Age and Ageing Advance Access originally published online on November 14, 2007
Age and Ageing 2008 37(2):220-222; doi:10.1093/ageing/afm153
Effect of gender on stroke management in Glasgow
SIR—Stroke is a leading cause of death and disability [1]. However, its impact can be attenuated by judicious use of proven acute [3] and secondary preventative [5] strategies. There is evidence from across Europe and North America that sex differences may exist in the management of a variety of cardiovascular conditions [6–9] including stroke [10–13]. Available data suggests that women with stroke may be less likely than men to receive optimal antithrombotic therapy, carotid revascularisation or appropriate imaging. Such potential for gender bias is a source of significant concern and we read with interest Dr Rudd's recent report in this journal [14] which did not find evidence of systematic gender bias within the sentinel audit of stroke services in England and Wales. We sought to investigate any potential gender discrepancy in use of stroke interventions using a subset of data from a national audit of stroke care in Scotland.The Scottish Stroke Care Audit [15] was established in 2002 under the aegis of the Scottish Stroke Collaboration. It aims to monitor the performance of Scottish hospitals against nationally agreed standards for stroke care and to encourage the collection of a common data set by Scottish health boards to allow comparisons to be made between units and to facilitate benchmarking. The SSCA collects a mandatory core dataset for all patients in participating hospitals admitted with a diagnosis of stroke. This dataset includes identifiers, simple demographics, information about patient interaction with health services and diagnosis. A minimum dataset, with the mandatory set at its centre, was defined to provide further information on quality of stroke care service; this includes information on the process of care and its appropriateness, and performance of services in relation to national standards.
Case ascertainment occurred through scrutiny of acute stroke unit, general ward and A&E registers, review of day ward and medical assessment ward attendances, interrogation of radiology booking system databases, review of data routinely collected by the Information and Statistics Division of the Scottish Executive and collation of discharge summaries. A more detailed account of case ascertainment methodology can be found elsewhere [15].
For the purposes of this project, data for patients with a diagnosis of stroke admitted from 1 June 2004 to 31 August 2006 to the five major urban acute hospitals across Glasgow were collated. Each participating hospital contains a dedicated stroke unit. The Multi-Centre Research Ethics Committee for Scotland (MREC) has previously reviewed the Scottish Stroke Care Audit protocol and opined that Local Research Ethics Committee (LREC) approval for collecting and using the minimum dataset to reflect performance of stroke services is not required. Data were extracted from unstructured case records, clerking proformas, integrated care pathways and structured discharge summaries. They were then entered manually to the database, with data validation at times of entry and extraction.
We collated data from the audit and compared male and female demographics. Comparison was made between men and women in numbers of admission to acute and rehabilitation stroke units; use of antiplatelet agents and anticoagulants; use of antihypertensive agents and lipid lowering therapy. In addition, stroke subtype (as assessed by Oxfordshire Community Stroke Project (OCSP)), mortality and ability to walk unaided at discharge were compared between both sexes. Statistical analysis of data was performed using chi-squared test for proportions and two sample t-tests where appropriate. All statistical analyses were performed using Minitab software (version 14, Minitab Inc, PA, USA).
During the period of study, 3,261 patients were identified at involved sites: 1,706 female (52.3%), and 1,556 male (47.7%). Demographics stratified by gender are summarised in Table 1.
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Effect of gender on stroke interventions are summarised in Table 2. There was no difference between women and men in rates of admission to acute stroke or rehabilitation units. Rates of computed tomography (CT) scanning and magnetic resonance imaging (MRI) were similar with no significant sex difference in access to these services across the five hospital sites.
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With regard to drug therapy, although men were more likely to have been on aspirin at onset of stroke symptoms, this difference was not sustained at discharge, with no difference between sexes in use of aspirin at this time. There was a significant difference in the use of dual antiplatelet therapy at discharge, with more men than women receiving combination antiplatelet therapy with both aspirin and dipyridamole at discharge. There were similar rates of anticoagulant use at discharge between females and males.
The use of angiotensin-converting enzyme (ACE) inhibitors and statins also differed between sexes, with men more likely to have these agents prescribed at discharge. The opposite is true in the use of thiazide diuretics, with significantly more women being prescribed these at discharge than men.
These data suggest that gender may influence treatment decisions after stroke, a finding reported by previous studies but never before in the UK. A recent UK-based study [14] of data derived from the Stroke Sentinel Audit [16] did not identify gender-based discrepancies in stroke care; however this study did not address specific aspects of pharmacological therapy such as choice of blood pressure lowering or antithrombotic drugs. As such, our report develops but in our view is not inconsistent with earlier UK-based data.
We found that women in our cohort of patients were less likely to be prescribed statins or ACE inhibitors. They were also less likely to be discharged on combination antiplatelet therapy with both aspirin and dipyridamole, but this is likely to be because more men than women were on aspirin on admission. Women were more likely to die in hospital than men, although this may in part be because the women were older than men and had a higher proportion of total anterior circulation events. There were no differences between genders in access to imaging services or acute stroke units or rehabilitation wards.
These findings do correspond to other studies, which have shown that women tend to be older and have a worse prognosis than men. However, our project has shown for the first time that there are treatment inequalities between men and women, particularly in relation to the use of lipid lowering agents (statins) and antihypertensives (ACE inhibitors and diuretics). Previous studies have not identified this difference. We found that the use of combination antiplatelet therapy differed between sexes at discharge—this has been commented on in other data series [11], however, our study period coincides with availability of evidence of superiority of dual antiplatelet treatment over monotherapy with aspirin [17]. One explanation for the lower use of antiplatelet therapy in women might be the presence of greater comorbidity, possibly reflected in the higher inhospital mortality. Men were more likely to be taking aspirin at presentation because of their higher rate of ischemic heart disease; and it is possible that these individuals had a pre-existing antiplatelet treatment augmented with another agent, whereas, those on no antiplatelet treatment had aspirin alone.
We do not have baseline data on actual blood pressure values or trends in blood pressure during admission, and this may explain the underuse of ACE inhibitors in the female group if, for example, this group were significantly more hypotensive than men, but this would not account for the increased use of thiazide diuretics in this group, and evidence supports the use of both ACE inhibitors and diuretics across a wide range of blood pressures [18].
In conclusion, despite equity of access to stroke services, we have identified evidence consistent with an influence of gender upon prescribing in stroke survivors. Further work is now required to clarify the underlying reasons for the observed disparity and to assess the degree to which this pattern is repeated elsewhere.
- Prescribing patterns after stroke may be influenced by gender.
The authors have no relevant disclosures or conflicts of interest.
1 Stobhill Hospital, Glasgow, UK
2 Department of Medicine and Therapeutics, University of Glasgow, UK
* To whom correspondence should be addressed Email: cc.doctors{at}ntlworld.com
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