Diverging mortality pathways for chronic wounds: A 26-year analysis of United States national data, 1999-2024

Pressure ulcers (PUs) and chronic non-healing wounds (NHWs) are common, costly, and often fatal conditions among older adults living with multiple illnesses. Although the two arise through distinct biological pathways, they are frequently reported together in a way that can obscure how each is actually trending. We separated the two conditions and examined their mortality trajectories across 26 years of United States national data.

Using the CDC WONDER database, we retrospectively analyzed death records from 1999 through 2024. Pressure ulcers were identified by ICD-10 code L89; non-healing wounds by codes L97 or L98.4. Each condition was treated as an independent primary outcome rather than being merged into a single indicator. Age-adjusted mortality rates (AAMRs) and crude mortality rates (CMRs) per 100,000 population were computed against the 2000 U.S. standard population, and Joinpoint regression applying a grid search across zero to three joinpoints with permutation-based model selection was used to characterize temporal trends. Subgroup rates by demographic and geographic strata are reported for the combined wound-associated decedent population as a whole, since suppression of small cell counts precludes stable code-specific estimation within narrower strata.

Pressure ulcers appeared on 255,054 death certificates (AAMR 2.8 per 100,000; 95% CI 2.7-2.9), while non-healing wounds appeared on 69,230 (AAMR 0.7; 95% CI 0.7-0.7); only 5834 decedents (1.8%) carried codes for both. Annual PU deaths increased 1.3-fold, from 9154 in 1999 to 12,016 in 2024, peaking at 13,411 in 2022; NHW deaths rose 2.6-fold over the same span, from 1792 to 4703. As a proportion of all wound-associated deaths, the NHW share climbed from 16.5% to 28.6%. NHW mortality has climbed steadily since 2012, with the AAMR moving from 0.6 to 1.1 per 100,000 (APC 5.64; p < 0.000001). For the combined wound-associated cohort, the AAMR declined from 4.0 in 1999 to 3.1 in 2018 (APC -1.22; 95% CI -1.94 to -0.31; p = 0.042), climbed to 4.2 by 2022, and eased slightly to 3.9 by 2024, though neither of the latter two shifts reached statistical significance (p = 0.151 and p = 0.237, respectively). Mortality rose sharply with age, reaching a crude rate of 82.5 per 100,000 among those 85 and older. AAMRs were comparable between men (3.4; 95% CI 3.4-3.5) and women (3.5; 95% CI 3.4-3.6); early-period declines reached significance in women (APC -1.20, p = 0.024) but not men (APC -1.02, p = 0.051). The highest rates were observed among Black or African American (9.8; 95% CI 9.4-10.2) and American Indian or Alaska Native (5.6; 95% CI 4.4-6.8) populations, while the Asian or Pacific Islander rate was lowest and declined significantly across the full period (1.6; 95% CI 1.3-1.8; APC -0.94, p = 0.022). Rates were highest in the South (4.2; 95% CI 4.1-4.3), which rose significantly after 2016 (APC 4.25, p = 0.0008), and in non-metropolitan counties (3.7; 95% CI 3.5-3.8), which overtook metropolitan rates (3.5; 95% CI 3.4-3.5) after 2008.

Pressure ulcer and non-healing wound mortality followed opposite 26-year trajectories, arguing against a single pooled measure. The rising non-healing wound share and persistent racial, regional, and urban-rural disparities support condition-specific prevention and broader access to wound care. These descriptive findings should be interpreted as associations, not causal effects.