Confounding by Pre-Morbid Functional Status in Studies of Apparent Sex Differences in Severity and Outcome of Stroke

Renoux, Christel; Coulombe, Janie; Li, Linxin; Ganesh, Aravind; Silver, L E; Rothwell, Peter M.

doi:10.1161/strokeaha.117.018187

Cited by 58 publications

(48 citation statements)

References 34 publications

(26 reference statements)

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“…Women’s all-cause mortality after stroke has been put forward as lower when adjusting for other relevant factors [ 18 ], but there are also results opposing that [ 19 ] as well as dismissing any significant differences [ 20 ]. Variations in the findings on sex differences between previous studies [ 21 – 25 ] may not only reflect differences in the population but also differences in the adjustments performed. Such general differences in statistical approach have also been pointed out in recently published American guidelines [ 14 ].…”

Section: Discussionmentioning

confidence: 90%

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Sex as predictor for achieved health outcomes and received care in ischemic stroke and intracerebral hemorrhage: a register-based study

et al. 2018

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BackgroundDifferences in stroke care and health outcomes between men and women are debated. The objective of this study was to explore the relationship between patients’ sex and post-stroke health outcomes and received care in a Swedish setting.MethodsPatients with a registered diagnosis of acute intracerebral hemorrhage (ICH) or ischemic stroke (IS) within regional administrative systems (ICD-10 codes I61* or I63*) and the Swedish Stroke Register during 2010–2011 were included and followed for 1 year. Data linkage to multiple other data sources on individual level was performed. Adjustments were performed for age, socioeconomic factors, living arrangements, ADL dependency, and stroke severity in multivariate regression analyses of health outcomes and received care. Health outcomes (e.g., survival, functioning, satisfaction) and received care measures (regional and municipal resources and processes) were studied.ResultsStudy population: 13,775 women and 13,916 men. After case-mix adjustments for the above factors, we found women to have higher 1-year survival rates after both IS (ORfemale = 1.17, p < 0.001) and ICH (ORfemale = 1.65, p < 0.001). Initial inpatient stay at hospital was, however, shorter for women (βfemale, IS = − 0.05, p < 0.001; βfemale, ICH = − 0.08, p < 0.005). For IS, good function (mRS ≤ 2) was more common in men (ORfemale = 0.86, p < 0.001) who also received more inpatient care during the first year (βfemale = − 0.05, p < 0.001).ConclusionsA lower proportion of women had good functioning, a difference that remained in IS after adjustments for age, socioeconomic factors, living arrangements, ADL dependency, and stroke severity. The amount of received hospital care was lower for women after adjustments. Whether shorter hospital stay results in lower function or is a consequence of lower function cannot be elucidated. One-year survival was higher in men when no adjustments were made but lower after adjustments. This likely reflects that women were older at time of stroke, had more severe strokes, and more disability pre-stroke—factors that make a direct comparison between the sexes intricate.Electronic supplementary materialThe online version of this article (10.1186/s13293-018-0170-1) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 90%

“…We found the rates of good 1-year functioning after IS to be lower in women, in line with previous studies [ 21 – 23 ]. There are also studies pointing to no significant differences [ 24 , 25 ]. Any such differences could be attributable to sex bias in the diagnosis and treatment or to the biological differences in the disease.…”

Section: Discussionmentioning

confidence: 99%

Sex as predictor for achieved health outcomes and received care in ischemic stroke and intracerebral hemorrhage: a register-based study

et al. 2018

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“…Studies of activity limitations demonstrated that prestroke function was an important contributor to the sex difference in this outcome. 15,18 Although many authors considered prestroke function or cardiovascular comorbidities as confounders, few considered musculoskeletal (eg, osteoporosis or arthritis) or mental disorders that are more prevalent in women compared with men. 60 Associated with prestroke health is women's older age than men at the time of stroke.…”

Section: Discussionmentioning

confidence: 99%

“…[17][18][19][22][23][24] Common covariates included age, stroke severity, and comorbidities. There were 6 comparisons rendered nonsignificant by adjustment for covariates, 15,16,20,21,25 which were most commonly age, stroke severity, comorbidities, and health behaviors. Adjustment for covariates reduced the sex differences by between 2% and 47%.…”

