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Published on: October 25, 2016
Factors contributing to sex differences in functional outcomes and participation after stroke
Hoang T Phan1, Christopher L Blizzard1, Mathew J Reeves1
1From 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.
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 RRunadjusted 1.32, 95% confidence interval [CI] 1.18-1.48; 5 years: RRunadjusted 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: RRadjusted 1.08, 95% CI 0.97-1.20; 5 years: RRadjusted 1.05, 95% CI 0.94-1.18). Women also had greater participation restriction than men (pooled MDunadjusted -5.55, 95% CI -8.47 to -2.63), but this difference was again attenuated after adjustment for the aforementioned factors (MDadjusted -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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