Causes of death across different locations in the United States, 2015 to 2022

Abstract

Objective

The objective of this study was to investigate the leading underlying causes of death across different locations in the USA from 2015 to 2022.

Methods

Data on the leading underlying causes of death in each location of death—including medical outpatient facility or emergency room, medical inpatient facility, medical facility/dead on arrival, decedent’s home, hospice facility, and nursing home/long-term care—within the USA in individuals ≥18 years were extracted from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database.

Results

There were 22,236,700 deaths in our studied locations during the study period. Most deaths were in the decedents’ homes (34.5%), followed by inpatient medical facilities (31.8%). Malignant neoplasms were the leading cause of death in hospice facilities (32.8%–40.0%) and decedents’ homes (25.9%–31.5%), followed by heart disease. Heart disease was the most common cause of death in nursing homes/long-term care facilities (20.0%–23.6%), outpatient or emergency medical facilities (36.5%–44.7%), those dead on arrival at medical facilities (35.4%–40.3%), and inpatient medical facilities (14.3%–20.4%), with COVID-19 becoming the top cause of death in 2020 and 2021 in inpatient medical facilities.

Conclusion

Overall, heart disease and malignant neoplasm were among the top three causes of death in all studied locations in our study period.

Medical advances have led to longer life spans, albeit at the price of increasing disability and debility near the end of life. This has been accompanied by growing options for the level of care for patients in their final months, ranging from prioritizing comfort and symptom management in the patient’s own home to using complex or invasive options to keep the patient alive in the intensive care unit.

Statistics from 2000 to 2018 show a decrease in the percentage of deaths that occurred in hospitals, from 48.0% to 35.1%.¹ This was accompanied by a simultaneous increase in deaths in care facilities (hospice, nursing home, long-term care) from 22.9% to 26.8%.¹ Decedent home deaths also increased from 22.7% to 31.4%.^1,2 Heart disease and cancer have remained the leading causes of death in the USA for many years and resulted in approximately 40% of the deaths in the USA in 2022, followed by accidents (unintentional injuries), COVID-19, cerebrovascular disease, and chronic lower respiratory disease.^3,4 However, what the most common causes of death are in different locations remains unclear. We sought to investigate the causes of death across different locations in the USA.

Methods

Deaths occurring within the USA in individuals 18 years or above were extracted from the multiple cause of death files using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) from 2015 to 2022.^5,6 The World Health Organization defines the underlying cause of death as “the disease or injury that initiated the train of morbid events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury.”⁷ According to CDC WONDER:

The Multiple Cause of Death data set contains mortality and population counts for all U.S. counties. Data are based on death certificates for U.S. residents. Each death certificate contains a single underlying cause of death, up to twenty additional multiple causes, and demographic data. The number of deaths, crude death rates, age-adjusted death rates and 95% confidence intervals for death rates can be obtained by cause of death (4 digit ICD-10 codes, 113 selected causes of death, 130 selected causes of infant death, drug and alcohol related causes of death, injury intent and injury mechanism categories), place of residence (national, region, division, state, and county), age (single year of age, 5-year age groups, 10-year age groups and infant age groups), race (American Indian or Alaskan Native, Asian/Pacific Islander, Black or African American, White), Hispanic ethnicity, gender and year. Data are also available by urbanization categories for county of residence, place of death, month and week day of death, and whether an autopsy was performed. Maps and charts are also available. The data are updated annually.⁸

We excluded cases where the place of death was noted as “other or unknown.” We extracted the top underlying leading causes of death in each location of death, including outpatient medical facility or emergency room (ER), inpatient medical facility, medical facility/dead on arrival, decedent’s home, hospice facility, and nursing home/long-term care. We reported the percentage of deaths of each cause: the number of deaths due to the cause at a location divided by the total number of deaths at a particular location.