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confidence: 99%

“…In several studies, prestroke modified Rankin Scale was the largest contributor to sex differences in activity limitations. 15,18 In the 3 studies of intracerebral hemorrhage, 26-28 women had more activity limitations than men demonstrated by significantly higher odds of poor outcome (range, 1.77-2.00), 28 a higher proportion with poor outcome (58.4% versus 45.3%), 27 or a lower proportion with good outcome (33.4% versus 41%). 26 In adjusted analyses, some studies showed no statistically significant sex difference at 90 days 27 and 12 months.…”

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Focused Update of Sex Differences in Patient Reported Outcome Measures After Stroke

Gall

Phan

Madsen

et al. 2018

Stroke

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W omen experience worse outcomes after stroke than men 1 despite their lower age-adjusted incidence of stroke.2 Previous reviews of sex differences in select stroke outcomes, including activity limitations, 3-5 participation restriction, 4 poststroke depression (PSD), 3 and health-related quality of life (HRQoL), 3,4 demonstrated that women had worse outcomes than men across many of these measures. Women's greater age and stroke severity, as well as poorer prestroke function, seem to contribute to the sex difference in outcomes, but data on other contributing factors are limited.4 Existing reviews included studies published >5 years ago, and given the rapid increase in the number of studies addressing sex differences in stroke outcomes, an updated review is warranted. MethodsFull details of our methods are provided in the online-only Data Supplement. A previous review included studies up to 2007, 3 so we reviewed studies from 2007 onwards that examined sex differences in patient reported outcome measures (PROMs) at ≤12 months after stroke, including activity limitations, HRQoL, participation restriction, impaired cognition, and mood. 6 Full results tables are shown in the online-only Data Supplement. Results Activity LimitationsOf 1875 articles identified, 22 studies (3 population based) that were designed to examine sex differences (Results and Table I in the online-only Data Supplement) met criteria for inclusion. The most common instrument to assess activity limitations was the modified Rankin Scale, followed by the Barthel Index.In 8 studies including ischemic and hemorrhagic strokes, unadjusted estimates showed that women had more activity limitations than men through significantly lower odds of good outcome (odds ratio [OR] range: 0.44-0.61) 7-9 or greater odds of poor outcome (OR range: 1.29-1.62).10-14 In multivariable adjusted analyses, women had worse outcome than men with significantly lower odds of good outcome (OR range: 0.37-0.75) or greater odds of poor outcome (OR range: 1.17-1.74). 7,8,10,12,13 In 2 studies, there was no statistically significant difference between women and men.11,14 Adjustment for covariates, most commonly age, stroke severity, comorbidities, and prestroke function, reduced the associations between 9% and 20%, suggesting these factors partly explain the greater activity limitations for women after stroke.In 11 studies of ischemic stroke ( Table I in the online-only Data Supplement), women generally had worse outcome than men demonstrated by greater odds of poor outcome (mostly modified Rankin Scale ≥3 versus <3; range in ORs: 1.13-2.40) or lower odds of good outcome (eg, modified Rankin Scale ≤1 versus >1 or independent walking).15-25 Among 13 multivariable adjusted comparisons between men and women (some studies had >1 comparison), women's significantly worse outcome compared with men persisted in 7 comparisons with a greater odds of poor outcome (range, 1.30-3.40) or a higher activities of daily living score. [17][18][19][22][23][24] Common covariates included age, stro...

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Acute Medical Therapies for Persons Living with Physical or Cognitive Disability

Ganesh,

Viswanathan

2024

The Palgrave Encyclopedia of Disability

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Confounding by Pre-Morbid Functional Status in Studies of Apparent Sex Differences in Severity and Outcome of Stroke

Abstract: Supplemental Digital Content is available in the text.

Cited by 58 publications

References 34 publications

Sex as predictor for achieved health outcomes and received care in ischemic stroke and intracerebral hemorrhage: a register-based study

Sex as predictor for achieved health outcomes and received care in ischemic stroke and intracerebral hemorrhage: a register-based study

Focused Update of Sex Differences in Patient Reported Outcome Measures After Stroke

Acute Medical Therapies for Persons Living with Physical or Cognitive Disability

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