Abstract WE568: Place of Death for Cerebrovascular Mortality, 2018–2023: Hospice–Forward U.S. Trends From CDC WONDER

Abstract

Background: Where cerebrovascular deaths occur reflects emergency access, end-of-life preferences, and palliative capacity. Whether hospice’s role changed during and after the pandemic is unclear. Hypothesis: Out-of-hospital (OOH) deaths rose in 2020 and stabilized thereafter; hospice’s share within OOH would not expand meaningfully post-2020. Methods: CDC WONDER Multiple Cause of Death (final, 2018–2023; I60–I69). Place of death was grouped as hospital (inpatient, emergency/outpatient, dead-on-arrival [DOA]) vs OOH (home, hospice facility, nursing/long-term care [LTC], other/unspecified). We computed annual counts, OOH share, and OOH composition (hospice, home, LTC). For adjustment, a binomial GLM (logit link) modeled OOH/(total) by Year, Sex, Race (Single-Race-6), Education with frequency weights; marginal year predictions were averaged by observed stratum totals. We explored small-cell instability with Beta–Binomial empirical-Bayes (EB) for Race×Year; subgroup cross-tabs were suppression-limited in U.S. totals. Results: There were 1,775,960 cerebrovascular deaths (2018–2023). OOH share was 80.0% (2018) , 81.7% (2020 peak) , 80.1% (2023) ; adjusted estimates closely matched crude ( 2018–2023 adj. range: 79.9%–81.7%), indicating trends were not explained by demographic shifts . Within OOH , hospice’s share was stable: 7.7% (2018) , 6.8% (2020) , 7.8% (2023) ; era means pre 2018–2019 vs post 2021–2023 were 7.7% vs 7.5% of OOH and 6.2% vs 6.0% of all deaths. By contrast, home deaths comprised a rising fraction of OOH ( 12.5% → 16.0% ; era means 12.6% → 16.7% ), while LTC was flat to slightly lower ( 15.8% → 15.4% ; era means 15.7% → 14.6% ). In hospitals, the mix shifted toward inpatient (92.9%→94.1%) and away from ER/outpatient (7.0%→5.9%); DOA ~0–0.1%. EB did not alter national conclusions given suppression in subgroup cross-tabs. Conclusions: Cerebrovascular deaths remain predominantly out-of-hospital (~80%) with a 2020 peak and stabilization thereafter. Hospice’s proportional role did not expand post-pandemic , while home deaths grew within the OOH mix. These findings suggest sustained reliance on community/residential settings without compensatory growth in facility-based hospice. Strengthening early palliative engagement , equitable hospice referral pathways , and community stroke preparedness —paired with monitoring of place-of-death indicators—may better align preferences, capacity, and system performance in the post-COVID era.