National trends in deaths with documented pressure injuries in the United States from 1999 to 2021

This study examined long-term trends in the documentation of pressure injuries (PIs) on death certificates in the United States from 1999 to 2021. We evaluated demographic, geographic, and clinical patterns associated with PI documentation and explored whether state-level healthcare expenditure and nursing unionization were linked to observed trends. Using CDC WONDER multiple cause-of-death data, we calculated age-adjusted mortality rates (AAMRs) and annual percent changes (APCs) for deaths in which PIs were listed as an underlying or contributing cause. Trends were assessed across demographic and geographic subgroups. Exploratory ecologic analyses examined correlations between state-level healthcare expenditure, nursing unionization measures, and PI-related AAMRs. A total of 216,717 deaths listed PIs among the causes of death during the study period. Overall AAMRs declined from 5.20 per 100,000 in 1999 to 3.12 in 2021, with a marked increase between 2019 and 2021 (APC: 15.14%). Higher AAMRs were observed among non-Hispanic Black individuals, residents of southern states, and decedents with cardiovascular, neurodegenerative, or cerebrovascular comorbidities. No significant associations were found between PI-related AAMRs and state-level healthcare expenditure or nursing unionization. National patterns of PI documentation on death certificates reveal persistent demographic and regional disparities. As PIs are rarely an underlying cause of death, these trends likely reflect broader patterns of frailty, comorbidity, and care complexity. Cautious interpretation is warranted, and future studies incorporating patient-level clinical data are needed to clarify mechanisms and guide prevention strategies. What is the primary question addressed by this study? What are the long-term trends in the documentation of pressure injuries on death certificates in the United States from 1999 to 2021, and how do these patterns vary by demographic, geographic, and clinical characteristics? What is the main finding of this study? The age-adjusted rate of deaths with documented pressure injuries declined from 1999 through 2018 but increased sharply between 2019 and 2021. Higher rates of pressure injury documentation were observed among non-Hispanic Black individuals, residents of southern states, and decedents with cardiovascular or neurodegenerative comorbidities, while no meaningful associations were identified with state-level healthcare expenditure or nursing unionization measures. What is the meaning of the finding? These findings suggest that pressure injury documentation on death certificates reflects underlying vulnerability, frailty, and disparities in care rather than direct causes of death, highlighting the need for equity-focused prevention strategies and improved care for high-risk populations. How did the COVID-19 pandemic coincide with changes in the documentation of pressure injuries on U.S. death certificates, and what lessons can be drawn to improve prevention and continuity of care during future healthcare system disruptions? How do regional differences in healthcare access, resources, and care delivery patterns correspond to variation in pressure injury documentation at death, and what system-level strategies may help reduce these geographic disparities? How are comorbid conditions such as cardiovascular disease and Alzheimer’s disease associated with the presence of pressure injuries among decedents, and how might preventive approaches be tailored for populations with high levels of medical frailty? How might nursing workforce characteristics, including staffing levels and training environments, influence pressure injury prevention practices, as reflected in mortality documentation trends? How can public health policies and community-based interventions address social and structural determinants that are associated with higher rates of pressure injury documentation among underserved populations?