Do Presenting Symptoms Explain Sex Differences in Emergency Department Delays Among Patients With Acute Stroke?

Abstract

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.

Unequal Access to Treatment With Intravenous Alteplase for Women With Acute Ischemic Stroke

“…This is also confirmed in other studies. 6 Also, in myocardial infarction, there is an underutilization of thrombolytic therapy in women and a delay in care seeking. 7 Possible reasons for this delay are differences in presenting symptoms and the older age of women on average.…”

Higher Prehospital Priority Level of Stroke Improves Thrombolysis Frequency and Time to Stroke Unit

“…This study showed no differences according to sex, which is in agreement with findings from Michigan where no sex differences concerning prehospital or in-hospital delay for patients arriving within 6 hours were found, although they found a longer in-hospital delay for women. 19 In a review on sex differences in stroke from 2010, 2 studies were presented showing women to be less likely to receive thrombolysis, whereas 5 studies found no sex differences. 20 Recruitment was prematurely terminated after a protocoldefined safety interim analysis at the EMCC.…”

Is There Gender Bias in Critical Care?

“…25 In the inpatient setting, women with stroke have longer waiting times after they arrive in the emergency department and receive less aggressive treatment and therapeutic workup following their admission. 24,26,27 One recent study found that women had 11% longer door-to-doctor times and 15% longer door-to-image times as men. 27 These differences have potentially enormous consequences because the primary therapy for treating acute ischemic stroke, tissue plasminogen activator, has a very short therapeutic window, so even brief delays could make patients ineligible.…”