Results

The sum of deaths in decedents’ homes, hospice facilities, nursing homes/long-term care, inpatient medical facilities, outpatient or ER medical facilities, and medical facilities where patients were dead on arrival in our study period of 2015 to 2022 was 22,236,700. The location with the highest number of deaths in our data set was decedents’ homes (7,682,126 deaths, 34.5%), followed by inpatient medical facilities (7,069,312 deaths, 31.8%) (Figures 1 and 2).

Figure 1.

Percentage of deaths by location in the USA from 2015 to 2022.

Figure 2.

Percentage of deaths in US regions in 2022 by location: (a) Northeast, (b) Midwest, (c) West, and (d) South.

The total number of deaths at decedents’ homes between 2015 and 2022 was 7,682,126. Malignant neoplasm was the leading cause of death, followed by heart disease, chronic lower respiratory disease, accidents (unintentional injuries), diabetes mellitus, and Alzheimer’s disease (Figure 3a). Among deaths occurring at home, malignant neoplasm was the cause of death in 31.5% in 2015 and 25.9% in 2022. On the other hand, deaths at home from heart disease remained around approximately 25.0% across different years and varied between 24.6% and 25.7%.

Figure 3.

Trends in leading underlying causes of death from 2015 to 2022 in the United States in (a) decedent’s home, (b) hospice facility, (c) nursing home/long-term care, (d) inpatient medical facility, (e) outpatient medical facility or emergency room, and (f) medical facility—dead on arrival.

The total number of deaths at hospice facilities between 2015 and 2022 was 1,705,114. Malignant neoplasm was the leading cause of death, followed by heart disease, cerebrovascular disease, chronic lower respiratory tract disease, and Alzheimer’s disease (Figure 3b). COVID-19 was the fifth and fourth most common cause of death in this location in 2020 and 2021, respectively. The percentage of deaths from malignant neoplasm was 40.0% in 2015 and 2016 and 33.4% in 2022. The percentage of deaths from heart disease remained around approximately 14.0% and varied between 13.7% and 14.6%. The percentage of deaths from cerebrovascular disease was 7.7% in 2015 and 8.8% in 2022.

The total number of deaths in nursing homes/long-term care was 4,261,902. Heart disease was the leading cause of death, followed by malignant neoplasm, Alzheimer’s disease, cerebrovascular disease, and chronic lower respiratory tract disease (Figure 3c). COVID-19 was the second and fifth most common cause of death in this location in 2020 and 2021, respectively.

The total number of deaths in inpatient medical facilities was 7,069,312. Excluding COVID-19, the most common cause of death was heart disease, followed closely by malignant neoplasm (Figure 3d). Cerebrovascular disease, chronic lower respiratory tract disease, and accidents (unintentional injuries) were other common causes of death, in that order. COVID-19 was the most common cause of death in this location in 2020 and 2021, resulting in 23.2% and 28.1% of deaths, respectively. COVID-19 was the third most common cause of death in 2022.

The total number of deaths in outpatient or ER medical facilities was 1,439,526. The most common cause of death was heart disease, followed by accidents (unintentional injuries), malignant neoplasm, diabetes mellitus, chronic lower respiratory tract diseases, and COVID-19 (Figure 3e). COVID-19 was the fifth, third, and fifth most common cause in 2020, 2021, and 2022, respectively. The percentage of deaths from heart disease was 44.7% in 2015 and 37.5% in 2022.

The total number of deaths for patients dead on arrival at medical facilities was 78,720. The most common cause of death was heart disease, followed by accidents (unintentional injuries), diabetes mellitus, malignant neoplasm, and assault (homicide) (Figure 3f).

For those with heart disease and malignant neoplasm listed as the underlying cause of death, the decedents’ homes remained the most common location of death, followed by inpatient medical facilities, throughout the study period (Figures 4a and 4b). For those with malignant neoplasm listed as the underlying cause of death, 11.89% to 14.85% of deaths occurred in hospice facilities, compared to 4.27% to 5.25% in those with heart disease during the study period. For those with heart disease and malignant neoplasm listed as the underlying cause of death, there was an increase in the percentage of deaths in decedents’ homes from 2019 to 2020, coinciding with a decrease in the percentage of deaths in inpatient medical facilities, nursing home/long-term care, and hospice facilities.

