Differences in Diagnostic Evaluation in Women and Men After Acute Ischemic Stroke

Abstract

Background Sex differences have been found in stroke risk factors, incidence, treatment, and outcomes. There are conflicting data on whether diagnostic evaluation for stroke may differ between men and women. Methods and Results We performed a retrospective cohort study using inpatient and outpatient claims between 2008 and 2016 from a nationally representative 5% sample of Medicare beneficiaries. We included patients ≥65 years old and hospitalized with ischemic stroke, defined by International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD ‐9‐ CM ) and ICD ‐10‐ CM diagnosis codes. Logistic regression was used to determine the association between female sex and the odds of diagnostic testing and specialist evaluation, adjusted for age, race, and number of Charlson comorbidities. Among 78 822 patients with acute ischemic stroke, 58.3% (95% CI , 57.9–58.6%) were women. Female sex was associated with decreased odds of intracranial vessel imaging (odds ratio [ OR ]: 0.94; 95% CI , 0.91–0.97), extracranial vessel imaging ( OR: 0.89; 95% CI , 0.86–0.92), heart‐rhythm monitoring ( OR: 0.92; 95% CI , 0.87–0.98), echocardiography ( OR: 0.92; 95% CI , 0.89–0.95), evaluation by a neurologist ( OR: 0.94; 95% CI , 0.91–0.97), and evaluation by a vascular neurologist ( OR: 0.94; 95% CI , 0.90–0.97), after adjustment for age, race, and comorbidities. These findings were unchanged in separate sensitivity analyses excluding patients who died during the index hospitalization or were discharged to hospice and excluding patients with atrial fibrillation diagnosed before their index stroke. Conclusions In a nationally representative cohort of Medicare beneficiaries, we found that women with acute ischemic stroke were less likely to be evaluated by stroke specialists and less likely to undergo standard diagnostic testing compared with men.

Striving for Socioeconomic Equity in Ischemic Stroke Care: Imaging and Acute Treatment Utilization From a Comprehensive Stroke Center

“…Consistent with a recent study [23], the only disparity we found by sex was lower CTA utilization in female patients. Although a sex-based neuroimaging disparity was not found by others [22], this finding, along with less CTA utilization in patients with diabetes mellitus, renal insufficiency, and age !…”

“…In the hospital setting, socioeconomic disparities exist for patients with stroke in terms of access to treatment [11,15,16]. Additionally, variability in stroke imaging utilization on the basis of age, sex, race, and insurance type has been reported [12,[22][23][24][25]. Furthermore, disadvantaged socioeconomic groups have historically been the last to benefit from newer medical technologies [26].…”

Discharge Against Medical Advice in Acute Ischemic Stroke: the Risk of 30-Day Unplanned Readmission

“…AIS patients were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes (433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, and 436) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes (I21). 18 These codes have a specificity of 95% and positive predictive value of 90% for AIS. 19 The NRD variable "DISPUNIFORM" was used to identify DAMA.…”

Toward a Better Understanding of Sex- and Gender-Related Differences in Endovascular Stroke Treatment: A Scientific Statement From the American Heart Association/American Stroke Association

“…19,20 Diagnostic workup: Women with AIS symptoms are less likely to see a stroke specialist and to undergo standard diagnostic testing than men. 21,22 Vascular imaging is performed less often in women. 22 Intravenous thrombolysis: Women are 13% less likely to receive intravenous thrombolysis than men in Western countries.…”

“…21,22 Vascular imaging is performed less often in women. 22 Intravenous thrombolysis: Women are 13% less likely to receive intravenous thrombolysis than men in Western countries. 18 Underuse and delay in intravenous thrombolysis in women are more pronounced in hospitals without specialized stroke unit care.…”