Gender difference in stroke case fatality: an integrated study of hospitalization and mortality

Gender differences in mortality of hospitalised stroke patients. Systematic review and meta-analysis

OBJECTIVE

Gender differences in mortality after stroke remains unclear in the current literature. We therefore aimed to systematically review the gender differences in mortality up to five years after ischaemic (IS) or haemorrhagic stroke (HS) to address this evidence gap.

METHODS

The literature was systematically searched using Ovid EMBASE, Ovid Medline, and Web of Science databases, from inception-November 2021. The quality of evidence was appraised using the CASP Cohort-study checklist. Unadjusted and adjusted odds and hazard ratios were meta-analysed, separately for IS and HS and a subgroup analysis of age-stratified mortality data was conducted.

RESULTS

Forty-one studies were included (n = 8,128,700; mean-age 68.5 yrs; 47.1% female). 37 studies were included in meta-analysis (n = 8, 8008, 110). Compared to men, women who had an IS had lower mortality risk in-hospital (0.94; 95%CI 0.91-0.97), at one-month (0.87; 95%CI 0.77-0.98), 12-months (0.94; 95%CI 0.91-0.98) and five-years (0.93 95%CI 0.90-0.96). The subgroup analysis showed that this gender difference in mortality was present in women ≥ 70 years up to one-month post-IS (in-hospital: 0.94; 95%CI 0.91-0.97; one-month: 0.87; 95% CI 0.77-0.98), however, in women < 70 years this difference was no longer present. Nevertheless, analysis of crude data showed women were at higher risk of mortality in-hospital, at 12-months and five-years (in-hospital: 1.05; 95%CI 1.03-1.07, 12-months: 1.10; 95%CI 1.06-1.14, five-years: 1.06; 95%CI 1.02-1.10). After HS, women had higher mortality risk in-hospital (1.03; 95%CI 1.01-1.04) however, no gender differences were found post-discharge.

CONCLUSION

The gender differences in post-stroke mortality differ by stroke type, age group and follow-up. Crude stroke mortality in women is higher than in men and this appears to be driven by pre-existing comorbidities. In adjusted models, women have a lower mortality risk following IS, independent of duration of follow-up. After HS, women had higher mortality in hospital however, no gender differences after hospital discharge were found.

Analysis of Prognostic Risk Factors for Ischemic Stroke in China: A Multicentre Retrospective Clinical Study; A National Survey in China

BACKGROUND

Stroke is a serious disease that threatens human health both in China and worldwide. Identifying and establishing its risk factors are prerequisites for intervention and evaluation of prognosis. Over the years, risk factors, such as age, diabetes, and hypertension, have gradually been established. However, at present, there is no consensus on the influence of sex on the prognosis of ischaemic stroke.

AIMS

The aims of our research was to analyse the correlation between sex and poststroke prognosis based on the results of the Third China National Stroke Registry [CNSR-III], as well as the influence of other risk factors that may be confounded by sex on ischaemic stroke and potential interventions.

METHODS

The CNSR-III recruited 14146 acute ischaemic stroke [AIS] patients between 2015 and 2018. Our study included 13,972 patients who had complete follow-up information. This research analysed basic information, socioeconomic status, lifestyle habits, medical history, and poststroke prognosis.

RESULTS

There was a conspicuous relationship between sex and functional prognosis, stroke recurrence and all-cause death due to ischemic stroke in univariate analysis. Male stroke patients had a better prognosis than female patients. In multivariate analysis, we found that age, atrial fibrillation [AF], diabetes, hypertension and the severity of stroke had adverse effects on ischemic stroke prognosis. After adjustment for other risk factors, the functional prognosis of female patients at 3 months was worse than that of male patients [odds ratio [OR] 1.16, 95% confidence interval [CI], 1.025- 1.314]. Sex had a nonsignificant association with stroke recurrence at 3 months [hazard ratio [HR] 1.141, 95% CI, 0.975-1.336]. Furthermore, compared to male patients, female stroke patients had a lower cumulative death rate at 12 months [HR 0.777, 95% CI, 0.628-0.963].

CONCLUSION

Our study identified sex differences in stroke-related disability, recurrence, and death and attempted to explain the causes of these differences. Our study clearly showed that a large proportion of this difference could be attributed to age, socioeconomic factors, lifestyle habits, and medical history, confounded by sex differences rather than sex per se.

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

BACKGROUND

Differences 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.

METHODS

Patients 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.

RESULTS

Study 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 (OR_female = 1.17, p < 0.001) and ICH (OR_female = 1.65, p < 0.001). Initial inpatient stay at hospital was, however, shorter for women (β_{female, IS} = - 0.05, p < 0.001; β_{female, ICH} = - 0.08, p < 0.005). For IS, good function (mRS ≤ 2) was more common in men (OR_female = 0.86, p < 0.001) who also received more inpatient care during the first year (β_female = - 0.05, p < 0.001).

CONCLUSIONS

A 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.

Gender-based differences in mortality and complementary therapies for patients with stroke in Taiwan

BACKGROUND

Stroke is a leading cause of death worldwide. In this retrospective study, we investigated the different effects of gender on medical behavior, medical service, medical cost, and death from stroke in Taiwan.

METHODS

We collected data on the stroke-associated mortality rate according to gender and age group for the period between 2009 and 2013 from the official registry of Ministry of Health and Welfare, Taiwan. We analyzed the data related to stroke-associated medical care and costs in 2013 from the National Health Insurance Research Database (NHIRD).

