Strategies to Reduce Racial and Ethnic Inequities in Stroke Preparedness Care Recovery

Despite great strides made in stroke prevention and acute treatment worldwide, racial and ethnic inequities continue to persist throughout the continuum of stroke care. A wide range of factors contribute to these disparities, and as such, careful consideration of the various imparting elements is necessary to address the problem. Social determinants of health (SDOH), or the structural context in which people live, work, and spend their time, has great impact on health outcomes. Incorporating SDOH into intervention design is likely key to developing and promoting effective strategies for inclusive and equitable care. Pitfalls to carefully parsing out the complex interactions between SDOH and stroke disparities in previous research include differences in intervention framework and methodological approaches, limiting comparison between studies, and less focus on more difficult upstream determinants, including housing and food insecurity. In addition, underrepresentation has played a role in large clinical trials, limiting generalizability.

In the statement Strategies to Reduce Racial and Ethnic Inequities in Stroke Preparedness, Care, Recovery, and Risk Factor Control, A Scientific Statement from the American Heart Association, Towfighi and authors suggest utilizing a common theoretical framework in which to study the roots of health inequities, and seek to identify gaps in successive steps of the stroke care continuum. By doing so, the authors aim to elucidate areas of potential intervention, guide the development of more focused strategies, and ultimately, improve stroke outcomes for all.

The Schulz model is proposed as a common theoretical framework to demonstrate the heterogeneity of SDOH and to center focused interventions. This model identifies various levels of determinants (fundamental, intermediate, and proximate), categorizing causes of inequities within each level. Understanding the intimate interconnections these determinants have upon knowledge and behaviors, vascular risk factors, and ultimately, stroke, is paramount to recognizing the complex effects that SDOH influence health outcomes. Approaches to addressing different levels must be targeted to be effective: for example, using changes in public policy to address the effects of economic instability on the fundamental level, and addressing heath literacy through focused projects on the proximate level.

The statement also gives a comprehensive step-by-step review of current evidence and gaps as defined through the patient experience, from pre-hospital to post-stroke care and recurrence reduction. In the pre-hospital setting, despite advances to increase delivery of effective acute stroke care, disenfranchised individuals are less likely to present in a timely manner or to use emergency services. Interventions focused on stroke preparedness have been optimistic in improving stroke recognition and intent to call 911, though limited in demonstrating duration of effect or impact on outcome measures, which varied between studies. Mass media campaigns have shown that repeated exposure might be necessary for sustained improvements in stroke preparedness. Additional prehospital strategies, such as mobile stroke units (MSUs) and an enhanced role of emergency medical services in pre-stroke care, have shown some promise, particularly for MSUs via faster acute stroke thrombolytic treatment and improved clinical outcomes. Though multi-level interventions hold appeal for impacting large numbers of individuals, the ability to tailor interventions utilizing SDOH within pockets of large communities might be more effective in impacting pre-hospital outcomes.

Racial/ethnic disparities in acute stroke delivery have been well described and persist, despite efforts to understand the root problems and address them. Solutions to reduce inequities at all levels – patient, provider, system, and policy – are urgently needed, and because of this, guidelines can assist in providing a framework from which to address disparities. Certification of stroke centers and quality improvement programs can help improve stroke systems of care by standardizing data and providing feedback, helping patients adhere to clinically proven therapies, educating providers, and integrating multiple care teams. Telestroke may help to eliminate some geographic disparities in under-resourced areas, though its effect on racial/ethnic disparities is less well understood. Artificial intelligence may well be effective, though the development of accurate algorithms by nature relies upon a diverse and heterogenous population to be generalizable.

In the realm of rehabilitation, the authors focus on the areas where future research has the greatest benefit potential, including telerehabilitation and exercise programs. Telerehabilitation, with its flexible nature for cultural tailoring and self-directed programming, holds promise to reduce barriers. However, for telerehabilitation to be available, policies to support reimbursement must be upheld, and technological support is required. Regarding exercise, though present published studies have shown neither specific reduction across race-ethnic groups nor sustained benefit, the potential for exercise, particularly in the realm of self-directed virtual tools, to mitigate inequities likely exists. Inequities in stroke-related disability, whereby Black and non-White persons have been noted to have greater difficulties affecting activities of daily living and a higher prevalence of symptoms affecting self-care, have been described; more targeted interventions are necessary to address underlying factors contributing to these disparities.

Optimizing transitions of care is an area of ripe potential to improve outcomes and prevent rehospitalizations after stroke. Various existing study models have shown limited benefit in improving recurrent strokes, functional status, or readmissions. Research is ongoing to identify sex and race-ethnic disparities within transitions of care, and to develop system-level initiatives to directly target these disparities, with the hope of improving outcomes.

Strategies to address risk factor control after stroke have had a variety of thoughtful methodologies including consideration of cultural tailoring, community partnership, and the inclusion of patient and community stakeholders. Despite this, there remains a gap in the understanding of what strategies will be most effective in reducing racial/ethnic inequities. Improving self-efficacy among minority groups may be the most effective approach, though additional studies at multiple levels are necessary. The consideration of community involvement, the effort to include under-represented minority groups, and research design such that studies can be cross compared remains essential moving forward.

Given the urgent need to understand and address racial/ethnic inequities and the effect of SDOH on those disparities, this statement draws attention to the research that has already been done and shines light on the work still ahead. To tackle these disparities and ultimately improve stroke outcomes, using a common standard methodological approach may be most effective in understanding these complex inequities and putting them into context.