Sex Differences in Long-Term Quality of Life Among Survivors After Stroke in the INSTRUCT

Hoang T. Phan, PhD; Christopher L. Blizzard, PhD; Mathew J. Reeves, PhD; Amanda G. Thrift, PhD; Dominique A. Cadilhac, PhD; Jonathan Sturm, PhD; Emma Heeley, PhD; Petr Otahal, GDipSc; Peter Rothwell, PhD; Craig S. Anderson, PhD; Priya Parmar, PhD; Rita Krishnamurthi, PhD; Suzanne Barker-Collo, PhD; Valery Feigin, PhD; Seana Gall, PhD


Stroke. 2019;50(9):2299-2306. 

In This Article

Abstract and Introduction


Background and Purpose: Women are reported to have poorer health-related quality of life (HRQoL) after stroke than men, but the underlying reasons are uncertain. We investigated factors contributing to the sex differences.

Methods: Individual participant data on 4288 first-ever strokes (1996–2013) were obtained from 4 high-quality population-based incidence studies from Australasia and Europe. HRQoL utility scores among survivors after stroke (range from negative scores=worse than death to 1=perfect health) were calculated from 3 scales including European Quality of Life-5 Dimensions, Short-Form 6-Dimension, and Assessment of Quality of Life at 1 year (3 studies; n=1210) and 5 years (3 studies; n=1057). Quantile regression was used to estimate the median differences in HRQoL for women compared to men with adjustment for covariates. Study factors included sociodemographics, prestroke dependency, stroke-related factors (eg, stroke severity), comorbidities, and poststroke depression. Study-specific median differences were combined into pooled estimates using random-effect meta-analysis.

Results: Women had lower pooled HRQoL than men (median differenceunadjusted 1 year, −0.147; 95% CI, −0.258 to −0.036; 5 years, −0.090; 95% CI, −0.119 to −0.062). After adjustment for age, stroke severity, prestroke dependency, and depression, these pooled median differences were attenuated, more greatly at 1 year (−0.067; 95% CI, −0.111 to −0.022) than at 5 years (−0.085; 95% CI, −0.135 to −0.034).

Conclusions: Women consistently exhibited poorer HRQoL after stroke than men. This was partly attributable to women's advanced age, more severe strokes, prestroke dependency, and poststroke depression, suggesting targets to reduce the differences. There was some evidence of residual differences in HRQoL between sexes but they were small and unlikely to be clinically significant.


The greater burden of stroke in women than in men has recently been recognized as a major concern worldwide.[1] Women generally have a poorer health-related quality of life (HRQoL) than men, both in the short- and long-term after stroke.[2,3] Despite the increased interest in sex differences, the reasons for worse HRQoL in women have been inadequately investigated.

Existing studies of sex differences in HRQoL after stroke have several limitations.[2,3] Most only incorporate short-term outcomes (up to 6 months), as shown in a systematic review of sex differences in HRQoL following stroke.[2] Many investigators also did not report sex-specific findings, used modeling that was not focused on the sex difference (ie, step-wise regression), or reported sex differences as incidental findings.[2] Of a small number of studies specifically designed to examine sex differences, most were based in hospital or restricted to a specific type of stroke or to certain age groups.[2] These limitations are problematic as selection bias may adversely affect the conclusions.[4] Although population-based stroke incidence studies[5] are the most generalizable and ideal study designs to examine sex differences,[6] few incorporate assessment of HRQoL or analysis of sex differences. In the most recent update on sex difference in outcome after stroke, only 2 out of 13 studies published since 2007 were designed to examine the sex difference in HRQoL, and neither of these were population-based studies.[3] There are also inconsistent findings about the causes of the sex difference in HRQoL because of variation in outcome measurement and adjustment for different covariates.[2]

The aim of this study was to quantify the sex differences in HRQoL among survivors up to 5 years after stroke and identify factors contributing to any observed sex differences, using individual participant data collected from ideal population-based incidence stroke studies conducted in different countries.