Stroke Care and Outcomes Among Patients Experiencing Homelessness

Introduction: Homelessness is associated with an increased risk of stroke, likely secondary to uncontrolled vascular risk factors and poor access to preventive care and chronic disease management. Its specific impact on acute stroke care and outcomes remains poorly understood. In this study, we conducted a systematic review and meta-analysis to summarize the available evidence. Methods: We searched PubMed, EMBASE, PsycINFO, Scopus, and Web of Science from 2000 to 2024 without language or geographical restrictions. Original observational studies of adults with acute stroke experiencing homelessness were included. Studies in animals and children, and studies without clear characterization of housing status and stroke outcomes were excluded. We compared post-stroke mortality, use of cerebrovascular diagnostics and therapeutics (including intravenous thrombolysis [IVT], mechanical thrombectomy, and vessel imaging), discharge destinations, and length of hospital stay between patients experiencing homelessness (PEH) and housed patients. We conducted a meta-analysis by pooling relative risk effect size. Results: Titles and abstracts of 1,598 articles were screened by two independent reviewers, and 80 studies were selected for full-text review. Seven studies comprising 620,327 (86.5% male, 54.5 average age) PEH and 3,035,234 (52.7% male, 57.4 average age) housed patients were included in the systematic review. Studies included in the meta-analysis were conducted in the United States. All seven studies were rated as moderate to high quality. Pooled analysis did not reveal differences in in-hospital mortality between PEH and housed patients (risk ratio [RR]; 1.10 95% confidence interval [CI] 0.82-1.48). PEH with ischemic stroke were receiving IVT less frequently compared to housed individuals (RR 0.86, 95% CI 0.77-0.97). Two studies reported on discharge destinations, both indicating that PEH were more likely to be discharged to self-care or leave against medical advice. Conclusions: Patients experiencing homelessness with stroke were less likely to receive IVT and more often discharged without support. Further research is needed to identify long-term stroke outcomes and address disparities of post-stroke care to improve outcomes in PEH with stroke. Registered: (Registration No. CRD42024582119).