Factors contributing to sex differences in functional outcomes and participation after stroke

Hoang T Phan¹, Christopher L Blizzard¹, Mathew J Reeves¹, Amanda G Thrift¹, Dominique A Cadilhac¹, Jonathan Sturm¹, Emma Heeley¹, Petr Otahal¹, Konstantinos Vemmos¹, Craig Anderson¹, Priya Parmar¹, Rita Krishnamurthi¹, Suzanne Barker-Collo¹, Valery Feigin¹, Yannick Bejot¹, Norberto Luiz Cabral¹, Antonio Carolei¹, Simona Sacco¹, Nicolas Chausson¹, Stephane Olindo¹, Peter Rothwell¹, Carolina Silva¹, Manuel Correia¹, Rui Magalhães¹, Peter Appelros¹, Janika Kõrv¹, Riina Vibo¹, Cesar Minelli¹, Seana L Gall²

Affiliations

¹ From the Menzies Institute for Medical Research Tasmania (H.T.P., C.L.B., P.O., S.L.G.), University of Tasmania, Hobart, Australia; Department of Health Management and Health Economics (H.T.P.), Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Medicine (A.G.T., D.A.C.), School of Clinical Sciences at Monash Health, Monash University, Clayton; Florey Institute Neuroscience and Mental Health (D.A.C.), Heidelberg, University of Melbourne, Victoria; Faculty of Health and Medicine (J.S.), University of Newcastle; George Institute for Global Health (E.H., C.A.), University of Sydney, New South Wales, Australia; Hellenic Cardiovascular Research Society (K.V.), Athens, Greece; National Institute for Stroke and Applied Neurosciences (P.P., R.K., V.F.), School of Public Health and Psychosocial Studies, Auckland University of Technology; School of Psychology (S.B.-C.), University of Auckland, New Zealand; University of Burgundy (Y.B.), University Hospital of Dijon, France; Clinica Neurológica de Joinville (N.L.C.), Joinville Stroke Registry, University of Joinville Region, Brazil; Department of Biotechnological and Applied Clinical Sciences (A.C., S.S.), Neurological Institute, University of L'Aquila, Italy; Stroke Unit (N.C.), Centre Hospitalier Sud Francilien, Corbeil-Essonnes; Stroke Unit (S.O.), University Hospital of Bordeaux, France; Stroke Prevention Research Unit (P.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK; UNIFAI (C.S., M.C., R.M.), Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Portugal; Department of Neurology (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Neurology and Neurosurgery (J.K., R.V.), University of Tartu, Estonia; and Hospital Carlos Fernando Malzoni and Neurologic Center of Research and Rehabilitation (C.M.), Matão, SP, Brazil.
² From the Menzies Institute for Medical Research Tasmania (H.T.P., C.L.B., P.O., S.L.G.), University of Tasmania, Hobart, Australia; Department of Health Management and Health Economics (H.T.P.), Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Medicine (A.G.T., D.A.C.), School of Clinical Sciences at Monash Health, Monash University, Clayton; Florey Institute Neuroscience and Mental Health (D.A.C.), Heidelberg, University of Melbourne, Victoria; Faculty of Health and Medicine (J.S.), University of Newcastle; George Institute for Global Health (E.H., C.A.), University of Sydney, New South Wales, Australia; Hellenic Cardiovascular Research Society (K.V.), Athens, Greece; National Institute for Stroke and Applied Neurosciences (P.P., R.K., V.F.), School of Public Health and Psychosocial Studies, Auckland University of Technology; School of Psychology (S.B.-C.), University of Auckland, New Zealand; University of Burgundy (Y.B.), University Hospital of Dijon, France; Clinica Neurológica de Joinville (N.L.C.), Joinville Stroke Registry, University of Joinville Region, Brazil; Department of Biotechnological and Applied Clinical Sciences (A.C., S.S.), Neurological Institute, University of L'Aquila, Italy; Stroke Unit (N.C.), Centre Hospitalier Sud Francilien, Corbeil-Essonnes; Stroke Unit (S.O.), University Hospital of Bordeaux, France; Stroke Prevention Research Unit (P.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK; UNIFAI (C.S., M.C., R.M.), Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Portugal; Department of Neurology (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Neurology and Neurosurgery (J.K., R.V.), University of Tartu, Estonia; and Hospital Carlos Fernando Malzoni and Neurologic Center of Research and Rehabilitation (C.M.), Matão, SP, Brazil. Seana.Gall@utas.edu.au.

PMID: 29703773
DOI: 10.1212/WNL.0000000000005602

Editorial

Factors contributing to sex differences in functional outcomes and participation after stroke

Hoang T Phan et al. Neurology. 2018.

. 2018 May 29;90(22):e1945-e1953.

doi: 10.1212/WNL.0000000000005602. Epub 2018 Apr 27.

