Hospital systems — and not necessarily only the primary ethnic population of those hospitals — may contribute to disparities involving palliative care for patients after ischemic stroke and intracerebral hemorrhage, a new study published in the journal Critical Care Medicine reports.

Usually, black and other ethnic minorities receive less palliative care after ischemic stroke and intracerebral hemorrhage (ICH). Past studies have suggested that the attitudes of the patients themselves — their religious beliefs and lack of knowledge or trust in palliative care solutions — drive their preferences for lifesaving options in critical care scenarios.

But the new analysis suggests that it might be the systems in place in hospitals serving minority populations — and not the belief systems of individual patients — that account for these racial disparities in care.

Analysis of data from the Nationwide Inpatient Sample confirmed that ethnic minorities who had a stroke were less likely to receive palliative care than whites. But it also showed that all patients with stroke—regardless of racial/ethnic identity—were less likely to receive palliative care if they were cared for in largely minority-serving hospitals.

“What is new about our study is that the racial make-up of a given hospital determines in part the use of palliative care after stroke regardless of race,” said lead author Roland Faigle, assistant professor of neurology at Johns Hopkins Medicine.

“When we examined the use of palliative care services in majority-white, racially integrated, and predominantly minority hospitals, both ethnic minority and white stroke patients alike were less likely to receive palliative care as the proportion of minority patients treated at a given hospital stratum increases.”

“Individual factors on the provider or the patient side are only one small part of the story in understanding health care disparities in services,” Dr. Faigle said. “Understanding system-level determinants of race disparities is critically important to develop effective mitigation strategies aimed at eliminating disparities in stroke care.”

For clinicians treating patients with stroke, Dr. Faigle said the most important message from the analysis is the need to be aware of any given patient's potential need for palliative care and to inquire whether resources to address such need are available and being used.

“In addition, physicians should have conversations with patients and their families about their understanding of the patient's prognosis and expressed wishes for aggressiveness of care, or lack thereof, at any time during the course of the hospitalization,” Dr. Faigle said.