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Yu AYX, Austin PC, Rashid M, Fang J, Porter J, Vyas MV, Smith EE, Joundi RA, Edwards JD, Reeves MJ, Kapral MK. Sex Differences in Intensity of Care and Outcomes After Acute Ischemic Stroke Across the Age Continuum. Neurology 2023; 100:e163-e171. [PMID: 36180239 DOI: 10.1212/wnl.0000000000201372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/23/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Sex differences in stroke care and outcomes have been previously reported, but it is not known whether these associations vary across the age continuum. We evaluated whether the magnitude of female-male differences in care and outcomes varied with age. METHODS In a population-based cohort study, we identified patients hospitalized with ischemic stroke between 2012 and 2019 and followed through 2020 in Ontario, Canada, using administrative data. We evaluated sex differences in receiving intensive care unit services, mechanical ventilation, gastrostomy tube insertion, comprehensive stroke center care, stroke unit care, thrombolysis, and endovascular thrombectomy using logistic regression and reported odds ratios (ORs) and 95% CIs. We used Cox proportional hazard models and reported the hazard ratios (HRs) and 95% CI of death within 90 or 365 days. Models were adjusted for covariates and included an interaction between age and sex. We used restricted cubic splines to model the relationship between age and care and outcomes. Where the p-value for interaction was statistically significant (p < 0.05), we reported age-specific OR or HR. RESULTS Among 67,442 patients with ischemic stroke, 45.9% were female and the median age was 74 years (64-83). Care was similar between both sexes, except female patients had higher odds of receiving endovascular thrombectomy (OR 1.35, 95% CI [1.19-1.54] comparing female with male), and these associations were not modified by age. There was no overall sex difference in hazard of death (HR 95% CI 0.99 [0.95-1.04] for death within 90 days; 0.99 [0.96-1.03] for death within 365 days), but these associations were modified by age with the hazard of death being higher in female than male patients between the ages of 50-70 years (most extreme difference around age 57, HR 95% CI 1.25 [1.10-1.40] at 90 days, p-interaction 0.002; 1.15 [1.10-1.20] at 365 days, p-interaction 0.002). DISCUSSION The hazard of death after stroke was higher in female than male patients aged 50-70 years. Examining overall sex differences in outcomes without accounting for the effect modification by age may miss important findings in specific age groups.
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Affiliation(s)
- Amy Ying Xin Yu
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada.
| | - Peter C Austin
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Mohammed Rashid
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Jiming Fang
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Joan Porter
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Manav V Vyas
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Eric E Smith
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Raed A Joundi
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Jodi D Edwards
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Mathew J Reeves
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Moira K Kapral
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
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