Original articleGender Differences in Stroke Care and Outcomes in Ontario
Introduction
Stroke is a leading cause of death and disability in women and men worldwide (Rosamond et al., 2007). Fortunately, effective treatments exist for improving stroke outcomes and for reducing the risk of stroke recurrence. Acute interventions such as thrombolysis and organized in-patient stroke care have been shown to decrease the risk of disability following stroke, and antithrombotic therapy, management of hypertension, lipid-lowering therapy, and carotid endarterectomy decrease the risk of recurrent stroke in appropriately selected patients (Rothwell et al., 2003, Saxena and Koudstaal, 2004, Stroke Unit Trialists’ Collaboration, 2007, Wardlaw et al., 2000).
Significant gender differences have been found in the management and outcomes of patients with cardiac disease, with studies showing that women are less likely than men to undergo diagnostic testing or receive interventions such as thrombolysis, care in an intensive unit, and revascularization procedures (Fowler et al., 2007, Nguyen et al., 2008, Pilote et al., 2007). Given the similarities in risk factors and demographics between individuals with coronary and cerebrovascular disease, it is plausible that similar disparities in care could exist in the setting of stroke. Research to date, however, has yielded inconsistent findings (Di Carlo et al., 2003, Eriksson et al., 2009, Glader et al., 2003, Kapral et al., 2005, Lewsey et al., 2009, Lisabeth et al., 2004, Muller-Nordhorn et al., 2006, Palnum et al., 2009, Reeves et al., 2009, Roquer et al., 2003, Smith et al., 2005, Smith et al., 2009).
We used data from a population-based audit of hospital-based stroke care in the province of Ontario, Canada, and compared the use of recommended acute stroke interventions (stroke unit care, thrombolysis, acute antithrombotic therapy, swallowing assessments), interventions for secondary stroke prevention (antihypertensive use, antithrombotic use, lipid-lowering therapy, carotid endarterectomy), and outcomes (death, readmissions) in women and men, with stratification by age and income quintile, and with adjustment for other prognostic factors.
Section snippets
Data Sources
The Registry of the Canadian Stroke Network performs a biennial audit on a random sample of 20% of all patients with stroke or transient ischemic attack (TIA) seen in the emergency department or admitted to hospital at every acute care institution across the province of Ontario, Canada (Kapral, et al., 2009). For the audit, cases are identified from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database (for admitted patients) and National Ambulatory Care Reporting
Results
The study sample included 4,046 patients seen between April 1, 2004, and March 31, 2005; 51% were women. The stroke type was ischemic in 52%, TIA in 38%, intracerebral hemorrhage in 8%, and subarachnoid hemorrhage in 3%, with no differences in stroke type or severity between women and men (Table 1). The mean age was 74 years, and women were older than men (75.9 vs. 72.3 years; p < .0001), more likely to reside in neighborhoods with a lower median income, and less likely to be independent before
Discussion
In this population-based study of all acute care institutions across the province of Ontario, Canada, we found no gender differences in the delivery of a number of key stroke care quality indicators, including thrombolysis, neuroimaging, dysphagia screening, stroke unit admission, consultations (from neurology, physiotherapy, occupational therapy, speech language pathology, and nutrition), or use of antithrombotic therapy. However, women were less likely than men to be prescribed lipid-lowering
Dr. Kapral is an internist and health services researcher in the area of stroke in women.
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Cited by (0)
Dr. Kapral is an internist and health services researcher in the area of stroke in women.
Drs. Degani and Hall are epidemiologists with expertise in health services research and cardiovascular disease.
Dr. Fang is a biostatistican.
Drs. Silver and Saposnik are stroke neurologists and researchers.
Ms. Robertson and Ms. Richards are research nurses with expertise in cardiovascular disease.
Dr. Bierman, principal investigator of the POWER Study, is OWHC Chair in Women's Health and Associate Professor, Bloomberg Faculty of Nursing; Health Policy, Evaluation, and Management; and Medicine, University of Toronto; and Scientist, Li Ka Shing Knowledge Institute, St. Michael's Hospital.
This report does not necessarily reflect the views of Echo or the Ontario Ministry of Health and Long-Term Care or any other supporting or sponsoring institution.
The Project for an Ontario Women’s Health Evidence-based Report (POWER) Study is funded by Echo: Improving Women’s Health in Ontario, an agency of the Ontario Ministry of Health and Long-Term Care. The Registry of the Canadian Stroke Network is funded by the Canadian Stroke Network and the Ontario Ministry of Health and Long-Term Care. The Institute for Clinical Evaluative Sciences is supported by an operating grant from the Ontario Ministry of Health and Long-Term Care. Dr. Kapral is supported by a New Investigator Award from the Canadian Institutes for Health Research (CIHR), as well as career support from the Canadian Stroke Network and the University Health Network Women’s Health Program, and is a member of the GENESIS (Gender and Sex Determinants of Circulatory and Respiratory Diseases): Interdisciplinary Enhancement Teams Grant Program, Canadian Institutes of Health Research and the Heart and Stroke Foundation of Canada.