End-of-life stroke care shows troubling gaps for Black, Hispanic and rural patients
Black, Hispanic and rural stroke patients nearing death are more likely sent home than to hospice, a Northeastern study finds.
A Northeastern University study found that Black, Hispanic and rural patients nearing the end of life after an ischemic stroke are more likely to be discharged home rather than to a professional care facility, where they could receive better medical support and greater comfort in their final days.
“Even without looking at quality of care, this study shows that there is a bias in discharging patients, especially … discharging those patients who are at their end of life,” says Nasim Ferdows, assistant professor of public policy, urban affairs and health sciences, and a co-author of the study. “It’s important for the decision-makers to consider this when they are making a decision on where to discharge their patients to reduce specifically racial, ethnic disparities or rural disparities.”
The findings highlight gaps in hospice and institutional care access for rural and minority populations and underscore the need for targeted policies and medical interventions to ensure more equal care for post-stroke patients.
The researchers were surprised to find that Black and Hispanic patients had higher odds of being discharged home and not to professional care facilities, regardless of the severity of their stroke, whether they had other health problems or the type of their insurance. The difference was more profound among patients who died within 90 days after leaving the hospital.
Even when higher-intensity care might be medically recommended, previous studies demonstrated that Black and Hispanic patients often face greater barriers to rehabilitation or hospice care and are more likely to be sent home.
Rural residents are also less likely to receive timely, guideline-based stroke care and may have difficulty accessing post-acute services due to facility shortages, long travel distances and limited care infrastructure.
Ferdows’ study highlights how these disparities affect patients at the end of their lives.
“This is very important for care providers and decision-makers when they are deciding on discharge management,” Ferdows says.
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According to the American Heart Association, stroke remains a leading cause of long-term disability and mortality in the United States and globally, as well as a significant contributor to health care system costs. Recovery from ischemic stroke depends heavily on the care received during the post-acute period, when rehabilitation services and discharge decisions play critical roles in shaping outcomes.
The researchers analyzed past Medicare records of more than 6,800 individuals, or a 5% sample of patients who were hospitalized for an ischemic stroke in 2021. Their goal was to examine how discharge plans differed between racial groups and between rural and urban patients who lived at least 90 days after leaving the hospital and those who did not.
The researchers grouped participants into two categories: white patients and a combined group of Black and Hispanic patients. Within the sample, 18% of patients identified as racial or ethnic minorities, and 19% resided in rural areas.
Among all patients, 44.4% were discharged to home or home health care; 39.9% to a skilled nursing facility or inpatient rehabilitation facility; 10.5% to hospice or another hospital, and 5.2% died during hospitalization. Among patients discharged home, 81.6% were white and 12.8% were Black and Hispanic.
Of those who survived discharge, 13.6% died within 90 days. Among these, Black and Hispanic patients had lower odds of discharge to hospice or other settings compared with white patients, the study shows.
Patients residing in rural areas had lower odds of discharge to hospice or other settings compared with their urban counterparts.
“We hope our findings help advance efforts to make post-stroke rehabilitation and hospice care more equitable for all patients,” says Mengyuan Cheng, a Northeastern doctoral student and co-author of the study.
Ferdows’ research group is currently looking at the quality of care at different facilities where patients are being discharged to and how patient insurance type affects discharge decisions.
