Differences In Stroke Care Research Articles

Evaluation of stroke services in Anglia stroke clinical network to examine the variation in acute services and stroke outcomes

BackgroundStroke is the third leading cause of death in developed countries and the leading cause of long-term disability worldwide. A series of national stroke audits in the UK highlighted the differences in stroke care between hospitals. The study aims to describe variation in outcomes following stroke and to identify the characteristics of services that are associated with better outcomes, after accounting for case mix differences and individual prognostic factors.Methods/DesignWe will conduct a cohort study in eight acute NHS trusts within East of England, with at least one year of follow-up after stroke. The study population will be a systematically selected representative sample of patients admitted with stroke during the study period, recruited within each hospital. We will collect individual patient data on prognostic characteristics, health care received, outcomes and costs of care and we will also record relevant characteristics of each provider organisation. The determinants of one year outcome including patient reported outcome will be assessed statistically with proportional hazards regression models. Self (or proxy) completed EuroQol (EQ-5D) questionnaires will measure quality of life at baseline and follow-up for cost utility analyses.DiscussionThis study will provide observational data about health service factors associated with variations in patient outcomes and health care costs following hospital admission for acute stroke. This will form the basis for future RCTs by identifying promising health service interventions, assessing the feasibility of recruiting and following up trial patients, and provide evidence about frequency and variances in outcomes, and intra-cluster correlation of outcomes, for sample size calculations. The results will inform clinicians, public, service providers, commissioners and policy makers to drive further improvement in health services which will bring direct benefit to the patients.

Gender Differences in Stroke Care and Outcomes in Ontario

Background Studies of potential gender differences in stroke care and outcomes have yielded inconsistent findings. The Project for an Ontario Women’s Health Evidence-based Report study measured established stroke care indicators in a large, representative sample of women and men with stroke or transient ischemic attack (TIA) admitted to acute care institutions in the province of Ontario, Canada. Methods The Registry of the Canadian Stroke Network performs a biennial audit on a random sample of 20% of patients with stroke or TIA seen at more than 150 acute care institutions across Ontario. We used data from the 2004/05 audit to compare stroke care by gender, with stratification by age and neighborhood income. Results The sample consisted of 4,046 patients (51% women). There were no significant gender differences in the use of thrombolysis, neuroimaging, carotid imaging, dysphagia screening, antithrombotic therapy, or neurology and other consultations. Women with ischemic stroke or TIA were less likely than men to be prescribed statins or undergo carotid imaging and endarterectomy within 6 months of stroke; women were more likely than men to receive antihypertensives. There were no significant gender differences in readmission or mortality rates after stroke. Interpretation In this population-based study, we found little evidence of gender differences in stroke care or outcomes other than lipid-lowering therapy, carotid imaging, and endarterectomy. Further study is needed to assess the contribution of the provincial stroke strategy in eliminating gender differences in management of acute stroke and to better understand and target remaining gender differences in management.

Age and Gender Variations in the Management of Ischaemic Stroke in China

Stroke is a major health issue in China. We aimed to describe the management of patients admitted to hospitals in China with acute ischaemic stroke, and to determine whether there were any differences by age and gender. Using a multicentre prospective hospital register across all eight major economic (geographic) regions in China, data on the socioeconomic characteristics, medical history, clinical features, and in-hospital investigations, management, and outcomes were collected on consecutive patients with acute stroke due to cerebral ischaemia during a 5-month period in 2006. Overall, traditional Chinese medicine and neuroprotectant use were remarkably high, with nearly 80% of patients receiving the former and >70% receiving the latter in hospital. Length of hospital stay was also long (median duration 16-days). Multivariate analyses revealed no clinically important differences in management between the genders. For the age-specific analyses, there were significant trends of decreasing use of thrombolysis (P=0·04), warfarin (P=0·01), corticosteroids (P=0·03), and lipid-lowering therapy (P=0·001); however, more assisted feeding (P=0·004) and rising rates of disability and in-hospital complications occurred with increasing age. New information is provided regarding the current state of ischaemic stroke management in China. Notably, there is high use of traditional Chinese medicine and neuroprotectants and long lengths of hospital stay. Similar to many other countries, differences in stroke care and management by age and gender also exist to a small extent in China.

Race/ethnicity, quality of care, and outcomes in ischemic stroke.

