Nearly a third of Americans now die from strokes at home rather than in hospitals, with rural and Black communities bearing the heaviest burden of this troubling healthcare disparity.
At a Glance
- Ischemic stroke deaths occurring at home have dramatically increased from 8.44% in 1999 to 29.31% in 2020
- Rural residents and Black Americans are disproportionately affected by this shift in stroke mortality location
- Stroke mortality rates, which had been declining until 2010, have since increased, particularly in non-metropolitan areas
- The trend raises questions about whether patients prefer home care or lack access to hospital-based treatment
- Researchers recommend expanding telemedicine, mobile stroke units, and culturally tailored healthcare programs
A Significant Shift in Stroke Mortality
Stroke remains the fifth leading cause of death in the United States, but where Americans are dying from strokes has changed dramatically over the past two decades. According to research published in PLOS One by Jason Lim and colleagues from Georgetown University School of Medicine, nearly 30% of ischemic stroke deaths now occur at home rather than in medical facilities. This represents a stark increase from just 8.44% in 1999. The comprehensive study analyzed cause-of-death records from 1999 to 2020 using the CDC WONDER database, covering 237,617 ischemic stroke deaths nationwide.
The research reveals a concerning reversal in stroke mortality trends. While stroke deaths had been declining through 2010, rates have since worsened across all geographical settings, with the most significant increases occurring in non-metropolitan areas. This pattern highlights growing disparities in stroke care and outcomes. Alongside the overall increase in mortality rates, researchers observed a substantial shift in where patients die, with at-home and hospice deaths rising considerably after 2010, while hospital deaths decreased proportionally.
Rural and Racial Disparities
The trend of dying at home from stroke is notably more pronounced among Black/African American individuals and those living in rural communities. This disparity points to potential inequities in healthcare access, quality of care, or both. Rural residents face particular challenges, including longer distances to specialized stroke centers, fewer neurologists, and limited access to time-sensitive treatments like tissue plasminogen activator (tPA), which must be administered within hours of stroke onset to be effective.
For Black Americans, the situation is compounded by known risk factors that contribute to higher stroke incidence, including higher prevalence of hypertension and diabetes, lower socioeconomic status, and other unquantified factors. The REGARDS study, a large geographically diverse cohort study, has specifically investigated these disparities, finding that Black Americans face a disproportionate stroke burden, particularly in the southeastern “stroke belt” and “stroke buckle” regions of the United States.
Choice or Necessity?
A critical question emerging from the research is whether the increase in at-home stroke deaths represents personal preference or lack of access to hospital-based care. The researchers note that the shift might partially reflect evolving preferences in end-of-life care, with more Americans choosing to spend their final days at home rather than in clinical settings. However, they caution that the disproportionate impact on rural and minority populations suggests that structural barriers to care may be a significant factor.
The COVID-19 pandemic further complicated this picture, with the research showing increased stroke deaths across most demographic groups during this period. This may have accelerated existing trends as some patients avoided hospitals due to infection concerns or faced additional barriers to emergency care during periods of healthcare system strain. The pandemic’s impact underscores the vulnerability of stroke care systems to disruption, especially for already marginalized populations.
Addressing the Disparities
The researchers call for new assessments of factors impacting stroke outcomes and highlight the need for targeted health policy interventions. Their recommendations include expanding telemedicine to increase specialist access in underserved areas, deploying mobile stroke units to bring critical care directly to patients, and developing culturally tailored healthcare programs that address the specific needs of diverse communities. Additionally, policies addressing structural barriers to care—such as transportation limitations, insurance coverage gaps, and provider shortages—are essential.
The study advocates for engaging directly with affected communities to inform policy decisions and clinical guidelines, ensuring an equitable and responsive healthcare environment. By addressing these disparities, healthcare systems can work to reverse the troubling trend of increasing at-home stroke deaths and ensure that all Americans have access to timely, effective stroke care regardless of where they live or their racial background.
