Background: Sex differences in stroke outcomes are crucial to secondary prevention but previous reports showed inconsistent results. We aimed to explore the sex differences in stroke outcomes in the Third China National Stroke Registry, a prospective multi-center registry study. Methods: Among the 15166 patients enrolled between 2015 and 2018, 9038 patients with acute ischemic stroke (AIS) were included. The primary outcomes were stroke recurrence, mortality, and unfavorable functional outcome (modified Rankin Scale [mRS] > 2) at 3, 6, and 12 months. Cox regression model was used for stroke recurrence and mortality and logistic regression was used for the unfavorable functional outcome, and adjusted as follows: (1) Model 1: without adjustment; (2) Model 2: adjusted for potential risk factors, National Institutes of Health Stroke Scale (NIHSS) at admission, pre-stroke mRS, tissue plasminogen activator (TPA) treatment, TOAST classification, and onset-to-door time; (3) Model 3: adjusted for covariates from model 2 in addition to blood pressure and blood serum covariates. Multiple imputation was used for missing values, and sensitivity analyses were conducted to describe sex differences by age groups. Results: One-third (2802/9038) of the patients were women. Women were significantly older than men (64.78±10.84 vs. 61.26±11.42, p<0.001). In the fully adjusted model, female patients were more likely to have unfavorable functional outcomes at 3 months (odds ratio [OR], 1.28 [1.09, 1.50]), especially among patients aged 65 years or older (OR, 1.39 [1.14, 1.70]), but no difference was discovered in patients aged < 65 years. There were no sex differences in stroke recurrence and mortality at 3, 6, or 12 months or unfavorable functional outcomes at 6 or 12 months after adjustment. Conclusions: Compared to men, women with AIS were less likely to have favorable outcomes at three months in China, especially among those over 65 years of age. Experts should aim to tailor secondary prevention strategies for high-risk patients.

Background Intravenous Tissue Plasminogen Activator (IV rt-PA) significantly improves AIS patients' functional outcomes within the treatment window, yet the usage of IV rt-PA among AIS patients are substantially lower in China than in developed countries. Healthcare resource utilization manages effective treatment patterns for patients who are adherent to IV rt-PA. This study investigates the association between healthcare resource inputs and IV rt-PA adherence and the impact of Gross Regional Product (GRP) on IV rt-PA. Methods 1,456 hospitals from 31 provinces with 158,003 acute ischemic stroke patients who had received IV rt-PA between 2015-2019 were recruited by the Chinese Stroke Center Alliance. The study outcome was the adherence rate of IV rt-PA in each hospital. Healthcare resource input was identified from three aspects: human, material, and economic. Multivariable linear regression was conducted by adjusting healthcare system characteristics and by further adjustment of GRP. Results The median (interquartile range) of IV rt-PA rate was 19.1% (8.6% -34.6%). Physician-nurse ratio (β=0.023, p<0.001), nurse-bed ratio (β=0.0343, p<0.001), and total health expenditure (β=0.00002, p<0.001) were positively associated with the IV rt-PA adherence rate after controlling healthcare system factors. Through additional adjusting of GRP, only health expenditure was significantly positively associated with IV rt-PA adherence rate (β=0.000018, p<0.001). Conclusions More health spending and being equipped with equally proportional physician-nurses and nurse-bed combinations in the provincial hospital will increase adherence to IV rt-PA among AIS patients. The difference in GRP among provinces may stimulate hospitals to provide more healthcare input from the workforce, thus indirectly increasing the usage of IV rt-PA.