Background and Purpose-Many studies have reported poorer stroke outcomes in women, and some studies have reported sex differences in care. We analyzed data from a hospital-based stroke registry to determine whether acute stroke care and discharge status differed by sex. Methods-Detailed chart-level information was collected on 2566 subjects admitted for acute stroke or transient ischemic attack to 15 Michigan hospitals in 2002. Sex differences in stroke care and patient status at discharge (in-hospital mortality and modified Rankin Scale score) were assessed after adjusting for differences in demographics, clinical characteristics, and comorbidities by multivariable models. Modified Rankin Scale score data were analyzed by proportional-odds models. Results-Women were older than men (70 vs 67 years) and were more likely to have congestive heart failure and hypertension. Men were more likely to smoke and have a history of heart disease and dyslipidemia. After multivariable adjustment, women were less likely to receive thrombolytic therapy (odds ratio [OR]ϭ0.56; 95% CI, 0.37 to 0.86) or lipid testing (ORϭ0.76; 95% CI, 0.61 to 0.94) and were more likely to suffer urinary tract infections (ORϭ2.57; 95% CI, 1.87 to 3.54). In-hospital mortality was similar in women and men (9% vs 8%); however, women had poorer discharge modified Rankin Scale scores (ORϭ1.17; 95% CI, 1.01 to 1.35). Conclusions-Although considerable parity exists in many aspects of acute stroke care, women were less likely than men to receive thrombolytic treatment and lipid testing, even after adjustment. However, given the largely similar care observed, it is unlikely that differences in care explain the poorer functional outcomes in female stroke survivors.
Background:In-hospital stroke (IHS) represents 5–15% of all hospitalized acute stroke cases, and is associated with poor outcomes. IHS represents an important area for prevention since many cases occur in high-risk patients undergoing cardiovascular procedures. Our objectives were to compare the quality of care, treatments, and outcomes of IHS with out-of-hospital stroke (OHS) cases. Methods: A 6-month prospective cohort of IHS and OHS stroke cases from a statewide acute stroke registry of 15 representative hospitals was assembled. Data were abstracted on demographic, clinical characteristics, in-hospital care (including tPA treatment), discharge instructions, and in-hospital outcomes (mortality and modified Rankin Scale [mRS] at discharge). Results:177 (6.5%) of the 2,743 cases in the registry were IHS cases. 40% of IHS cases were admitted with a cardiovascular or neurologically related problem, and 68% underwent an invasive diagnostic or surgical procedure prior to their stroke. IHS cases were less likely to have the cerebral vasculature examined or to have a lipid panel drawn. Compared to OHS, IHS had higher case fatality (14.6 vs. 6.9%; p = 0.04), greater functional impairment (mRS ≧4) (61 vs. 36%; p < 0.001), and were less likely to be discharged home (23 vs. 52%, p < 0.01). Conclusions:In this prospective registry, 1 in 15 acute stroke cases occurred in the hospital, and almost 70% had an invasive procedure undertaken prior to their stroke event. In-hospital cases received similar quality of care as OHS cases, but had significantly worse outcomes.
Treatment with IV rt-PA was underutilized in this hospital-based stroke registry. The primary reason for nontreatment was delayed presentation. Reducing prehospital and in-hospital response times would help increase IV rt-PA use, as would greater emergency medical services use. Improving the documentation of onset times would help clarify the underlying causes of delayed presentation.
Background and Purpose-Previous studies report that women with stroke may experience longer delays in diagnostic workup than men after arriving at the emergency department. We hypothesized that presenting symptom differences could explain these delays. Methods-Data were collected on 1922 acute stroke cases who presented to 15 hospitals participating in a statewide stroke registry. We evaluated 2 in-hospital time intervals: emergency department arrival to physician examination ("door-todoctor") and emergency department arrival to brain imaging ("door-to-image"). We used parametric survival models to estimate time ratios, which represent the ratio of average times comparing women to men, after adjusting for symptom presentation and other confounders. Results-Women were significantly less likely than men to present with any stroke warning sign or suspected stroke (87.5% versus 91.4%) or to report trouble with walking, balance, or dizziness (9.5% versus 13.7%). Difficulty speaking and loss of consciousness were associated with shorter door-to-doctor times. Weakness, facial droop, difficulty speaking, and loss of consciousness were associated with shorter door-to-image times, whereas difficulty with walking/balance was associated with longer door-to-image times. In adjusted analyses, women had 11% longer door-to-doctor intervals (time ratio, 1.11; 95%, CI 1.02 to 1.22) and 15% longer door-to-image intervals (time ratio, 1.15; 95% CI, 1.08 to 1.25) after accounting for presenting symptoms, age, and other confounders. Furthermore, these sex differences remained evident after restricting to patients who arrived within 6 or within 2 hours of symptom onset. Conclusions-Women with acute stroke experienced greater emergency department delays than men, which were not attributable to differences in presenting symptoms, time of arrival, age, or other confounders.
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