Authors

Affiliations

¹ From the Menzies Institute for Medical Research Tasmania (H.T.P., C.L.B., P.O., S.L.G.), University of Tasmania, Hobart, Australia; Department of Health Management and Health Economics (H.T.P.), Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Medicine (A.G.T., D.A.C.), School of Clinical Sciences at Monash Health, Monash University, Clayton; Florey Institute Neuroscience and Mental Health (D.A.C.), Heidelberg, University of Melbourne, Victoria; Faculty of Health and Medicine (J.S.), University of Newcastle; George Institute for Global Health (E.H., C.A.), University of Sydney, New South Wales, Australia; Hellenic Cardiovascular Research Society (K.V.), Athens, Greece; National Institute for Stroke and Applied Neurosciences (P.P., R.K., V.F.), School of Public Health and Psychosocial Studies, Auckland University of Technology; School of Psychology (S.B.-C.), University of Auckland, New Zealand; University of Burgundy (Y.B.), University Hospital of Dijon, France; Clinica Neurológica de Joinville (N.L.C.), Joinville Stroke Registry, University of Joinville Region, Brazil; Department of Biotechnological and Applied Clinical Sciences (A.C., S.S.), Neurological Institute, University of L'Aquila, Italy; Stroke Unit (N.C.), Centre Hospitalier Sud Francilien, Corbeil-Essonnes; Stroke Unit (S.O.), University Hospital of Bordeaux, France; Stroke Prevention Research Unit (P.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK; UNIFAI (C.S., M.C., R.M.), Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Portugal; Department of Neurology (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Neurology and Neurosurgery (J.K., R.V.), University of Tartu, Estonia; and Hospital Carlos Fernando Malzoni and Neurologic Center of Research and Rehabilitation (C.M.), Matão, SP, Brazil.
² From the Menzies Institute for Medical Research Tasmania (H.T.P., C.L.B., P.O., S.L.G.), University of Tasmania, Hobart, Australia; Department of Health Management and Health Economics (H.T.P.), Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Medicine (A.G.T., D.A.C.), School of Clinical Sciences at Monash Health, Monash University, Clayton; Florey Institute Neuroscience and Mental Health (D.A.C.), Heidelberg, University of Melbourne, Victoria; Faculty of Health and Medicine (J.S.), University of Newcastle; George Institute for Global Health (E.H., C.A.), University of Sydney, New South Wales, Australia; Hellenic Cardiovascular Research Society (K.V.), Athens, Greece; National Institute for Stroke and Applied Neurosciences (P.P., R.K., V.F.), School of Public Health and Psychosocial Studies, Auckland University of Technology; School of Psychology (S.B.-C.), University of Auckland, New Zealand; University of Burgundy (Y.B.), University Hospital of Dijon, France; Clinica Neurológica de Joinville (N.L.C.), Joinville Stroke Registry, University of Joinville Region, Brazil; Department of Biotechnological and Applied Clinical Sciences (A.C., S.S.), Neurological Institute, University of L'Aquila, Italy; Stroke Unit (N.C.), Centre Hospitalier Sud Francilien, Corbeil-Essonnes; Stroke Unit (S.O.), University Hospital of Bordeaux, France; Stroke Prevention Research Unit (P.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK; UNIFAI (C.S., M.C., R.M.), Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Portugal; Department of Neurology (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Neurology and Neurosurgery (J.K., R.V.), University of Tartu, Estonia; and Hospital Carlos Fernando Malzoni and Neurologic Center of Research and Rehabilitation (C.M.), Matão, SP, Brazil. Seana.Gall@utas.edu.au.

PMID: 29703773
DOI: 10.1212/WNL.0000000000005602

Abstract

Objective: To examine factors contributing to the sex differences in functional outcomes and participation restriction after stroke.

Methods: Individual participant data on long-term functional outcome or participation restriction (i.e., handicap) were obtained from 11 stroke incidence studies (1993-2014). Multivariable log-binomial regression was used to estimate the female:male relative risk (RR) of poor functional outcome (modified Rankin Scale score >2 or Barthel Index score <20) at 1 year (10 studies, n = 4,852) and 5 years (7 studies, n = 2,226). Multivariable linear regression was used to compare the mean difference (MD) in participation restriction by use of the London Handicap Scale (range 0-100 with lower scores indicating poorer outcome) for women compared to men at 5 years (2 studies, n = 617). For each outcome, study-specific estimates adjusted for confounding factors (e.g., sociodemographics, stroke-related factors) were combined with the use of random-effects meta-analysis.

Results: In unadjusted analyses, women experienced worse functional outcomes after stroke than men (1 year: pooled RR_unadjusted 1.32, 95% confidence interval [CI] 1.18-1.48; 5 years: RR_unadjusted 1.31, 95% CI 1.16-1.47). However, this difference was greatly attenuated after adjustment for age, prestroke dependency, and stroke severity (1 year: RR_adjusted 1.08, 95% CI 0.97-1.20; 5 years: RR_adjusted 1.05, 95% CI 0.94-1.18). Women also had greater participation restriction than men (pooled MD_unadjusted -5.55, 95% CI -8.47 to -2.63), but this difference was again attenuated after adjustment for the aforementioned factors (MD_adjusted -2.48, 95% CI -4.99 to 0.03).

Conclusions: Worse outcomes after stroke among women were explained mostly by age, stroke severity, and prestroke dependency, suggesting these potential targets to improve the outcomes after stroke in women.

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Comment in

Sex differences in stroke outcomes: A case for better health care for older women.
Andrew NE, Srikanth V. Andrew NE, et al. Neurology. 2018 May 29;90(22):995-996. doi: 10.1212/WNL.0000000000005591. Epub 2018 Apr 27. Neurology. 2018. PMID: 29703771 No abstract available.

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Factors contributing to sex differences in functional outcomes and participation after stroke

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Factors contributing to sex differences in functional outcomes and participation after stroke

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