Differences in the pre‐hospital management of women and men with stroke by emergency medical services in New South Wales

Abstract

andmark trials of intravenous thrombolysis 1 and endovascular thrombectomy 2 have transformed acute stroke care in recent years. As the efficacy of these treatments is highly time-dependent, rapid pre-hospital assessment is critical for optimising outcomes, and emergency medical services play a major role in realising their potential benefits.Differences in pre-hospital activation of emergency medical services for men and women with stroke have been examined in several studies (Supporting Information, table 1). Some investigators found no sex differences, 3 others that women were more likely to be transported to hospital by ambulance, 4 or that the mean time between symptom onset and presenting to hospital was longer for women than men. 5 However, most studies were not population-based and sample sizes were small. As many investigations were not designed to detect sex differences in pre-hospital activation of emergency medical services, they did not consider important confounding factors, such as age. [3][4][5] It is recognised that atypical clinical manifestations of stroke on initial presentation are more frequent in women. 6 Further, a large United States study found that the proportion of missed stroke diagnoses was nearly seven times as large for patients aged 18-44 years presenting to emergency departments (4.0%) as for those aged 75 years or more (0.6%). 7In our population-based study, we examined the pre-hospital care and management provided by emergency medical services to people admitted to hospital in New South Wales with stroke diagnoses. We investigated whether pre-hospital emergency medical services care was different for women and men, and whether any sex differences were influenced by age. MethodsWe analysed linked administrative data for women and men admitted to NSW hospitals during 1 July 2005 -31 December 2018 with a principal diagnosis and one additional diagnosis code for stroke at separation (International Classification of Diseases, tenth revision, Australian modification [ICD-10-AM] codes I60-68, G45) and no previous admissions with a stroke diagnosis in any diagnosis field after 31 July 2001 (ie, lookback period of four years).The NSW Admitted Patient Data Collection (APDC) includes hospital records from all NSW public and private hospitals and day procedure centres. APDC records include demographic data

Stroke is more than a hemiparesis: the pre‐hospital detection of stroke

“…Second, in countries where more women than men live alone (because of greater longevity), less information from family and relatives about women may be available to emergency medical service workers 5 . However, in the study by Wang and colleagues, younger women (under 70 years of age) with stroke were more frequently evaluated by emergency services personnel as having non‐stroke conditions than men, whereas differences between older men and women were not statistically significant 1 …”

“…Given the sex differences in pre‐hospital assessments of people later diagnosed with stroke and the care provided by emergency medical services described by Wang and colleagues, 1 differences in stroke symptom presentation warrant further study. In order to improve outcomes for women with stroke, we first need to identify them.…”

“…In most pre‐hospital services, the selection criteria are based on symptoms related to large vessel occlusions, such as the face/arm/speech (FAST) criteria. In a population‐based cohort study linking hospital and ambulance data, Wang and colleagues report that women under 70 years of age with stroke are more likely than men to be assessed by paramedics as having non‐stroke conditions, and are consequently less likely to receive specific stroke‐related care from emergency medical services 1 …”

“…Differences in symptom presentation by men and women with myocardial infarction and other cardiologic conditions are recognised, but differences in stroke symptom presentation have not been as well characterised. In the report by Wang and colleagues in this issue of the MJA , women subsequently diagnosed in hospital with stroke were more likely than men to be assessed by paramedics as having anxiety, nausea, headache, or being unconscious, rather than stroke 1 . Two recent meta‐analyses similarly found that women with stroke exhibit non‐focal symptoms more often than men, including generalised weakness, change in mental status, confusion, headache, and loss of consciousness 2,3 …”

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“…Early stroke intervention saves lives, but in a large populationbased NSW study (more than 200 000 people admitted to hospital with stroke; mean age, 73 years), Xia Wang and her colleagues 15 found troubling differences in the pre-hospital management by emergency medical services of women and men admitted to hospital with stroke. Women diagnosed with stroke after admission to hospital were more frequently assessed by paramedics as having anxiety, nausea, headache, or being unconscious, rather than stroke, and paramedics were less likely to diagnose stroke in women than in men under 70 years of age.…”