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. 2025 Apr 9;20(4):e0319867.
doi: 10.1371/journal.pone.0319867. eCollection 2025.

Trends and disparities in ischemic stroke mortality and location of death in the United States: A comprehensive analysis from 1999-2020

Jason K Lim  1 , Jenlu Pagnotta  2 , Richard Lee  1 , Do H Lim  3 , Jeffrey M Breton  1 , Zachary A Abecassis  3 , Raymond M Meyer  3 , Jeffrey C Mai  1 , Michael R Levitt  3   4
Affiliations

Trends and disparities in ischemic stroke mortality and location of death in the United States: A comprehensive analysis from 1999-2020

Jason K Lim et al. PLoS One. .

Abstract

Background: Stroke remains the fifth leading cause of mortality in the United States, with significant geographical and racial disparities in outcomes. Understanding trends in location of death for ischemic stroke patients is crucial for improving end-of-life care and addressing healthcare inequities.

Methods & findings: This retrospective study used Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) data to examine ischemic stroke mortality, stratified by urbanization level and race. Age-adjusted mortality rates were calculated using the 2000 US standard population. Age-adjusted ischemic stroke mortality rates increased across all urbanization levels since 2009, with the most pronounced rises in non-metropolitan areas. An increasing proportion of deaths occurred at home, shifting from inpatient medical facilities. Significant disparities were observed in access to specialized end-of-life stroke care, particularly for racial minorities and rural residents. Black/African American individuals and those in rural settings were more likely to die in less specialized environments due to healthcare access barriers.

Conclusions: The findings highlight a critical shift in the patterns of mortality and end-of-life care preferences among ischemic stroke patients over the past two decades. These findings highlight significant shifts in the patterns of mortality and location of death among ischemic stroke patients over the past two decades, with notable differences across urbanization levels and racial groups. The increasing proportion of home deaths and persistent disparities in location of death suggest a need for further research to understand the underlying factors driving these trends and their implications for end-of-life care quality and access.

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Conflict of interest statement

Dr. Michael R. Levitt has received unrestricted educational grants from Medtronic and Stryker; has consulting agreements with Aeaean Advisers, Metis Innovative, Genomadix, AIDoc and Arsenal Medical; holds equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, Synchron and Hyperion Surgical; serves on the editorial board of Journal of NeuroInterventional Surgery; and is on the Data Safety Monitoring Board of Arsenal Medical. These competing interests do not alter our adherence to PLOS ONE policies on sharing data and materials, as there are no patents or products related to this submission.

Figures

Fig 1
Fig 1. Age-adjusted death rates for ischemic strokes classified by race. 1999-2020.
The graph shows the trends in age-adjusted death rates per 100,000 people for Asian/Pacific Islander (blue), Black/African American (orange), and White (green) populations. Data were obtained from the CDC WONDER database. Age-adjusted rates were calculated using the 2000 U.S. standard population.
Fig 2
Fig 2. Age-adjusted death rates for ischemic strokes classified by urbanization level. 1999-2020.
The graph displays the age-adjusted death rates per 100,000 people for different urbanization levels: Large Central Metro (blue), Large Fringe Metro (orange), Medium Metro (green), Small Metro (brown), Micropolitan (Nonmetro) (red), and NonCore (Nonmetro) (purple). Data were obtained from the CDC WONDER database. Age-adjusted rates were calculated using the 2000 U.S. standard population.
Fig 3
Fig 3. Ischemic stroke deaths classified by race and location of death. 1999-2020.
Fig 4
Fig 4. Percent of deaths for ischemic strokes classified by location of death, by year. 1999-2020.
The graph displays the percentage of deaths occurring in different locations over time. Data were obtained from the CDC WONDER database. Locations of death include Decedent’s home, Hospice facility, Medical Facility - Dead on Arrival, Medical Facility - Inpatient, Medical Facility - Outpatient or ER, Medical Facility - Status unknown, Nursing home/long term care, Other, and Place of death unknown.
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