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

Ridder, Inger de; Dirks, Maaike; Niessen, Louis; Dippel, Diederik W.J.

doi:10.1161/strokeaha.113.002263

Cited by 35 publications

(31 citation statements)

References 7 publications

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“…15 Although women were >7 years older and stroke symptom onset was more often unknown in women, our study depicted no sex differences in the use of intravenous recombinant tissue-type plasminogen activator with a thrombolysis rate of 14.5% for men and women. This is in accordance with a recent analysis by the Promoting Acute Thrombolysis for Ischaemic Stroke (PRACTISE) study investigators 16 and might be explained by a nowadays generally more wider application of intravenous thrombolysis beyond the previous classical contraindications such as especially higher age. 17 Regarding the use of thrombolysis, it is also crucial to highlight that in our specialized stroke unit care setting, no clinically significant sex-related differences in onset-to-door time, door to neuroimaging time, and door-to-needle time were identified.…”

Section: Discussionsupporting

confidence: 91%

Sex-Related Differences of Acute Stroke Unit Care

Gattringer

Ferrari

Knoflach

et al. 2014

Stroke

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Background and Purpose-Sex-related differences in quality of acute stroke care are an important concern with limited data available, specifically regarding stroke unit (SU) setting. We used the prospective nationwide Austrian SU registry to address this issue. Methods-Our analysis covered an 8-year time period (January 2005 to December 2012) during which all patients with transient ischemic attack or ischemic stroke admitted to 1 of 35 Austrian SU had been captured in the registry. These data were analyzed for age-adjusted preclinical and clinical characteristics and quality of acute stroke care in men and women. In addition, we assessed the outcome at 3 months in multivariate analysis. Results-A total of 47 209 individuals (47% women) had received SU care. Women were significantly older (median age:77.9 versus 70.3 years), had higher pre-existing disability and more severe strokes. Correcting for age, no significant sex-related differences in quality of care were identified with comparable onset-to-door times, times to and rates of neuroimaging, as well as door-to-needle times and rates of intravenous thrombolysis (14.5% for both sexes). Despite equal acute stroke care and a comparable rate of neurorehabilitation, women had a worse functional outcome at 3-month follow-up (modified Rankin scale 3-5: odds ratio,

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Section: Discussionsupporting

confidence: 91%

Sex-Related Differences of Acute Stroke Unit Care

Gattringer

Ferrari

Knoflach

et al. 2014

Stroke

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“…Some studies of acute ischemic stroke (AIS) patients report longer times from symptom onset to emergency department (ED) arrival for women, 1–5 but other studies report no significant difference in time to ED arrival between women and men. 6–11 The relationship between gender and time to ED arrival in AIS is important to clarify given worse short- and long-term outcomes in women and was highlighted as an issue in the recently published stroke prevention guidelines for women by Bushnell et al 6,12–14 In addition, in some study populations, women are less likely than men to receive standard-of-care therapies for acute ischemic stroke, and delayed time to arrival is the most common reason for exclusion from acute time-sensitive therapies in both genders.…”

Section: Introductionmentioning

confidence: 99%

Gender and Time to Arrival among Ischemic Stroke Patients in the Greater Cincinnati/Northern Kentucky Stroke Study

Madsen

Sucharew

Katz

et al. 2016

Journal of Stroke and Cerebrovascular Diseases

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Background Some studies of stroke patients report longer pre-hospital delays in women, but others conflict; studies vary in their inclusion of factors including age and stroke severity. We aimed to investigate the relationship between gender and time to emergency department (ED) arrival and the influence of age and stroke severity on this relationship. Methods Ischemic stroke patients ≥ 20 years old who presented to 15 hospitals within a 5-county region of Greater Cincinnati/Northern Kentucky during 2010 were included. Time from symptom onset to ED arrival and covariates were abstracted by study nurses and reviewed by study physicians. Data were analyzed using logistic regression with time to arrival dichotomized at ≤ 3 hours, in the overall sample and then stratified by NIHSS and age. Results 1991 strokes (55% women) were included. Time to arrival was slightly longer in women (geometric mean 337 minutes [95%CI 307–369] vs. 297 [95%CI 268–329], p =0.05), and 24% of women vs. 27% of men arrived within 3 hours (p=0.15). After adjusting for age, race, NIHSS, living situation, and other covariates, gender was not associated with delayed time to arrival (OR=1.00, 95%CI 0.78–1.28). This did not change across age or NIHSS categories. Conclusions After adjusting for factors including age, NIHSS, and living alone, women and men with ischemic stroke had similar times to arrival. Arrival time is not likely a major contributor to differences in outcome between men and women.

