Study: Disparities persist in prescribing comfort care for ischemic stroke patients

Receiving palliative or hospice care services was found to improve quality of life for hospitalized ischemic stroke patients, however, disparities persist in which patients are prescribed or have access to these holistic comfort care options, according to new research published today in the Journal of the American Heart Association, an open access journal of the American Heart Association.

Prior to the COVID-19 pandemic, stroke ranked No. 5 among all causes of death in the U.S. Nearly 9 in 10 strokes are ischemic strokes caused by a blockage in a blood vessel that carries blood to the brain. Despite advances in acute stroke treatment and management, stroke remains a leading cause of serious long-term disability in the U.S.

"Stroke death rates have declined over the past decade, however, as more people survive stroke, many face lingering consequences including varying levels of disability," said lead study author Farhaan S. Vahidy, Ph.D., M.B.B.S., M.P.H., FAHA, an associate professor of outcomes research and the associate director of the Center for Outcomes Research at Houston Methodist, in Houston, Texas. "Many stroke patients are candidates for comfort care, including palliative or hospice care, which can improve outcomes and quality of life. It is important that stroke patients who could benefit with better quality of life from comfort care have these options available."

Palliative care provides holistic support to patients with stroke and other chronic conditions to relieve symptoms and improve quality of life. Hospice care is end-of-life care and is usually reserved for patients among whom most treatment options are no longer feasible. And like palliative care, hospice care also aims to relieve symptoms and improve quality of life.

To better understand comfort care use among ischemic stroke patients in the U.S., researchers examined hospital patient data from 2006 to 2015 from the Agency for Healthcare Research and Quality. They found:

• Of the nearly 4.3 million stroke hospital discharges, 3.8% received hospice or palliative care.
• Prescribing comfort care increased during the 10-year period. Ischemic stroke patients were almost five times more likely to receive a comfort care intervention in 2014 to 2015, compared to 2006 to 2007.
• The increasing trend in patients' comfort care use was evident even among patients who had acute stroke treatments, including with intravenous clot busting medications, called thrombolytic therapy, and mechanical clot removal, or endovascular thrombectomy.
• Some hospital types, including large hospitals and urban teaching hospitals, had higher rates of comfort care.
• The average length of hospital stays for ischemic stroke patients who received comfort care was longer than stays for patients who did not receive comfort care, yet the average hospitalization costs for patients who received comfort care were lower.
• Although comfort care continues to be associated with higher in-hospital deaths, 10-year outcome trends among patients receiving the services showed a significant decline in in-hospital deaths and a significant increase in the proportion of patients either discharged home or transferred to long term care facilities.

Comfort care use was notably lower among people who identify with non-white racial and ethnic groups. For example, use was 41% lower among Black stroke patients compared to white patients. Other factors independently associated with higher comfort care utilization were older age, female sex, non-Medicare (private) health insurance and higher incomes.

Disparities in the prescribing of comfort care interventions among ischemic stroke patients was an important finding that needs to be carefully examined. To our knowledge such disparities have not been previously reported. And, while more stroke patients are getting comfort care, overall use is still low, especially among people from underrepresented racial and ethnic groups."

Farhaan S. Vahidy, Ph.D., M.B.B.S., M.P.H., FAHA, Study Lead Author adn Associate Director, Center for Outcomes Research, Houston Methodist.

A limitation of the study is that the investigators examined information that did not differentiate between palliative care and hospice care usage.

"Our work provides a preliminary framework to ensure optimal use of comfort care services among ischemic stroke patients. More work needs to be done to improve access and availability to more stroke patient, to enhance communication with patients and their care providers and to empower patients to make decisions about their care as they recover from and adjust to such a life-altering health event," Vahidy said.