Figure 4.

Trends stratified by location in the USA from 2015 to 2022 for different underlying causes of death: (a) diseases of the heart, (b) malignant neoplasm, and (c) COVID-19.

The top five causes of death by location in the USA stratified by age group, sex, metropolitan status, and US regions are also presented. The number and percentage of death by location and year are shown in Figure 5 and Supplemental Tables 1 to 5.

Figure 5.

Trends in the proportions of death by location in the USA from 2015 to 2022.

Discussion

This study reveals key trends and shifts in causes of mortality across different locations, also highlighting the profound impact of the COVID-19 pandemic. Heart disease and malignant neoplasm were among the top three causes of death in all studied locations in our study period, with heart disease leading except for in decedents’ homes and hospice facilities.

In recent years, home has become the most common location of death in the USA.^9,10 There has been a decrease in the proportion of deaths in hospitals and nursing facilities and an increase in the proportion of deaths in homes and hospice facilities.⁹ Furthermore, patients of racial and ethnic minority, female patients, and younger patients had lower odds of death at home than older patients, White patients, and male patients.

Within the USA, cardiovascular disease mortality in homes increased from 21.3% in 2003 to 30.9% in 2017, with a concomitant decline in the proportion of cardiovascular disease deaths in hospitals (36.5% in 2003 to 27.3% in 2017) and nursing facilities (25.1% in 2003 to 20.6% in 2017).¹¹ Furthermore, differences in mortality location were observed according to subcategories of cardiovascular disease, with stroke patients the least likely to die at home. Underserved racial and ethnic groups were also found to be less likely to die at home.

In an investigation of cardiovascular mortality related to heart failure in comparison to cancer deaths in the USA from 2003 to 2017, it was found that the proportions of heart failure deaths increased from 0.2% to 8.2 (P < 0.001) in hospice facilities, increased from 20.6% to 30.7% (P < 0.001) at home, and decreased from 44.5% to 31.0% (P < 0.001) in medical facilities.¹² During the study period, the proportion of cancer deaths also increased from 0.6% to 14.2% (P < 0.001) in hospice facilities and increased from 38.9% to 42.7% (P < 0.001) in homes but decreased from 36.7% to 26.4% (P < 0.001) in medical facilities.¹¹ The proportion of deaths in hospice facilities increased at a faster rate for cancer deaths than for heart failure deaths. On the other hand, the proportion of deaths at home increased at a faster rate for heart failure than for cancer deaths.

Our results show that in both hospice facilities and decedents’ homes, malignant neoplasm dominated as the cause of death. This was especially true for hospice facilities, where approximately triple the number of deaths occurred due to malignant neoplasm than heart disease, the second most common cause. This may be due to the predictable time frame for the patient’s death after a diagnosis of a malignant neoplasm.

Heart disease remains the most common cause of death in hospitals and nursing homes/long-term care facilities, according to our results. One reason may be the rapid deterioration that is often seen in patients after an acute heart event such as a myocardial infarction, heart failure, or cardiac arrest, resulting in the requirement for hospital and intensive care unit care.

An analysis of locations of death in the USA before and after the COVID-19 pandemic from 2010 to 2023 demonstrated increases in in-hospital mortality and non-COVID-19 home mortality as well as decreases in non-COVID-19 mortality in nursing facilities and non-COVID-19 mortality in hospice facilities at the beginning of the pandemic. In March 2023, non-COVID-19 home death rates remained significantly elevated compared with prepandemic trends, whereas non-COVID-19 mortality rates in nursing homes and hospice facilities remained significantly decreased.¹³

According to our data, the impact of COVID-19 mortality was greatest at inpatient medical facilities, where in 2020 and 2021, COVID-19 was the most common cause of death. In fact, inpatient medical facilities were the only location where COVID-19 was the most common cause of death in any year. The burden of COVID-19 is further highlighted by the large separation between deaths caused by COVID-19 and other etiologies, particularly in 2020 and 2021 when COVID-19 mortality was at its peak. At inpatient medical facilities in 2021, COVID-19 led to 28.1% of deaths, and heart disease, the second most common cause of death at inpatient medical facilities in 2021, led to 14.3% of deaths. Nursing homes/long-term care also had a substantial burden of COVID-19, because it was the second and fifth most common cause of death in these locations in 2020 and 2021, respectively.

