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Recent research indicates a notable rise in the incidence of deaths occurring at home due to ischemic stroke, in contrast to those occurring in hospitals and medical facilities. Additionally, when deaths do occur outside of homes, individuals from rural areas and Black Americans are more frequently found to have died in less specialized care environments.
The study highlights a reversal in the trend of stroke mortality rates, which had been declining steadily over the past decade but are now showing an upward trajectory.
These results, emerging from research conducted by scholars at Georgetown University School of Medicine and the University of Washington, are detailed in a publication in PLOS One. The study emphasizes the necessity for more comprehensive investigations into the factors influencing these trends, as well as their ramifications for accessibility and the quality of end-of-life care (entitled “Trends and disparities in ischemic stroke mortality and location of death in the United States: A comprehensive analysis from 1999-2020,” published on April 9, 2025).
An ischemic stroke occurs when blood flow to the brain is obstructed, often by a blood clot, and it remains the most prevalent type of stroke experienced predominantly by older populations. As the Baby Boomer generation ages, there is an urgent need to enhance access to stroke care, especially given the rising incidence of stroke among younger demographics.
In their study, researchers utilized data from the Centers for Disease Control and Prevention (CDC) database known as WONDER (Wide-ranging Online Data for Epidemiologic Research), which encompasses a variety of public health topics, including cancer statistics and vaccination rates. For this research, the focus was on “Underlying Cause-of-Death” records to identify stroke-related fatalities, categorizing individuals by age, gender, race, and level of urbanization. The researchers then analyzed the correlations between the total number of deaths, the death rates, and the locations at which these deaths occurred.
Some significant findings from the analysis are as follows:
Between 1999 and 2020, the percentage of individuals who passed away at home surged from 8.44% to 29.31%, while deaths occurring in medical facilities declined from 46.41% to 29.56%;
People in rural areas were more likely to succumb at nursing homes or long-term care facilities instead of specialized medical centers;
There were higher death rates among Black Americans at medical facilities, including cases classified as “dead on arrival”;
Conversely, Caucasian Americans demonstrated lower mortality rates within emergency facilities, with a tendency to die in hospice settings, nursing homes, or extended care facilities.
According to Jason Lim, the lead author and a medical student at Georgetown University, the significant uptick in deaths occurring at home can be attributed to several factors, including a societal shift towards valuing patient autonomy and dignity in end-of-life care decisions. More families are opting to allow their loved ones to spend their final moments in the familiar surroundings of home rather than in hospitals.
“This reflects broader societal trends that emphasize the importance of patient choice, especially in cases involving terminal illnesses like strokes,” Lim states.
Moreover, Lim points out that advancements in palliative care and hospice services have improved the feasibility of high-quality end-of-life care being provided at home.
“The increase in home fatalities may not necessarily indicate a deficiency in access to care; rather, it may signify enhancements in service delivery models that bring specialized care directly to patients,” he adds.
However, Lim warns that the study also uncovers significant disparities, particularly affecting racial minorities and residents of rural regions, who are more frequently found to die outside of specialized medical facilities.
“This raises the concern that some at-home fatalities may be linked to barriers preventing timely access to specialized care, which could include financial issues, gaps in insurance coverage, geographic distances from stroke centers, or limited transport options,” he explains.
“Further research is essential to decipher these factors and to ensure equitable choices for everyone at the end of their lives.”
Michael R. Levitt, MD, the study’s senior author from the University of Washington, noted that while understanding access to stroke care is critical, it is equally important to investigate why ischemic stroke death rates, after years of decline, are now on the rise. The authors hypothesize that increasing obesity rates, stagnation in the effectiveness of cardiovascular health initiatives that began in the 1970s and 1980s, and advancements in technology that enhance stroke identification could be contributing factors.
“This study illustrates that different demographic groups within the U.S. experience stroke-related deaths in distinct ways, potentially highlighting disparities in the availability of specialized healthcare, especially in rural and underserved regions. We aspire to build upon this research to enhance stroke care across the nation,” Levitt states.
Lim also notes that tailored interventions could range from the deployment of mobile stroke units in urban areas to educational initiatives on stroke symptom recognition in rural settings.
“The strategies for addressing disparities in areas like Seattle or Washington D.C. will vastly differ from those needed for places like West Virginia,” Lim explains.
Finally, Lim acknowledges that a limitation of the study is the nature of the CDC WONDER data, which, while extensive, does not allow for the examination of individual patient histories; it provides instead only aggregated data without any personal identifiers.
“A deeper understanding of factors like insurance status and socioeconomic background could aid in formulating more targeted policy interventions and recommendations, ultimately leading to the initiation of pilot studies,” Levitt adds.
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