Trends and Disparities in In-Hospital Mortality Among Ischemic Stroke Patients During the COVID-19 Era: A Nationwide Study (2016–2022)

Abstract

Background and Purpose

The COVID-19 pandemic disrupted stroke systems of care, but its impact on in-hospital mortality and disparities among ischemic stroke patients remains unclear. We examined nationwide trends in stroke mortality before and during the COVID-19 era, with a focus on demographic and socioeconomic disparities.

Methods

We used the National Inpatient Sample (2016–2022) to identify adult hospitalizations with a primary diagnosis of ischemic stroke. Crude in-hospital mortality rates were calculated annually and stratified by sex, age group, race/ethnicity, and insurance status. Multivariable logistic regression was used to estimate adjusted odds of in-hospital mortality, controlling for year, age, sex, race/ethnicity, payer, and comorbidities.

Results

Among 950,518 ischemic stroke admissions, in-hospital mortality rose from 6.32% in 2019 to 8.24% in 2021—a 30% relative increase during the COVID-19 era. Mortality was highest among patients aged ≥85 years (11.1%), males (7.2%), and those with self-pay status (OR 2.33 vs. Medicare). Crude mortality increased most among Hispanic (+36.1%), American Indian/Alaska Native (+35.5%), and Black patients (+26.7%). After adjustment, the odds of in-hospital death remained significantly elevated in 2020 (OR 1.05), 2021 (OR 1.17), and 2022 (OR 1.09) compared to 2016. Regional disparities were also observed, with the greatest adjusted mortality increases in the Northeast and West. Race-stratified models confirmed disproportionately higher pandemic-era mortality among minority groups

Conclusion

In-hospital stroke mortality rose significantly during the COVID-19 era, with disproportionately greater increases among racial and ethnic minority groups and socioeconomically vulnerable patients. These findings underscore the need for equity-focused interventions in stroke systems of care.