Imperfect Patients: Disparities in Treatment of Stroke Patients with Premorbid Disability

Abstract

Background: Despite the high proportion of stroke patients with a pre-existing impairment, patients with disabilities are often excluded from stroke treatment trials. Trials are designed for “perfect patients”: patients who are functionally independent and thus generally younger with fewer comorbidities; ironically, such patients are less likely to experience stroke than those with premorbid disability. Exclusionary practices in trials may translate into disparities in stroke care in practice. Through a review of literature, our purpose is to illuminate how people with disabilities are treated across the care continuum following a stroke. Methods: We completed a qualitative systematized review of articles pertaining to the care of patients with premorbid disability and stroke and their outcomes. Using a critical disability studies' theoretical lens, we analyzed inequity across the stroke care continuum. Findings: Among 24 included studies, we found evidence that people with disabilities did not receive equitable access to treatment ranging from being admitted to stroke units to receiving post-stroke rehabilitation. However, observational studies suggest that stroke therapies may be beneficial in selected patients with disabilities when measures of success are framed more achievable (e.g. return to pre-stroke status). This leaves us concerned about how people with pre-existing impairments might be structurally disabled within current systems of stroke care. Conclusion: We use our critical disability studies' theoretical lens to argue that an intersectional approach to stroke treatment is much needed if we are to remedy structural inequities embedded throughout the care continuum.

Addressing Disparities in Acute Stroke Management and Prognosis

“…Although this review will largely focus on racial or ethnic inequities as that is where the preponderance of research exists, it is important to acknowledge that members of other historically oppressed communities, such as lesbian, gay, bisexual, transgender, queer; lesbian, gay, bisexual, transgender, questioning+ people, disabled people, or those who live in rural communities, also experience disparities in stroke. 6 , 7 These communities comprise a diverse range of people with a variety of personal and social identities that interconnect to create differing experiences of discrimination and privilege within society. 8 The role of intersectionality in stroke equity, therefore, is also essential to acknowledge and incorporate into interventions.…”

Addressing Access to Stroke Treatment for Patients with Pre-existing Disabilities

“…In this issue of the journal, Cruise et al conducted a systematic review of the literature to illuminate various dimensions related to the treatment and management of stroke patients with a premorbid disability with the goal of determining potential biases in practice that may result in a disparity in access to best practices in this population. 5 They identified 24 observational studies and addressed four themes: differences in outcomes in patients with disability versus without prestroke disability, differences in treatment, choice of stroke outcome, and treatment practices.…”