Vikas Pandey, MD

Shah BR, Khan NA, O’Donnell MJ, and Kapral MK. Impact of Language Barriers on Stroke Care and Outcomes. Stroke. 2015

As a stroke fellow and previous neurology resident in Miami covering a county hospital where the majority of patients speak either Spanish or Haitian Creole exclusively (Spanish 70%, Creole 10%), the linked article regarding language barriers in stroke care is one I can definitely relate to. My high school level Spanish improved exponentially during residency and this enabled me to obtain accurate patient accounts and histories, pinpoint better time of onsets and allowed for better recognition of tPA contraindications when I was the first-responding resident. My Haitian Creole ability however is still essentially nonexistent (leading to an interaction similar to Chris Tucker and Jackie Chan referenced in the title). By not being able to communicate easily to a significant number of my patients, I personally felt the care I was delivering to be suboptimal as language is obviously the critical way to tell the patient what has happened to him/her, what disabilities this will lead to, what expectations to have in terms of recovery, and what things can be done for prevention. Even going through a translator without experience in the medical field may not be enough to relay this message properly.

The group out of Ontario, Canada decided to test whether the presence of a language barrier during delivery of care for ischemic stroke led to worsened mortality and clinical outcome. They selected patients from the Ontario Stroke Registry who were admitted with acute stroke (ischemic or hemorrhagic) or TIA seen in the emergency department or hospitalized in 12 stroke centers in Ontario Province. They determined that a language barrier was present if the patient’s preferred language was not English at most of the hospitals within the network except at one which operated mainly bilingually in which case the patient had a language barrier if they could not speak English or French. After excluding subarachnoid hemorrhages, the final cohort had 14,293 patients of which 1,506 (10.5%) had a language barrier. They found that 7 day mortality rate was 7% among those with a language barrier and 9.2% among those without one (p= 0.006). There was a similar and significant difference at 30 day and 1 year mortality. They also adjusted for other variables such as age, sex, ethnicity and socioeconomic status, stroke characteristics, and vascular risk factors and found no difference in the results. There was no difference in in-hospital complications. The rate of thrombolysis also did not differ.

The observation that patients with a language barrier conversely did better in regards to initial and out-of-hospital mortality is a somewhat surprising one. The authors did find, however, that this difference became less significant when taking into account the desire for aggressive versus supportive care. This lead to a higher percentage of language-barrier patients that left the hospital with a residual neurological deficit. Perhaps one explanation for this would be the presumption that not being able to fully explain the extent of the patient’s condition to the patient’s family (who may also have the language barrier present) may lead to maintenance of aggressive care and less early mortality. Another factor playing a role in this is the possibility of inefficacy of in-hospital rehab in patients with language barriers. The authors also noted that the impedance in communication may have led to more assessments and imaging during hospitalization that may have improved the mortality numbers. So while my feelings of inadequacy when treating Haitian patients at my hospital may be unsettling, there is a possibility that this barrier is leading to more frequent imaging and more in-depth patient assessment and examinations, hopefully leading to better outcome.