Abstract
Objective: We sought to determine sex differences in outcomes in patients with severe stroke who had been admitted to inpatient rehabilitation.Methods: We studied 1,316 patients aged 18 to 99 (mean 72) classified as case-mix groups 0108, 0109, and 0110 of the Medicare case-mix classification system. These groups encompass the most severe strokes. Three outcomes were analyzed: (1) 3-year mortality from admission to rehabilitation; (2) combined outcome of transfer to acute care or death within 90 days from admission to rehabilitation; (3) functional outcome, including proportional recovery in motor functioning and good functional outcome as defined by achievement of a Functional Independence Measure (FIM)-motor score ≥65 points at discharge. Multivariable regression analyses were used to assess sex-difference in each outcome between women and men. The covariates examined included age, marital status, comorbidities, time from stroke onset to rehabilitation admission <30 days, ischemic stroke, dysphagia, neglect, motor FIM score at admission, and cognitive FIM score at admission.Results: Kaplan-Meier estimated 3-year mortality rate was 20.7% in women and 22.0% in men. The crude hazard ratio (HR) of death for women compared with men was 0.94 (95% CI 0.74–1.20). After adjustment for significant covariates, the HR of 3-year mortality was 0.73 (95% CIs 0.56–0.96; p = 0.025). Comorbidity, including diabetes, anemia, coronary artery disease, atrial fibrillation, and chronic obstructive pulmonary disease, significantly increased mortality risk by 49–88%. The incidence of the combined outcome was 8.3% in women and 8.4% in men. The crude HR of the combined end-point for women compared with men was 1.05 (95% CI 0.72–1.53). After adjustment for significant covariates, the HR was 0.95 (95% CIs 0.65–1.40; p = 0.810). Likewise, no significant difference in proportional recovery or in the rate of achievement of a good functional outcome between women and men was observed.Conclusion: Among patients admitted to inpatient rehabilitation after severe stroke, women and men had comparable crude mortality rates at 3 years. After multivariable adjustment, however, women had lower mortality risk. No sex-differences in the risk of being transferred to acute care or dying within 90 days from admission to rehabilitation or in responsiveness to rehabilitation were observed.
Highlights
Stroke is a leading cause of death and disability worldwide [1]
Two recently published systematic reviews from the International Stroke Outcomes Study (INSTRUCT) research group suggest that sex differences in mortality and functional outcomes are eliminated after adjustment for age, pre-stroke functional limitation, and stroke severity [6, 7]
Age, marital status, diabetes, Coronary artery disease (CAD), Chronic obstructive pulmonary disease (COPD), Atrial fibrillation (AF), anemia, dysphagia, neglect, and cognitive status were significantly associated with mortality risk at multivariable Cox analysis (Supplementary Table 1)
Summary
Stroke is a leading cause of death and disability worldwide [1]. According to the most recent report from the Global Burden of Disease Stroke Collaboration, there were 1·03 million incident strokes in Western Europe and 0·81 in North America in 2016 [1]. An association between functional gain achieved with rehabilitation and mortality risk has been demonstrated [11, 12] Another aspect to consider is that most individual studies have been based on patient populations with prevalent mild or moderate stroke and the relevance of research findings to the critical population with severe stroke remains elusive. Better understanding of sex differences in this challenging patient population could provide new insightful information and opportunities to reduce potential sex disparities To address this issue, we studied 1,316 patients classified as case-mix groups (CMGs) 0108, 0109, and 0110 of the Medicare case-mix classification system [14], which was developed to account for “the level of severity of a given case” [15]. Case-mix groups 0108, 0109, and 0110 encompass the most severe strokes
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