Prior studies suggest differences in stroke care associated with race/ethnicity. We sought to determine whether such differences existed in a population of black, Hispanic, and white patients hospitalized with stroke among hospitals participating in a quality-improvement program. We analyzed in-hospital mortality and 7 stroke performance measures among 397,257 patients admitted with ischemic stroke to 1181 hospitals participating in the Get With The Guidelines-Stroke program 2003 through 2008. Relative to white patients, black and Hispanic patients were younger and more often had diabetes mellitus and hypertension. After adjustment for both patient- and hospital-level variables, black patients had lower odds relative to white patients of receiving intravenous thrombolysis (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.77 to 0.91), deep vein thrombosis prophylaxis (OR, 0.88; 95% CI, 0.83 to 0.92), smoking cessation (OR, 0.85; 95% CI, 0.79 to 0.91), discharge antithrombotics (OR, 0.88; 95% CI, 0.84 to 0.92), anticoagulants for atrial fibrillation (OR, 0.84; 95% CI, 0.75 to 0.94), and lipid therapy (OR, 0.91; 95% CI, 0.88 to 0.96), and of dying in-hospital (OR, 0.90; 95% CI, 0.85 to 0.95). Hispanic patients received similar care as their white counterparts on all 7 measures and had similar in-hospital mortality. Black (OR, 1.31; 95% CI, 1.28 to 1.35) and Hispanic (OR, 1.16; 95% CI, 1.11 to 1.20) patients had higher odds of exceeding the median length of hospital stay relative to whites. During the study, quality of care improved in all 3 race/ethnicity groups. Black patients with stroke received fewer evidence-based care processes than Hispanic or white patients. These differences could lead to increased risk of recurrent stroke. Quality of care improved substantially in the Get With The Guidelines-Stroke Program over time for all 3 racial/ethnic groups.

Understanding Stroke in Women

See related article, pages 909–914. “The pure and simple truth is rarely pure and never simple”. —Oscar Wilde Sex differences in clinical care and outcomes have been documented in multiple studies of patients with coronary artery disease, with research showing differences in presentation, disparities in diagnosis and management, and worse clinical outcomes in women compared to men.1,2 There has been concern that similar sex differences exist in the care and outcomes of patients with stroke, given the parallels in patient populations and risk factors in individuals with cardiac and cerebrovascular disease. To date, however, the research on the interaction between gender and stroke has been limited and results have been inconsistent. Thus, any new information on this topic is welcome. In this issue of Stroke , Eriksson et al3 report on an analysis of 24 633 stroke events in 2006 from the large, well-designed, population-based Swedish National Quality Register (RIKS-Stroke). They found that compared to men, women were older (mean age difference 4.8 years) and were more often unconscious on presentation. No differences were found in processes of care such as administration of thrombolysis or discharge on anticoagulants. Women were more likely to develop deep venous thromboses and fractures, whereas men …

Sex Differences in Stroke Care and Outcome in the Swedish National Quality Register for Stroke Care

Previous reports concerning sex-related differences in stroke management and outcome are inconsistent and are sometimes difficult to interpret. We used data from a national stroke register to further explore possible differences between men and women in baseline characteristics, stroke treatment, and outcome. This study included 24633 stroke events registered in Riks-Stroke, the Swedish national quality register for stroke care, during 2006. Information on background variables and treatment was collected during the hospital stay. After 3 months, the patients' living situation and outcome were assessed. Women were older than men when they had their stroke (mean age, 78.4 versus 73.6 years; P<0.001). On admission to the hospital, women were more often unconscious. Among conscious patients, there was no sex-related difference in the use of stroke unit care. Men and women had equal probability to receive thrombolysis and oral anticoagulants. Women were more likely to develop deep venous thromboses and fractures, whereas men were more likely to develop pneumonia during their hospital stay. Women had a lower 3-month survival, a difference that was associated with higher age and impaired level of consciousness on admission. Women were less often living at home at the 3-month follow-up. However, the difference in residency was not present in patients <85 years who were living at home without community support before the stroke. Reported sex differences in stroke care and outcome were mainly explained by the women's higher age and lower level of consciousness on admission.

