Who Gets Comfort Care at the End? Stroke Study Reveals Stark Racial and Income Gaps

Mechanical thrombectomy has transformed the treatment of acute ischemic stroke. By threading a catheter through blood vessels to physically pull a clot out of the brain’s arteries, physicians can reverse what was once a certain catastrophe, and a landmark series of randomized trials has made the procedure the standard of care for large-vessel occlusions. Yet the technology has limits. Even in the best hands, roughly 10 to 15 percent of patients who undergo thrombectomy die before leaving the hospital, and for those patients and their families, the quality of the final days depends heavily on one intervention that receives far less attention than the clot itself: palliative care.

A new retrospective cohort study published in Neurocritical Care suggests that access to that comfort-focused care is far from equal. Analyzing seven years of national hospitalization data, researchers found that among patients who died after mechanical thrombectomy for stroke, Black and Hispanic patients were significantly less likely than white patients to receive a palliative care encounter, and patients from lower-income neighborhoods faced lower odds as well. The disparities compounded each other: low-income Black and Hispanic patients had roughly half the odds of receiving palliative care compared with their white counterparts.

The research team, led by Solomon Kim, Beshoy Saad, and For-Shing Lui of California Northstate University, drew on the National Inpatient Sample, the largest publicly available all-payer hospital database in the United States, covering the years 2016 through 2022. They identified adults aged 18 and older who underwent mechanical thrombectomy for acute ischemic stroke and died during the same hospitalization. After applying the database’s survey weights, the sample of 4,495 patients represented approximately 22,000 people nationwide, with a mean age of 72.5 years and a nearly even sex split at 49.3 percent female.

Palliative care receipt was identified using the ICD-10-CM code Z51.5, the administrative marker for an encounter with palliative care services. Overall, 63.5 percent of patients who died after thrombectomy received such an encounter. But the headline number concealed deep divisions. Among white patients, 66.8 percent received palliative care; among Hispanic patients, 55.1 percent; and among Black patients, only 51.9 percent. That fifteen-point gap between white and Black patients represents thousands of families over the study period who may have faced the death of a loved one without the symptom management, communication support, and decision-making guidance that palliative care teams provide.

To isolate the effect of race and ethnicity from other factors, the researchers used survey-weighted multivariable logistic regression, adjusting for age, sex, insurance status, income, and calendar year. Even after these statistical controls, Black patients had 41 percent lower odds of receiving palliative care than white patients, an adjusted odds ratio of 0.59 with a 95 percent confidence interval of 0.48 to 0.74. Hispanic patients had 36 percent lower odds, with an adjusted odds ratio of 0.64 and a confidence interval of 0.49 to 0.82. Socioeconomic geography mattered independently: patients living in ZIP codes in the lowest quartile of median household income had 18 percent lower odds of receiving palliative care than those in the highest quartile, an adjusted odds ratio of 0.82.

The most striking finding emerged from the study’s intersectional analysis, which examined race and income together rather than separately. Low-income Black and Hispanic patients had an adjusted odds ratio of 0.50, meaning their odds of receiving a palliative care encounter were half those of white patients. This pattern suggests that the disadvantages do not simply add together but interact, with socioeconomic deprivation amplifying racial inequities in end-of-life care. The authors report that the results remained robust across multiple sensitivity analyses, strengthening confidence that the associations are not statistical artifacts.

Why would such gaps exist in the high-technology setting of a neurointerventional suite? The study cannot answer that question directly, because administrative billing data record what happened but not why. The authors point to several plausible mechanisms documented in the broader literature. Palliative care referral depends partly on clinician judgment, and studies of implicit bias in healthcare professionals suggest that unconscious assumptions can shape which patients are offered conversations about goals of care. Cultural factors also play a role: research on end-of-life decision-making among racially and ethnically diverse groups has documented differences in preferences, in trust toward the medical system, and in exposure to information about hospice and palliative services, all of which can influence whether families accept a referral when one is offered.

Structural factors likely contribute as well. Hospitals serving predominantly minoritized and lower-income communities may have less access to palliative care consult teams, particularly outside large academic centers. Prior studies have estimated that a substantial fraction of intensive care unit patients who might benefit from palliative care never receive a consultation, and trigger-based models of need consistently identify more candidates than are actually referred. Insurance status, which the study adjusted for, is only one dimension of access; the availability of palliative services within a given hospital and the staffing of those services vary enormously across the American healthcare landscape.

The stakes are high because palliative care is not merely a courtesy at the end of life. Randomized trials in oncology, including the influential ENABLE III study and Temel and colleagues’ landmark trial of early palliative care in metastatic lung cancer, have shown that palliative involvement can improve quality of life, mood, and in some cases survival, while systematic reviews and meta-analyses have documented benefits for both patients and caregivers. Stroke presents a particularly acute version of the problem, because the decline after a devastating brain injury often follows an unpredictable trajectory that neurologists have called the fourth trajectory of serious illness, blending elements of sudden crisis and prolonged decline. The American Heart Association and American Stroke Association have issued dedicated statements on palliative and end-of-life care in stroke, underscoring that comfort-focused care is an integral part of stroke medicine rather than an admission of failure.

The authors are careful about the limits of their evidence. Because the National Inpatient Sample is administrative, the Z51.5 code may undercount or misclassify palliative care encounters, and the observational design precludes causal conclusions; the associations they report could reflect differences in patient or family preferences, hospital resources, clinician behavior, or unmeasured clinical severity. Still, the consistency and magnitude of the findings, particularly the halving of odds among low-income minority patients, argue that something systematic is at work. The study’s data are publicly available through the Healthcare Cost and Utilization Project, and the analysis code has been shared openly, inviting replication and extension. What the researchers call for next is investigation into modifiable contributors, the levers that hospitals and health systems can actually pull: standardized palliative care triggers for high-mortality procedures, clinician education on equitable goals-of-care conversations, and investment in consult services at hospitals that currently lack them. As mechanical thrombectomy continues to expand to more hospitals and longer treatment windows, ensuring that its occasional failures are met with equal compassion, regardless of a patient’s race or ZIP code, becomes a measure of whether stroke medicine’s remarkable technical progress is matched by progress in its humanity.

Subject of Research: Racial and socioeconomic disparities in palliative care use among patients dying after mechanical thrombectomy for acute ischemic stroke

Article Title: Racial and Socioeconomic Disparities in Palliative Care Utilization Among Patients with In-Hospital Mortality After Mechanical Thrombectomy for Stroke

Article References: Kim, S., Saad, B., & Lui, F.-S. (2026). Racial and Socioeconomic Disparities in Palliative Care Utilization Among Patients with In-Hospital Mortality After Mechanical Thrombectomy for Stroke. Neurocritical Care. https://doi.org/10.1007/s12028-026-02636-7

Image Credits: AI Generated

DOI: 10.1007/s12028-026-02636-7

Keywords: stroke, mechanical thrombectomy, palliative care, health disparities, end-of-life care, neurocritical care, National Inpatient Sample, health equity, acute ischemic stroke, socioeconomic status, racial disparities, Racial