Background: Patients with rheumatoid Arthritis (RA) may die prematurely of complications such as interstitial lung disease and cardiovascular disease. Nationwide population-based studies on premature mortality burden in RA are scarce.

Objectives: To analyze premature mortality burden in RA at the population level using the following measures: Years of Potential Life Lost (YPLL) rate, age-standardized mortality rate (ASMR), median age at death, and odds of premature death.

Methods: We used the Centers for Disease Control and Prevention’s WONDER database to obtain death counts for RA in the United States by age (≤44, 45-64 and ≥65 years), race/ethnicity [non-Hispanic (NH) American Indian or Alaska Native (American Indian), NH-Asian/Pacific Islander (Asian/Pacific Islander), NH-black or African American (Black), NH-white (White), and Hispanic or Latino (Hispanic)], and sex. We used these data to: 1) construct histograms depicting the number of RA deaths for each age by race/ethnicity and calculate the cumulative percent death at each age and the median age of death; 2) analyze the odds ratio (OR) of premature death (<65 years age) by Chi-square test; 3) calculate ASMR per 100,000 with 95% confidence interval (CI); 4) analyze trends in RA mortality over the 22-year period using Joinpoint regression trend analysis; 5) perform multiple regression analysis by race/ethnicity adjusting for age, and sex, and then include interactions in the model to identify any effect modification among these variables; and 6) compute YPLL-75 by adding the years of potential life lost (75–age at death) for each decedent, and then calculate the YPLL-rate as total YPLL/population*100,000.

Results: From 1999 through 2020, there were 147,338 female and 52,890 male RA decedents. The RA-ASMR was 2-fold higher in females (3.5, [95% CI, 3.4, 4.5]) than in males (1.72, [1.71, 1.74]), and higher at ≥65-years age (18.9, [18.8, 19.0]) than at 45-64 (1.45, [1.43, 1.46]) and ≤44-years (0.03, [0.02, 0.03]). The Asian/Pacific Islander group had the lowest RA-ASMR (1.26, [1.21, 1.3]), followed by Hispanic (2.15, [2.11, 2.19]), Black (2.25, [2.21, 2.29]), White (2.87, [2.86, 2.88]), and American Indian (5.1, [4.9, 5.4]). Premature mortality rates (<65 years age) significantly decreased from 1999-2018 in Black, Hispanic and White people at annual percent changes (APC) of -2.1 (-2.9, -1.3) to -4.2 (-9.7, -2.1), but American Indians never had a significant decrease in ASMR over the 22-year period (APC, -0.8; [-1.5, +0.1]). During the COVID-19 pandemic, RA mortality rates increased at an APC of 12.3 (0.9, 18.0) in White, 28.4 (7.6, 38.8) in Black, 29.1 (14.8, 37.1) in Hispanic and 33.2 (0.4, 66.3) in American Indians. Before the age of 45, the mortality rates were 11-fold higher in American Indians and 3-fold higher in Black people than in Asian/Pacific Islander, Hispanic, and White people. The odds ratio of premature death (<65-years age) was 3.6 (3.3, 4.0) for American Indian and >2 for Hispanic and Black people compared to White people (p<0.001). Consistently, the median age at death with RA was 9-10 years younger for American Indians, and 5-6 years younger for Hispanic and Black people than in Asian/Pacific Islander and White people. The adjusted odds of death <65 years of age by multiple logistic regression analysis was significantly lower in Asian/Pacific Islander, Hispanic and Black people but significantly higher in American Indian than in White people in both females and males. Finally, the YPLL-rate was the highest in American Indian (31.0), followed by White (13.4), Black (9.8), Hispanic (6.5), and Asian/Pacific Islanders (3.3). Among the contributing proximate causes of death at <65 years age, interstitial lung disease, diabetes mellitus, COVID-19, and alcoholic cirrhosis of liver were more common in American Indians than in White people, whereas chronic obstructive lung disease and cardiovascular diseases were more common in White than in American Indian people.

Conclusion: Premature mortality with RA, as measured by ASMR, median age at death, odds of premature death, and YPLL rate, differed by sex and race/ethnicity. By all measures, American Indians had the most profound increase in RA mortality at younger ages. RA mortality rates never significantly decreased in American Indians and increased the most in this group during the pandemic. Comprehensive, prospective investigations into socioenvironmental versus biological factors, income/poverty, health insurance, education, and access to care are needed to identify the highest risk individuals and to guide precision public health.

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Acknowledgements: NIL.

Disclosure of Interests: None declared.

© The Authors 2025. This abstract is an open access article published in Annals of Rheumatic Diseases under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ). Neither EULAR nor the publisher make any representation as to the accuracy of the content. The authors are solely responsible for the content in their abstract including accuracy of the facts, statements, results, conclusion, citing resources etc.