Factors contributing to sex differences in functional outcomes and participation after stroke

Phan, Hoang; Blizzard, Christopher Leigh; Reeves, Mathew J.; Thrift, Amanda G.; Cadilhac, Dominique A; Sturm, Jonathan; Heeley, Emma; Otáhal, Petr; Vemmos, Konstantinos; Anderson, Craig S.; Parmar, Priya; Krishnamurthi, Rita; Barker‐Collo, Suzanne; Feigin, Valery L.; Béjot, Yannick; Cabral, Norberto Luiz; Carolei, Antonio; Sacco, Simona; Chausson, Nicolas; Olindo, Stéphane; Rothwell, Peter M.; Silva, Carolina; Correia, Manuel; Magalhães, Rui; Appelros, Peter; Kõrv, Janika; Vibo, Riina; Minelli, César; Gall, Seana

doi:10.1212/wnl.0000000000005602

Cited by 47 publications

(40 citation statements)

References 38 publications

(34 reference statements)

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“…Because of the inconsistency of covariate measurements between studies from different populations, we used the two-stage method of analysis proposed for IPD meta-analysis 29 using the same approach demonstrated in previous publications from INSTRUCT, including for mortality 6 and functional outcome. 18 The first stage involved building study-specific crude and adjusted models to estimate women:men mortality rate ratio (MRR) or RR of having poorer functional outcomes for women compared with men. For mortality outcome, we used Poisson regression with the logarithm of the number of person-years at risk of dying within that period entered as an offset.…”

Section: Discussionmentioning

confidence: 99%

“…16 The details of the design of INSTRUCT have been described elsewhere. 6,17,18 This analysis focused on participants with IS and AF in the INSTRUCT, and included nine studies whose investigators have agreed to participate ( Supplementary Table S1). [19][20][21][22][23][24][25][26][27] These studies were conducted in Australia, New Zealand, Brazil, Greece, Sweden, Portugal, Italy, and Estonia between 1993 and 2014.…”

Section: Meta-analysis Of Ipdmentioning

confidence: 99%

“…The details of study outcomes of the INSTRUCT have been described elsewhere. 6,18 Measures of mortality rate at 1 year were available among all nine studies, whereas those at 5 years were available among 5five of nine studies. Mortality rate was obtained from national death registries (the studies from Melbourne, Perth, Orebro, and Tartu) or the combination of hospital records, death certificates, or participant followups (remaining studies: Joinville, Arcadia, Porto, Auckland, L'Aquila).…”

Section: Outcome Measurementmentioning

confidence: 99%

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Sex Differences in Disease Profiles, Management, and Outcomes Among People with Atrial Fibrillation After Ischemic Stroke: Aggregated and Individual Participant Data Meta-Analyses

Wang

Phan

et al. 2020

Women's Health Reports

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Objectives: To examine sex differences in disease profiles, management, and survival at 1 and 5 years after ischemic stroke (IS) among people with atrial fibrillation (AF). Methods: We performed a systematic literature search of reports of AF at IS onset according to sex. We undertook an individual participant data meta-analysis (IPDMA) of nine population-based stroke incidence studies conducted in Australasia, Europe, and South America (1993-2014). Poisson regression was used to estimate women:men mortality rate ratios (MRRs). Study-specific MRRs were combined using random effects meta-analysis. Results: In our meta-analysis based on aggregated data from 101 studies, the pooled AF prevalence was 23% (95% confidence interval [CI]: 22%-25%) in women and 17% (15%-18%) in men. Our IPDMA is of 1,862 IS-AF cases, with women (79.2-9.1, years) being older than men (76.5-9.5, years). Crude pooled mortality rate was greater for women than for men (1-year MRR 1.

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Section: Discussionmentioning

confidence: 99%

Section: Meta-analysis Of Ipdmentioning

confidence: 99%

Section: Outcome Measurementmentioning

confidence: 99%

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Sex Differences in Disease Profiles, Management, and Outcomes Among People with Atrial Fibrillation After Ischemic Stroke: Aggregated and Individual Participant Data Meta-Analyses

Wang

Phan

et al. 2020

Women's Health Reports

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“…Previous studies of sex differences in post-stroke outcomes provided conflicting findings (5). Two recently published systematic reviews from the International Stroke Outcomes Study (INSTRUCT) research group suggest that sex differences in mortality and functional outcomes are eliminated after adjustment for age, pre-stroke functional limitation, and stroke severity (6,7). The higher mortality risk for women was even reversed after adjustment (6).…”

