Quality Indicators Highlight Sex Differences in Stroke Care

Damian McNamara

May 28, 2018

GOTHENBURG, Sweden — Door-to-needle time less than 60 minutes, arrival at a stroke unit before 4 hours, and use of thrombectomy were among quality measures that men were more likely to experience than women in a study of more than 83,000 hospital admissions for acute stroke.

Men were also more likely to receive a swallow screen within 4 hours, physiotherapy assessment within 72 hours, and early supported discharge compared with women in the study, which received the Paola De Rango award here at the 4th European Stroke Organisation Conference (ESOC) 2018.

The new findings "are somewhat surprising given that 10 years ago we looked at the same data and found no evidence of a difference," (Age Ageing. 2007;36:247-455) George Dunn, senior project coordinator of the Sentinel Stroke National Audit Programme at the Royal College of Physicians in London, UK, told Medscape Medical News. "A lot has changed in stroke care since then, but because this is such an important issue, we decided to look again."

"There were no quality measures that favored females," he added.

However, the study showed five measures with no evidence favoring men or women, including receipt of a brain scan within 1 hour and stroke nursing care within 24 hours. Another three 72-hour measures were not different: occupational therapy assessment; speech and language therapist assessment; or swallow assessment.

The research adds data to a body of literature without consensus. "Some studies suggest poorer care by women while others suggest equivalent care," he said.

The findings are based on 83,484 admissions for acute stroke from April 2016 to March 2017. All admissions were prospectively recorded in the Sentinel Stroke National Audit Programme (SSNAP), a national quality stroke register for England, Wales, and Northern Island. The patient population was 49% women.

Men were favored by a small amount versus women on measures including arrival at a stroke unit within 4 hours, received a swallow screen within 4 hours, or received early supported discharge. However, the researchers reported more pronounced differences for receiving thrombolysis, door-to-needle time within 60 minutes, and physiotherapy within 72 hours.

Table. Stroke Treatment Indicators for Women vs Men

Endpoint Adjusted OR 95% CI
Arrival at stroke unit within 4 h 1.04 1.01 - 1.07
Swallow screen within 4 h 1.05 1.01 - 1.10
Early supported discharge 1.05 1.01 - 1.08
Receiving thrombolysis 1.10 1.05 - 1.15
Door-to-needle time within 60 min 1.15 1.05 - 1.25
Physiotherapy within 72 h 1.11 1.03 - 1.19
CI: confidence interval; OR: odds ratio.

Median age at admission was 74 years among men and 80 years among women. "Women have stroke at an older age — both for hemorrhagic and ischemic stroke," Dunn said.

Diabetes was more prevalent among men and atrial fibrillation was more prevalent among women. "We expect this is likely due to the older age of females suffering stroke," he added.

The researchers chose the 11 prespecified measures of quality in acute stroke care before analyzing the data. They adjusted their findings for age, stroke type, atrial fibrillation, diabetes, hypertension, heart failure, longer time to hospital for women, and other factors.

Study strengths included a large number of cases, data entered using a secure web tool that allows internal validation, and complete geographic coverage of three countries (representing about 95% of acute stroke admissions). Only assessing acute care and not assessing outcomes were limitations.

The findings are "worrying," Dunn said. "We think more research should be done to make sure the data are consistent, and if so, steps should be taken to rectify the situation, because clearly this is unfair."

"It was a well-done study — the design and sample size of more than 80,000 people. It's quite impressive," said Valery Feigin, MD, PhD, director of the National Institute for Stroke and Applied Neurosciences School of Rehabilitation and Occupation Sciences at the Auckland University of Technology in New Zealand, commenting on the study for Medscape Medical News.

"I think the most important finding from the study is that there was a difference in favor of men in getting rehabilitation earlier and time to needle was shorter, which is a very big predictor of outcomes," Feigin added. "It's a very important study that could explain why men have better outcomes."

Dunn and Feigin have reported no relevant financial relationships.

4th European Stroke Organisation Conference (ESOC) 2018. Presented May 17, 2018.

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