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“…41 This is despite a pooled analysis of randomised controlled trials demonstrating that women are more likely than men to benefit from thrombolysis. 42,43 Research to assess and clarify the impact of sex on thrombolysis utilisation and outcomes using individual patient data collated from randomised trials is ongoing and should clarify this effect, if any.…”

Section: Patient-related Factors That Can Influence Clinician Decisiomentioning

confidence: 99%

“…For instance, there is a suggestion that sex may have a population-level effect on thrombolysis administration, with evidence of underutilisation of intravenous thrombolysis in women, 40 although this may reflect a different age and presentation profile in women. 41 This suggestion comes despite a pooled analysis of randomised controlled trials demonstrating that women are more likely than men to benefit from thrombolysis. 42,43 The panel did not consider sex to be a conscious consideration at the individual, bedside level.…”

Section: Box 1 Patient-related Factors That Could Influence Decision-mentioning

confidence: 99%

Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment

Thomson

Brún

Flynn

et al. 2017

Health Serv Deliv Res

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BackgroundIntravenous thrombolysis for patients with acute ischaemic stroke is underused (only 80% of eligible patients receive it) and there is variation in its use across the UK. Previously, variation might have been explained by structural differences; however, continuing variation may reflect differences in clinical decision-making regarding the eligibility of patients for treatment. This variation in decision-making could lead to the underuse, or result in inappropriate use, of thrombolysis.ObjectivesTo identify the factors which contribute to variation in, and influence, clinicians’ decision-making about treating ischaemic stroke patients with intravenous thrombolysis.MethodsA discrete choice experiment (DCE) using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted to better understand the influence of patient-related and clinician-related factors on clinical decision-making. An online DCE was developed following an iterative five-stage design process. UK-based clinicians involved in final decision-making about thrombolysis were invited to take part via national professional bodies of relevant medical specialties. Mixed-logit regression analyses were conducted.ResultsA total of 138 clinicians responded and opted to offer thrombolysis in 31.4% of cases. Seven patient factors were individually predictive of the increased likelihood of offering thrombolysis (compared with reference levels in brackets): stroke onset time of 2 hours 30 minutes (50 minutes); pre-stroke dependency modified Rankin Scale score (mRS) of 3 (mRS4); systolic blood pressure (SBP) of 185 mmHg (140 mmHg); stroke severity scores of National Institutes of Health Stroke Scale (NIHSS) 5 without aphasia, NIHSS 14 and NIHSS 23 (NIHSS 2 without aphasia); age 85 years (65 years); and Afro-Caribbean (white). Factors predictive of not offering thrombolysis were age 95 years; stroke onset time of 4 hours 15 minutes; severe dementia (no memory problems); and SBP of 200 mmHg. Three clinician-related factors were predictive of an increased likelihood of offering thrombolysis (perceived robustness of the evidence for thrombolysis; thrombolysing more patients in the past 12 months; and high discomfort with uncertainty) and one factor was predictive of a decreased likelihood of offering treatment (clinicians’ being comfortable treating patients outside the licensing criteria).LimitationsWe anticipated a sample size of 150–200. Nonetheless, the final sample of 138 is good considering that the total population of eligible UK clinicians is relatively small. Furthermore, data from the Royal College of Physicians suggest that our sample is representative of clinicians involved in decision-making about thrombolysis.ConclusionsThere was considerable heterogeneity among respondents in thrombolysis decision-making, indicating that clinicians differ in their thresholds for treatment across a number of patient-related factors. Respondents were significantly more likely to treat 85-year-old patients than patients aged 68 years and this probably reflects acceptance of data from Third International Stroke Trial that report benefit for patients aged > 80 years. That respondents were more likely to offer thrombolysis to patients with severe stroke than to patients with mild stroke may indicate uncertainty/concern about the risk/benefit balance in treatment of minor stroke. Findings will be disseminated via peer-review publication and presentation at national/international conferences, and will be linked to training/continuing professional development (CPD) programmes.Future workThe nature of DCE design means that only a subset of potentially influential factors could be explored. Factors not explored in this study warrant future research. Training/CPD should address the impact of non-medical influences on decision-making using evidence-based strategies.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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

Cited by 35 publications

References 7 publications

Sex-Related Differences of Acute Stroke Unit Care

Sex-Related Differences of Acute Stroke Unit Care

Gender and Time to Arrival among Ischemic Stroke Patients in the Greater Cincinnati/Northern Kentucky Stroke Study

Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment

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