Section: Introductionmentioning

confidence: 99%

Sex Differences in Long-Term Mortality and Functional Outcome After Rehabilitation in Patients With Severe Stroke

et al. 2020

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Objective: We sought to determine sex differences in outcomes in patients with severe stroke who had been admitted to inpatient rehabilitation.Methods: We studied 1,316 patients aged 18 to 99 (mean 72) classified as case-mix groups 0108, 0109, and 0110 of the Medicare case-mix classification system. These groups encompass the most severe strokes. Three outcomes were analyzed: (1) 3-year mortality from admission to rehabilitation; (2) combined outcome of transfer to acute care or death within 90 days from admission to rehabilitation; (3) functional outcome, including proportional recovery in motor functioning and good functional outcome as defined by achievement of a Functional Independence Measure (FIM)-motor score ≥65 points at discharge. Multivariable regression analyses were used to assess sex-difference in each outcome between women and men. The covariates examined included age, marital status, comorbidities, time from stroke onset to rehabilitation admission <30 days, ischemic stroke, dysphagia, neglect, motor FIM score at admission, and cognitive FIM score at admission.Results: Kaplan-Meier estimated 3-year mortality rate was 20.7% in women and 22.0% in men. The crude hazard ratio (HR) of death for women compared with men was 0.94 (95% CI 0.74-1.20). After adjustment for significant covariates, the HR of 3-year mortality was 0.73 (95% CIs 0.56-0.96; p = 0.025). Comorbidity, including diabetes, anemia, coronary artery disease, atrial fibrillation, and chronic obstructive pulmonary disease, significantly increased mortality risk by 49-88%. The incidence of the combined outcome was 8.3% in women and 8.4% in men. The crude HR of the combined end-point for women compared with men was 1.05 (95% CI 0.72-1.53). After adjustment for significant covariates, the HR was 0.95 (95% CIs 0.65-1.40; p = 0.810). Likewise, no significant difference in proportional recovery or in the rate of achievement of a good functional outcome between women and men was observed.Conclusion: Among patients admitted to inpatient rehabilitation after severe stroke, women and men had comparable crude mortality rates at 3 years. After multivariable Scrutinio et al.Sex Differences in Severe Stroke adjustment, however, women had lower mortality risk. No sex-differences in the risk of being transferred to acute care or dying within 90 days from admission to rehabilitation or in responsiveness to rehabilitation were observed.

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“…Older age at presentation, preexisting comorbidities, obesity, and atrial fibrillation (AF) are more common in women [1,2,6,7]. When these conditions are factored into the multivariate analysis, some studies suggest that the outcome may be similar in both sexes [3], while others report poor outcome in women [1,8,9]. A recent analysis from 5 pooled trials revealed that compared to men, women showed slower recovery following ischemic but not hemorrhagic strokes [6].…”

Section: Introductionmentioning

confidence: 99%

Sex-Specific Differences in Short-Term and Long-Term Outcomes in Acute Stroke Patients from Qatar

et al. 2020

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Background: Sex differences may determine presentation, utility of treatment, rehabilitation, and occurrences of major adverse cardiovascular events (MACEs) in acute stroke (AS). Objective:The purpose of the study was to evaluate the short-term prognosis and long-term outcomes in MACEs in Qatari nationals admitted with AS. Methods: All AS patients admitted between January 2014 and February 2019 were included. We evaluated the preadmission modified Rankin scale (mRS) score, etiology and severity of symptoms, complications, and functional recovery at discharge and 90 days. MACEs were recorded for 5 years. Results: There were 891 admissions for AS (mean age 64.0 ± 14.2 years) (male, n = 519 [mean age ± SD 62.9 ± 14.1 years]; female, n = 372 [mean age ± SD 65.6 ± 14.2 years] p = 0.005). There were no differences in the preadmission mRS and severity of symptoms as measured on National Institute of Stroke Scale. At discharge, the outcome was better (mRS 0–2) in men (57.8 vs. 46.0%), p = 0.0001. This difference persisted at the 90-day follow-up (mRS 0–2, male 69.4% vs. female 53.2%, p = 0.0001). At the 90-day follow-up, more women died (total deaths 70; women 38 [10.2%] versus men 32 [6.2%], p = 0.03). MACEs occurred in 25.6% (133/519) males and 30.9% (115/372) females over the 5-year follow-up period (odds ratio 0.77, 95% confidence interval 0.57–1.0, p = 0.83). Conclusions: Female patients have a poor short-term outcome following an AS when corrected for age and comorbidities. While our study cannot explain the reasons for the discrepancies, higher poststroke depression and social isolation in women may be important contributory factors, and requires further studies are required to confirm these findings.

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Factors contributing to sex differences in functional outcomes and participation after stroke

Abstract: Worse outcomes after stroke among women were explained mostly by age, stroke severity, and prestroke dependency, suggesting these potential targets to improve the outcomes after stroke in women.

Cited by 47 publications

References 38 publications

Sex Differences in Disease Profiles, Management, and Outcomes Among People with Atrial Fibrillation After Ischemic Stroke: Aggregated and Individual Participant Data Meta-Analyses

Sex Differences in Disease Profiles, Management, and Outcomes Among People with Atrial Fibrillation After Ischemic Stroke: Aggregated and Individual Participant Data Meta-Analyses

Sex Differences in Long-Term Mortality and Functional Outcome After Rehabilitation in Patients With Severe Stroke

Sex-Specific Differences in Short-Term and Long-Term Outcomes in Acute Stroke Patients from Qatar

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