Language barriers between physicians and patients are not associated with thrombolysis of stroke mimics

Abstract

Background: Acute stroke is a time-sensitive condition in which rapid diagnosis must be made in order for thrombolytic treatment to be administered. A certain proportion of patients who receive thrombolysis will be found on further evaluation to have a diagnosis other than stroke, so-called "stroke mimics." Little is known about the role of language discordance in the emergency department diagnosis of acute ischemic stroke. Methods: This is a retrospective analysis of all acute ischemic stroke patients who received IV tissue plasminogen activator (tPA) in our emergency department between July 2011 and December 2015. Baseline characteristics, patient language, and final diagnosis were compared between encounters in which the treating neurologist and patient spoke the same language (concordant cases) and encounters in which they did not (discordant cases). Results: A total of 350 patients received IV tPA during the study period. English was the primary language for 52.6%, Spanish for 44.9%, and other languages for 2.6%; 60.3% of cases were classified as language concordant and 39.7% as discordant. We found no significant difference in the proportion of stroke mimics in the language concordant compared to discordant groups (16.6% vs 9.4%, p 5 0.06). Similarly, the proportion of stroke mimics did not differ between English-and Spanish-speaking patients (15.8% vs 11.5%, p 5 0.27). Conclusions: Language discordance was not associated with acute stroke misdiagnosis among patients treated with IV tPA. Prospective evaluation of communication during acute stroke encounters is needed to gain clarity on the role of language discordance in acute stroke misdiagnosis. Neurol Clin Pract 2016;6:389-396 L anguage discordance occurs when a patient and treating physician do not have proficiency in the same language and has been associated with decreased quality of acute care.1-3 However, little is known about the role of language discordance in the emergency department (ED) diagnosis of acute ischemic stroke (AIS).

Language disparity is not a significant barrier for time-sensitive care of acute ischemic stroke

“…The diversity of healthcare providers and interpreter/tele-interpreter service may have overcome language barriers. Our IVT rate and DTN time are comparable or better than what were reported recently from other Comprehensive Stroke Centers [ 14 , 19 , 21 , 22 , 24 ]. We have also shown that increased age and higher initial NIHSS scores were associated with unfavorable outcomes at hospital discharge.…”

“…Emergency medical service usage was actually reported higher in the Spanish-speaking patients than the English-speaking patients treated with IVT [18]. A retrospective single-center study showed that language discordance was not associated with acute stroke misdiagnosis among patients treated with IVT [19]. Another study reported reduced mortality in patients with language barriers [13].…”

The Relationship Between Limited English Proficiency and Outcomes in Stroke Prevention, Management, and Rehabilitation: A Systematic Review

“…A second study investigated the role of language-concordant vs. discordant encounters, defined by whether the primary treating physician and the patient possessed fluency in the same language. The proportion of stroke mimics was not shown to differ between the two groups, nor did it differ between patients who selfreported as primarily English or Spanish speakers (19). The third related study observed no differences in median doorto-imaging (DTI) time, imaging-to-needle (ITN) time, or DTN time between language-concordant and discordant groups (20).…”

“…Two studies found no association between English or non-English preference and either mode of arrival or time to hospital presentation (17,32). Three studies were carried out at the same New York City institution using data from patients who received IV-tPA (18)(19)(20). One found that Spanish speakers were more likely than English speakers to have arrived by EMS after adjusting for confounders, while prenotification rates were not significantly different among those who utilized EMS.…”

Impact of Patient Language on Emergency Medical Service Use and Prenotification for Acute Ischemic Stroke

“…However, at our center, we have previously shown that tPA treatment among eligible patients did not differ between English and Spanish speakers. 17 Additionally, the generalizability of our findings to other geographic areas may be limited.…”