Women with Acute Ischemic Stroke Less Likely to Receive Optimal Stroke Care

Sunil Sheth, MD
Credit: UTHealth Houston

A new study has brought forth evidence outlining gender-based disparities in access to optimal management of acute ischemic strokes, with women less likely to be routed to comprehensive stroke centers than their male counterparts.

Conducted by investigators at the University of Texas Health Science Center at Houston (UTHealth Houston), results of the study, which leveraged data from a multihospital registry in the greater Houston, Texas area, suggest women were nearly 10% less likely to be routed to a comprehensive stroke center compared to their male counterparts in adjusted analyses, despite these women with more significant stroke syndromes and living within comparable distance to the centers as their male counterparts.¹

“Timely treatment of stroke is incredibly important; the faster a doctor is able to get the vessel open, the better the patient’s chance of having a good outcome. These routing systems in hospitals are designed to get patients to the best care as quickly as possible,” said lead investigator Sunil Sheth, MD, associate professor of neurology and director of the vascular neurology program with McGovern Medical School at UTHealth Houston.² “We don’t know exactly why women were less likely than men to be routed to comprehensive stroke centers, but we do know that gender is an implicit bias. Getting to the granular level of what went into a hospital’s routing decision will be very important for future studies.”

Citing historic and contemporary disparities in stroke outcomes for women, Sheth and colleagues from UTHealth Houston and the Emory School of Medicine launched the current study with the intent of assessing whether distance to comprehensive stork centers, stroke severity, and patient sex was associated with direct-to-center prehospital routing among patients with large vessel occlusion acute ischemic stroke. With this in mind, investigators designed their research endeavor as a cross-sectional study of data from a subset of patients enrolled in the prospective Practical Implementation of Mechanical Thrombectomy (PRIME) study.¹

A prospective study examining all patients diagnosed with acute ischemic stroke at 10 certified stroke centers within a single health care system in the greater Houston area, which includes 6 primary stroke centersand 4 comprehensive stroke centers. Investigators noted no hospitals are designated as thrombectomy capable centers and all certified endovascular centers carried the comprehensive stroke centers designation during the study.¹

For the purpose of analysis, investigators identified a subset of 630 presenting to 1 of 10 hospitals between January 2019-June 2020. Of these 630 patients, 28 were excluded as their large vessel occlusion acute ischemic stroke occurred in-hospital, 5 were excluded due to missing information, 1 patient was excluded as they presented from out of state, and 93 patients were from addresses where a comprehensive stroke center would be more than 15 minutes travel from the nearest primary stroke center. In total, 503 individuals were included in the final analysis.¹

The primary outcome of interest for the study was prehospital routing to a comprehensive stroke center. Investigators pointed out modified Poisson regression, with adjustment for age, sex, race or ethnicity, first in‐hospital National Institutes of Health Stroke Scale (NIHSS) score, travel time, and distances to the closest primary stroke center and comprehensive stroke center, to compare likelihood of the primary outcome for men and women.¹

The 503-person cohort identified for inclusion had a median age of 68 (interquartile range, 59-79) years, 46% were female, 41% were White, 38% received intravenous tissue plasminogen activator treatment, and 60% underwent endovascular therapy. Initial results indicated 82% (n = 413) of patients were routed to a comprehensive stroke center.¹

Those presenting to comprehensive stroke centers were more likely to be male (56% vs 43%; P = .027), and receive intravenous thrombolysis (42% vs 20%; P < .001). Results of the investigators’ analysis suggested women with large vessel occlusion acute ischemic stroke were more likely to be older than their male counterparts (73 vs 65 years; P <.01) and had higher NIHSS scores (14 vs 12; P < .015). In multivariable analysis, results indicated women were less likely than their male counterparts to be routed to a comprehensive stroke center (adjusted Risk Ratio [aRR], 0.91; 95% confidence interval [CI], 0.84-0.99; P = .024). Further analysis indicated being less than 10 miles from the nearest comprehensive stroke center was associated with a 38% increase in the likelihood of routing to a comprehensive stroke center (aRR, 1.38; 95% CI, 1.26-1.52; P <.001).¹

“Older age at onset and severe stroke in women, compounded by a higher likelihood of age-related risk factors, can contribute to the higher rate of death from stroke and higher risk for disability after stroke in women,” said senior investigator Youngran Kim, PhD, assistant professor of management, policy, and community health with UTHealth Houston School of Public Health.² “Therefore, appropriate triage and prehospital routing can be even more critical for women. Whether large vessel occlusions in women are less likely to be identified using current screening tools due to older age, premorbidity, or nontraditional symptoms needs to be investigated.”

References:

1. Tariq MB, Ali I, Salazar-Marioni S, et al. Women With Large Vessel Occlusion Acute Ischemic Stroke Are Less Likely to Be Routed to Comprehensive Stroke Centers [published online ahead of print, 2023 Jul 18]. J Am Heart Assoc. 2023;e029830. doi:10.1161/JAHA.123.029830
2. Barkley C. Women less likely to be routed to comprehensive stroke centers for large vessel acute ischemic stroke, according to UTHealth Houston Research. UTHealth Houston. July 18, 2023. Accessed July 18, 2023. https://www.uth.edu/news/story/women-less-likely-to-be-routed-to-comprehensive-stroke-centers-for-large-vessel-acute-ischemic-stroke-according-to-uthealth-houston-research.