Abstract Body: Background: Heart failure (HF) remains a leading cause of morbidity and mortality, yet national data on where patients with HF die and how this varies across demographic groups are limited. Understanding death location is essential to improving end-of-life care and promoting equity in the United States.

Hypothesis: We hypothesized that the location of death among patients with HF has shifted over time and differs by age, sex, race, and ethnicity.

Methods: Using national mortality data from the National Center for Health Statistics for 2003–2021, we identified all U.S. adults aged ≥25 years whose underlying cause of death was HF (ICD-10: I110, I130, I132, I500, I509). Location of death was categorized as inpatient hospital, outpatient hospital, dead-on-arrival (DOA), scene, hospice, nursing home, or unknown. Demographic predictors included age group, sex, race, ethnicity, and year of death. Multivariable logistic regression evaluated associations with each category, and Joinpoint regression quantified temporal trends.

Results: Among 1,615,353 HF deaths, 45.7% occurred in inpatient hospitals, 22.0% in nursing facilities, 6.6% in hospice, 4.0% in outpatient settings, 0.1% were DOA, and 21.0% occurred at the scene. From 2003–2021, inpatient hospital deaths declined 3.2% annually and nursing home deaths 2.1%, while hospice deaths rose 19.6% (all p<0.001). Older adults (≥65 years) were more likely to die in nursing homes (OR 8.05) and hospice (OR 2.68) but less likely in hospitals. Males had higher odds of inpatient (OR 1.33) and lower odds of nursing home deaths (OR 0.66). Compared with White patients, Black patients had higher odds of hospital (OR 1.47) and outpatient (OR 2.57) deaths but lower odds of nursing home (OR 0.53) and hospice (OR 0.85) deaths. Hispanic patients had higher inpatient death (OR 1.40) but lower hospice (OR 0.65) and nursing home (OR 0.40) deaths.

Conclusions: Over two decades, HF deaths occurring in inpatient hospitals have declined, while hospice deaths increased sharply, signaling shifts toward community- and palliative-based end-of-life care. Persistent racial and ethnic disparities remain, with Black and Hispanic individuals more likely to die in acute-care settings and less likely in hospice or nursing facilities. These findings highlight ongoing inequities in end-of-life care access and emphasize the need for culturally informed palliative strategies to improve care for patients with HF.