Outpatient or ER medical facilities and medical facilities where patients were dead on arrival were the only two locations studied where malignant neoplasm was not among the top two causes of death. In these locations, heart disease remained the most common cause of death. However, accidents (unintentional injuries) were the second most common cause of death. In both of these locations, heart disease and accidents (unintentional injuries) constituted over 50% of all deaths.

Many factors potentially impact the location of death for patients. In France, people with higher levels of education and self-employment were more likely to die at home.¹⁴ It was also shown that the chances an individual was able to die at their preferred place were related to their socioeconomic position.¹⁴ In another study of patients with cancer, factors associated with an increased likelihood of home death included low functional status, preferences, home care, and extended family support.¹⁵ Furthermore, among patients receiving palliative care, physician home visits have been shown to increase the likelihood of a home death, whereas having seven or more hospitalizations in the previous year decreased the likelihood of a home death.¹⁶

Our findings also have important implications for clinical and policy decision making. Enhanced strategies for oncological and cardiovascular disease prevention, such as a greater focus on risk factor reduction, earlier detection through more effective screening practices, and greater resource allocation, may help to reduce the burden of these conditions on the general population. Regional variation in locations of death will require further evaluation, particularly because regional differences may result from socioeconomic differences, including access to care and insurance coverage for end-of-life care. Further efforts to ensure adequate access to high-quality end-of-life care may also reduce the burden these diseases place on patients, families, and caregivers. Because coverage for end-of-life care can vary based on health insurance and affect options for end-of-life care and location of death, further efforts will be needed to evaluate whether socioeconomic inequalities in insurance coverage alter patient and family decision making regarding location of death.¹⁷ A greater emphasis on equitable health care, such as access to high-quality end-of-life care in underserved areas, as well as ensuring adequate end-of-life medical insurance coverage for a range of end-of-life care, is also an important step to addressing disparities in healthcare across regions and demographic groups.

These data may have important clinical implications by highlighting the most common causes of death and their trends based on location at the time of death. The COVID-19 pandemic altered the mortality causes among different locations of death, because COVID-19 was a common cause of death, particularly in inpatient medical facilities (the most common cause in 2020 and 2021 and third most common in 2022). COVID-19 was the second and fifth most common cause of death in nursing homes/long-term care facilities in 2020 and 2021, respectively, and was not in the top five in 2022. Hospice facilities had relatively lower increases in mortality from COVID-19, and COVID-19 was not among the top five common causes of mortality at home. These findings may have been due to high inpatient mortality from acute COVID-19 and limited access to discharge facilities at the peak of the pandemic. These findings can help in planning future public health responses to potential pandemics by highlighting the changes in the top causes of death in various locations. Also, additional resources and public health focus on terminal conditions that are commonly encountered in the inpatient setting may be of value to allow transitions of care and subsequent mortality away from the costly and complex care provided in the inpatient setting.

This study has several limitations. There may have been inaccuracies and variability relating to the cause of death written on death certificates. There may have been variability in coding based on location and geographical region. Variability of coding for cause of death, especially for unwitnessed deaths at home, may also have led to potential misclassification of the cause of death in some situations. Mortality in any setting can occur under comfort or hospice care, which may underestimate the number of patients who choose comfort measures at the end of life.

In conclusion, heart disease and malignant neoplasm remain the most prevalent causes of death and remained among the top three causes of death in all studied locations in our study period. The impact of COVID-19 mortality was particularly devastating in inpatient medical facilities, followed by nursing home/long-term care.

Disclosure statement/Funding

The authors report no funding or conflicts of interest.