Investigating Disparities in Post-Stroke Rehabilitation

Sana Somani, MD, MBBS

Data from a recent study suggest that women and African American patients have lower functional performance during acute inpatient rehabilitation than men and Caucasian patients following intracerebral hemorrhagic (ICH) strokes. These findings were presented by Sana Somani, MD, MBBS, vascular neurology fellow, University of Maryland Medical Center, at the 2021 American Academy of Neurology (AAN) Annual Meeting, April 17-22.

Somani and colleagues performed a retrospective analysis on a cohort of 65 patients with ICH admitted between December 2016 through December 2019 to the University of Alabama at Birmingham care center. They found that being male was positively associated with Functional Independence Measure (FIM) efficiency (β = 1.02; P = .0063) after adjusting for race and ICH score, and FIM efficiency was lower in African American patients (β = -0.95; P = .0092) after adjusting for gender and ICH volume. No significant differences with respect to discharge FIM scores were observed between ICH volumes and scores.

NeurologyLive spoke with Somani to learn more about these disparities in stroke care, what might be causing them, and strategies to mitigate these disparities.

NeurologyLive: What factors do you think contribute to this finding of lower FIM efficiency in African American women undergoing post-stroke rehabiitation?

Sana Somani, MD, MBBS: It's difficult to determine exactly what contributes to this finding of lower FIM during rehab. I think we have to consider both the gender and racial disparities here. Starting with gender, women in general have a higher burden of premorbid disabilities and a longer lifespan, which renders a more difficult recovery and also increases their vulnerability for a functional decline. There have also been studies that have shown that hormonal changes, including a decline in estrogen and subsequent androgen access, makes women more susceptible to the development of cardiovascular risk factors. On top of all this, women are more likely to report depression after a stroke which can have a profound impact on the rate and quality of recovery. Now talking about race, there was an investigation that reported variation in the type and amount of therapy provided to older adults based on racial grouping after controlling for disability and medical diagnosis. So, there could be a potential implicit bias amongst physicians and therapists which differentiates between ethnicities. In African Americans, other possible explanations include psychological related variables, such as what attitudes does the patient have towards these health services? What are the incentives that help them engage in these demanding rehab activities? What are the beliefs these individuals have about health locus of control, which is actually a social learning theory that refers to whether health and its outcomes are under personal control or chance. Research has shown repeatedly that African Americans hold stronger beliefs regarding the importance of luck as a factor in health outcomes. So, I think all of these factors are likely contributors.

How do you think rehabilitation efficacy could be improved for these groups that have lower FIM?

I think efficacy can only be improved if we identify the cause of the difference. In terms of FIM efficiency, which I've reported in my study, which includes the FIM score change over the number of days at rehab, the only way to effectively improve efficiency, which would in turn, be considered rehab efficacy, would be to either increase the numerator, which is the score difference, or decrease their rehab stay, which is the denominator: that would mean ensuring that this particular population gets the care they deserve when they are in rehab. If that means a few more hours per day in rehab during their inpatient stay, I think we should have the bandwidth to accommodate that. The good thing is all these aspects are known before, so it would be reasonable to anticipate their outcomes earlier upon discharge from the hospital and plan accordingly beforehand. Another option, which is not necessarily favorably considered in this social demographic group, would be to follow up that rehab stay with a short stay in a skilled nursing facility that will provide them with the rehab care and ensure patient safety to before discharging the patient to home. Another thing to note is the aspect I highlighted before in terms of women having a higher burden of premorbid disabilities and a longer lifespan. I think we as neurologists, and even primary care physicians, need to be more active and work on primary prevention of strokes in this population. We have to be more aggressive in treating their atrial fibrillation (AFib), their hypertension, their diabetes, their cholesterol levels, all the factors that are potential risk factors for stroke, both ischemic and hemorrhagic. There's plenty of research on the pharmacogenomics and reported ratio differences of genetic polymorphisms. Lastly, if we know that African Americans hold stronger beliefs about particular aspects of their care, then it is our responsibility as healthcare providers to not only acknowledge but also try to accommodate this cultural awareness in our clinic, and in our counseling when we see patients and their families. Because once they are discharged, we are not the ones who will be with them at home. It will be the families, the caregivers who will need to support that patient, and we must do our absolute best in improving access and quality of care for minorities.

Transcript edited for clarity. For more coverage of AAN 2021, click here.

REFERENCE

Somani S, Nanavati H, Xiaohua Z, Lin C. African American women have lower functional performance during acute inpatient rehabilitation after intracerebral hemorrhagic strokes. Presented at 2021 American Academy of Neurology Annual Meeting; April 17-22. Abstract P5 073