WASHINGTON – A new analysis finds a significant uptick in the number of people dying at home due to ischemic stroke compared to inpatient medical facilities, and when not at home, individuals in rural communities and Black Americans were more likely to die in less specialized care environments.
Additionally, the researchers found that after a steady 10-year decline, overall death rates from stroke are now rising.
These findings, published in PLOS One by researchers at Georgetown University School of Medicine and the University of Washington , underscore the need for further research to understand the underlying factors driving these trends and their implications for access and end-of-life care quality. (" Trends and disparities in ischemic stroke mortality and location of death in the United States: A comprehensive analysis from 1999–2020;" April 9, 2025) .
Ischemic stroke occurs when the blood supply to the brain is blocked or reduced, such as by a blood clot. It is the most common type of stroke and it is more common in older people. Improving access to stroke care is critical especially with a large and aging Baby Boomer population, as well as rising stroke rates in younger people.
In the study, researchers reviewed information from a Centers for Disease Control and Prevention (CDC) database called WONDER ( Wide-ranging Online Data for Epidemiologic Research ), a collection of data on public health topics that includes cancer and vaccination rates. The researchers specifically studied "Underlying Cause-of-Death" records from individuals to identify those who died from stroke, and categorized each person according to reported age, sex, race, and urbanization level. They then studied the relationships between three factors: overall number of deaths, rates of death, and the location of deaths.
Key findings from the study included:
From 1999 to 2020, the overall percentage of patients who died at home increased from 8.44% to 29.31% and deaths in medical facilities decreased from 46.41% to 29.56%;
Individuals in rural communities were more likely to die at nursing homes or long-term care facilities than specialized centers;
Black Americans had the highest death rates at medical facilities, including "dead on arrival;" and
Caucasian Americans had the lowest rates of death in emergency facilities, and the highest rates of dying at hospice facilities, nursing homes, or long-term care facilities.
The study's lead author, Jason Lim, a medical student at Georgetown University School of Medicine, said that the striking increase of patients dying at home is likely due to multiple factors including a growing cultural shift around end-of-life care preferences, with more individuals and families choosing to spend their final moments in the comfort of home rather than in hospitals.
"This mirrors broader societal trends toward prioritizing patient autonomy and dignity, particularly in the context of terminal illnesses like stroke," he said.
In addition, Lim says advancements in home-based palliative and hospice services may have made it increasingly feasible to receive high-quality end-of-life care outside of hospital settings.
"In other words, the rise in home deaths may not always indicate a lack of access to care—it might also reflect improved delivery models that bring specialized services directly to patients," he explained.
But Lim cautioned that the study also found notable disparities, particularly among racial minorities and rural residents, who were more likely to die outside of specialized medical settings.
"This raises the possibility that some at-home deaths may reflect barriers to timely or specialized care, including financial constraints, insurance coverage gaps, geographic distance from stroke centers, or limited transportation options," he said.
"More work is needed to understand which is which—and how to ensure everyone has equitable options at the end of life."
The study's senior author, Michael R. Levitt, MD, of the University of Washington noted that in addition to better understanding access to stroke care, more research is needed to understand why after years of decline, ischemic stroke death rates have reversed and are now rising. He and the other authors speculate that this could be due to rising rates of obesity, plateaus in the effectiveness of cardiovascular health initiatives that started in the 1970s and 1980s, and possibly technological advances that better allow doctors to identify stroke.
"This study shows that different populations within the US experience stroke-related death in different ways, and may highlight the uneven distribution of specialist healthcare, particularly in rural and underserved areas. We hope to build on this study to improve stroke care systems across the country," Levitt says.
Lim says targeted interventions could look like mobile stroke units in an urban area, or education on signs of stroke in a rural location.
"Addressing disparities in Seattle or Washington DC looks vastly different than strategies for West Virginia," Lim said.
Lim noted that a weakness of the study was that while CDC WONDER contains a large amount of information, it does not allow researchers to examine individual patient histories—instead, it includes aggregated data without personal identifying information.
"Gaining further understanding of factors such as whether a patient has insurance and their socioeconomic status would allow us to create more targeted policy interventions and suggestions, and ultimately initiate a pilot study," Levitt said.