Quality of Ischemic Stroke Care in Emerging Countries

Limited information is available on stroke management in developing countries. An accurate monitoring of quality of stroke care will become crucial, particularly with the emerging paradigm of pay-for-performance. Our aim was to explore the feasibility of measuring standardized indicators of quality of ischemic stroke care in acute care facilities in Argentina. ReNACer is a prospective, multicenter, countrywide, stroke registry comprising 74 academic and nonacademic institutions in Argentina. The registry includes patient-level information on demography, clinical characteristics, diagnostic procedures, treatment, and the selected key performance indicators of quality of ischemic stroke care (access to thrombolysis or aspirin use in the acute setting, admission to designated stroke units, length of stay, risk-adjusted in-hospital pneumonia, risk-adjusted in-hospital mortality, discharge on antithrombotics, and antihypertensive agents). We included 1991 patients with ischemic stroke from 74 institutions in Argentina between November 2004 and October 2006. Seventy-nine per cent of the patients were prescribed antithrombotic therapy within 48 hours of admission, but only 1% received thrombolytics. No more than 5.7% were admitted to stroke units. In-hospital pneumonia was diagnosed in 14.3% of the patients and was higher in nonacademic facilities (16.4% versus 11.4%, P<0.02). The overall adjusted in-hospital mortality was 9.1%, also higher in nonacademic hospitals (10.6% versus 7.1%, P<0.008). At discharge, antithrombotics were prescribed in 90.2% and antihypertensive agents in 63.6% of the patients. In ReNACer, there was a limited access to stroke units and thrombolytics, and a relatively high incidence of in-hospital pneumonia. Differences in stroke care were observed between academic and nonacademic institutions. There is an urgent need to develop national stroke programs in Argentina.

Sex Differences in Acute Stroke Care in a Statewide Stroke Registry

Many studies have reported poorer stroke outcomes in women, and some studies have reported sex differences in care. We analyzed data from a hospital-based stroke registry to determine whether acute stroke care and discharge status differed by sex. Detailed chart-level information was collected on 2566 subjects admitted for acute stroke or transient ischemic attack to 15 Michigan hospitals in 2002. Sex differences in stroke care and patient status at discharge (in-hospital mortality and modified Rankin Scale score) were assessed after adjusting for differences in demographics, clinical characteristics, and comorbidities by multivariable models. Modified Rankin Scale score data were analyzed by proportional-odds models. Women were older than men (70 vs 67 years) and were more likely to have congestive heart failure and hypertension. Men were more likely to smoke and have a history of heart disease and dyslipidemia. After multivariable adjustment, women were less likely to receive thrombolytic therapy (odds ratio [OR]=0.56; 95% CI, 0.37 to 0.86) or lipid testing (OR=0.76; 95% CI, 0.61 to 0.94) and were more likely to suffer urinary tract infections (OR=2.57; 95% CI, 1.87 to 3.54). In-hospital mortality was similar in women and men (9% vs 8%); however, women had poorer discharge modified Rankin Scale scores (OR=1.17; 95% CI, 1.01 to 1.35). Although considerable parity exists in many aspects of acute stroke care, women were less likely than men to receive thrombolytic treatment and lipid testing, even after adjustment. However, given the largely similar care observed, it is unlikely that differences in care explain the poorer functional outcomes in female stroke survivors.

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Sex Differences in Stroke Care and Outcomes

Stroke is an important cause of death and disability in women as well as men. However, little is known about sex differences in stroke care and outcomes. The Registry of the Canadian Stroke Network (RCSN) captured data on patients with stroke seen at acute care hospitals across Canada. We used data from phase 1 (July 2001 to February 2002) and phase 2 (June to December 2002) of the RCSN to compare stroke presentation, management, and 6-month outcomes in women and men using multivariable regression techniques to adjust for age and other factors. The study sample included 3323 patients, with 1527 women. Stroke symptoms at presentation were similar in women and men, except that women were more likely to present with headaches and were less likely to have brain stem or cerebellar symptoms. There were no sex differences in the use of neuroimaging, thrombolysis, antithrombotic therapy, or consultations. Women were less likely than men to receive care on an acute stroke unit, but this difference was no longer significant after adjustment for age and other factors. Women were more likely than men to be discharged to long-term care and had greater disability at 6 months. Mortality and quality of life at 6 months were similar in women and men. Among patients participating in the RCSN, there were no major sex differences in stroke presentation or management. Compared with men, women were more often institutionalized and had a slightly worse functional status at 6 months after stroke.