RESULTS

The mortality rate due to stroke was higher in men than in women, despite more inpatient or outpatient medical treatment and higher medical costs, especially in patients aged <50years. Married women showed a significantly lower stroke-associated mortality compared to married men. Women were significantly more likely to accept Western medicine combined with traditional Chinese medicine (TCM) treatment than men (81.51% of women and 74.27% of men). They had lower medical expenditure and lower mortality from stroke than men did. Combined use of integrative Chinese and Western medicine also was associated with lower mortality from stroke than use of conventional Western medicine alone.

CONCLUSIONS

In Taiwan, stroke-associated mortality is higher in men. Marriage or female sex hormone may have protective effect against stroke in women. Women also more tended to seek TCM complementary therapies combined with Western medicine. Integrated Chinese and Western medicine could thus be a potential treatment for stroke.

Administrative data linkage to evaluate a quality improvement program in acute stroke care, Georgia, 2006-2009

Introduction

Tracking the vital status of stroke patients through death data is one approach to assessing the impact of quality improvement in stroke care. We assessed the feasibility of linking Georgia hospital discharge data with mortality data to evaluate the effect of participation in the Georgia Coverdell Acute Stroke Registry on survival rates among acute ischemic stroke patients.

Methods

Multistage probabilistic matching, using a fine-grained record integration and linkage software program and combinations of key variables, was used to link Georgia hospital discharge data for 2005 through 2009 with mortality data for 2006 through 2010. Data from patients admitted with principal diagnoses of acute ischemic stroke were analyzed by using the extended Cox proportional hazard model. The survival times of patients cared for by hospitals participating in the stroke registry and of those treated at nonparticipating hospitals were compared.

Results

Average age of the 50,579 patients analyzed was 69 years, and 56% of patients were treated in Georgia Coverdell Acute Stroke Registry hospitals. Thirty-day and 365-day mortality after first admission for stroke were 8.1% and 18.5%, respectively. Patients treated at nonparticipating facilities had a hazard ratio for death of 1.14 (95% confidence interval, 1.03–1.26; P = .01) after the first week of admission compared with patients cared for by hospitals participating in the registry.

Conclusion

Hospital discharge data can be linked with death data to assess the impact of clinical-level or community-level chronic disease control initiatives. Hospitals need to undertake quality improvement activities for a better patient outcome.

Long-term survival of older Australian women with a history of stroke

BACKGROUND

Although many people survive an initial stroke, little is known about long-term impacts of stroke on survival.

METHODS

Data from the Australian Longitudinal Study on Women's Health were used to compare 12-year survival rates in older women with prevalent stroke, incident stroke, and no stroke. Cox regression models were fitted to assess the effect of lifestyle and demographic characteristics on the relationship between stroke and all-cause mortality. The "no stroke" group was used as the reference category in all statistical models.

RESULTS

At baseline, 4% of the women reported a previous stroke (prevalent stroke). At survey 2 in 1999, a further 3% reported having a stroke between 1996 and 1999 (incident stroke). Stroke was significantly associated with reduced long-term survival. Age-adjusted hazards ratios (HRs) were: 1.64 (1.43-1.89) for the "prevalent stroke" group and 2.29 (1.97-2.66) for the "incident stroke" group. Adjusting for comorbidities reduced the HRs, but the risk of death was still significantly higher in the 2 stroke groups. Adjusting for demographic and lifestyle factors did not make any further difference to the relationship between stroke and survival. However, obesity and past smoking were also risk factors for mortality.

CONCLUSIONS

This study highlights the long-term impacts of stroke on life expectancy and the importance of comorbidities and other lifestyle factors in affecting poststroke survival.

Sex, stroke, and inflammation: the potential for estrogen-mediated immunoprotection in stroke

Stroke is the third leading cause of death and the primary cause of disability in the developed world. Experimental and clinical data indicate that stroke is a sexually dimorphic disease, with males demonstrating an enhanced intrinsic sensitivity to ischemic damage throughout most of their lifespan. The neuroprotective role of estrogen in the female brain is well established, however, estrogen exposure can also be deleterious, especially in older women. The mechanisms for this remain unclear. Our current understanding is based on studies examining estrogen as it relates to neuronal injury, yet cerebral ischemia also induces a robust sterile inflammatory response involving local and systemic immune cells. Despite the potent anti-inflammatory effects of estrogen, few studies have investigated the contribution of estrogen to sex differences in the inflammatory response to stroke. This review examines the potential role for estrogen-mediated immunoprotection in ischemic injury.

Charlson comorbidity index in ischemic stroke and intracerebral hemorrhage as predictor of mortality and functional outcome after 6 months

BACKGROUND

The Charlson Comorbidity Index (CCI) is commonly used in outcome and mortality studies. Our aim was to investigate the association between CCI score and the functional outcome and mortality 6 months after ischemic stroke (IS) or intracerebral hemorrhage.

METHODS

This was a prospective observational cohort of patients with spontaneous intracerebral hemorrhage and IS admitted to the stroke unit during 18 months. The modified Rankin scale (mRS) score was obtained for subjects 6 months after event. The CCI score was dichotomized (low comorbidity 0 or 1 versus high ≥ 2) for analysis. The mRS score was also dichotomized (good outcome, mRS score 0 or 1 versus poor outcome, mRS score ≥ 2).

RESULTS

In all, 175 patients were enrolled in the study. Logistic regression showed that those with a high CCI score (≥ 2) had 37.3% increased odds of having a poor outcome (≥ 2) at 6 months and 68.4% greater odds of death at 6 months.

CONCLUSIONS

Comorbid medical conditions independently influence outcome after IS or intracerebral hemorrhage.