health and Nutrition Examination Survey (NHANES) 2007-2012","volume":"7","author":"Tilert","year":"2018","journal-title":"EC Pulmonol Respir Med"},{"key":"2026080408522615400_igag065-B48","doi-asserted-by":"publisher","first-page":"1145","DOI":"10.2147\/COPD.S54476","article-title":"Influence of sex on chronic obstructive pulmonary disease risk and treatment outcomes","volume":"9","author":"Aryal","year":"2014","journal-title":"Int J Chron Obstruct Pulmon Dis"},{"key":"2026080408522615400_igag065-B49","doi-asserted-by":"publisher","first-page":"346","DOI":"10.1111\/jgs.16262","article-title":"Temporal and geographic variation in the incidence of Alzheimer\u2019s disease diagnosis in the US between 2007 and 2014","volume":"68","author":"Kirson","year":"2020","journal-title":"J Am Geriatr Soc."},{"key":"2026080408522615400_igag065-B50","doi-asserted-by":"publisher","first-page":"64","DOI":"10.1080\/10920277.2002.11073999","article-title":"Underlying and multiple cause mortality at advanced ages: United States 1980-1998","volume":"6","author":"Stallard","year":"2002","journal-title":"N Am Actuar J."}],"container-title":["Innovation in Aging"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/innovateage\/advance-article-pdf\/doi\/10.1093\/geroni\/igag065\/68627951\/igag065.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/innovateage\/article-pdf\/10\/8\/igag065\/68627951\/igag065.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/innovateage\/article-pdf\/10\/8\/igag065\/68627951\/igag065.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T12:52:33Z","timestamp":1785847953000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/innovateage\/article\/doi\/10.1093\/geroni\/igag065\/8719032"}},"subtitle":[],"editor":[{"given":"Monique Janiel","family":"Brown","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026]]},"references-count":50,"journal-issue":{"issue":"8","published-print":{"date-parts":[[2026,7,2]]}},"URL":"https:\/\/doi.org\/10.1093\/geroni\/igag065","relation":{},"ISSN":["2399-5300"],"issn-type":[{"value":"2399-5300","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026]]},"published":{"date-parts":[[2026]]},"article-number":"igag065"}}