Do presenting symptoms explain sex differences in emergency department delays among patients with acute stroke?

Abstract

Background and purpose: Previous studies report that women with stroke may experience longer delays in diagnostic workup than men after arriving at the emergency department. We hypothesized that presenting symptom differences could explain these delays.

Methods: Data were collected on 1922 acute stroke cases who presented to 15 hospitals participating in a statewide stroke registry. We evaluated 2 in-hospital time intervals: emergency department arrival to physician examination ("door-to-doctor") and emergency department arrival to brain imaging ("door-to-image"). We used parametric survival models to estimate time ratios, which represent the ratio of average times comparing women to men, after adjusting for symptom presentation and other confounders.

Results: Women were significantly less likely than men to present with any stroke warning sign or suspected stroke (87.5% versus 91.4%) or to report trouble with walking, balance, or dizziness (9.5% versus 13.7%). Difficulty speaking and loss of consciousness were associated with shorter door-to-doctor times. Weakness, facial droop, difficulty speaking, and loss of consciousness were associated with shorter door-to-image times, whereas difficulty with walking/balance was associated with longer door-to-image times. In adjusted analyses, women had 11% longer door-to-doctor intervals (time ratio, 1.11; 95%, CI 1.02 to 1.22) and 15% longer door-to-image intervals (time ratio, 1.15; 95% CI, 1.08 to 1.25) after accounting for presenting symptoms, age, and other confounders. Furthermore, these sex differences remained evident after restricting to patients who arrived within 6 or within 2 hours of symptom onset.

Conclusions: Women with acute stroke experienced greater emergency department delays than men, which were not attributable to differences in presenting symptoms, time of arrival, age, or other confounders.