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Women with Acute Ischemic Stroke Routed Less Often to Optimal Acute Care


Disparities in emergency routing persisted despite women being acutely sicker than men and living the same distance from a comprehensive stroke center, in a Houston, Tx study.

Youngran Kim, PhD 

(Photo UTHealth Houston)

Youngran Kim, PhD

(Photo UTHealth Houston)

Women experiencing an acute ischemic stroke were 9% less likely to be routed to a comprehensive stroke center (CSC) than men, according to findings of a study that analyzed patient data from the greater Houston metropolitan area.1 Investigators reported that the potentially life-threatening disparity was observed despite the women’s more severe presentation of stroke symptoms compared with men and their comparable proximity to a stroke center.1

“Timely treatment of stroke is incredibly important; the faster a doctor is able to get the vessel open, the better the patient’s chance of having a good outcome. These routing systems in hospitals are designed to get patients to the best care as quickly as possible,” said lead investigator Sunil Sheth, MD, associate professor of neurology and director of the vascular neurology program with McGovern Medical School at UTHealth Houston, in a statement.2 “We don’t know exactly why women were less likely than men to be routed to comprehensive stroke centers, but we do know that gender is an implicit bias. Getting to the granular level of what went into a hospital’s routing decision will be very important for future studies.”2

Current research on inequities based on sex in prehospital CSC routing is scarce, according to Sheth and colleagues. Their interest for this study whether distance to CSCs, stroke severity, and patient sex are associated with direct-to-CSC prehospital routing in patients with large vessel occlusion acute ischemic stroke (LVO AIS).

“We don’t know exactly why women were less likely than men to be routed to comprehensive stroke centers, but we do know that gender is an implicit bias. Getting to the granular level of what went into a hospital’s routing decision will be very important for future studies.”

For the cross-sectional study, the research team identified consecutive patients presenting with LVO AIS from a prospectively-collected multihospital registry for the greater Houston area from January 2019 to June 2020. Of the 10 stroke centers included, 6 are primary stroke centers (PSCs) and 4 are CSCs.

Of an initial cohort of 630 potential participants, 503 individuals were included in the final analysis.1 Reasons for exclusion included inpatient status during AIS, missing information, and an address where a CSC would be more than 15 minutes travel from the nearest PSC.

The primary outcome of interest for the study was the proportion of direct-to-CSC routing for patients with LVO AIS and factors associated with direct routing. To compare the likelihood of direct-to-CSC prehospital routing for men and women, Sheth et al applied a modified Poisson regression model that included age, sex, race or ethnicity, first in‐hospital National Institutes of Health Stroke Scale (NIHSS) score, travel time, and distances to the closest PSC and CSC.

The final 503-participant cohort was 46% women and had a median age of 68 years; 41% were White, 38% received intravenous tPA, and 60% underwent endovascular therapy. The researchers report that the majority of participants (82%) were routed directed to a CSC.


The team’s analysis found that women with LVO AIS were more likely to be older than men (73 vs 65 years; P<.01) and had higher NIHSS scores (14 vs 12; P<.015). Investigators reported that distance to the closest PSC and CSC, travel times to a presenting hospital, and comorbidities were comparable between men and women.

The researcher’s multivariable analysis confirmed that women were less likely to be routed to a CSC compared with men (adjusted RR, 0.91; 95% CI, 0.84–0.99; P=.024). The analysis also revealed that distance to nearest CSC was associated with 38% greater likelihood of being routed to a CSC (aRR, 1.38; 95% CI, 1.26–1.52; P<.001). In a sensitivity analysis of a subset of 220 patients for whom a home address was substituted for a missing EMS pickup address, women were still less likely to be routed to a CSC. The sex difference remained significant in the multivariable analysis (aRR, 0.83, 95% CI, 0.72–0.95; P=.008).

“The greater NIHSS score in women may be partially attributed to their older age, as age itself is a known contributing factor to sex differences in stroke severity,” said senior investigator Youngran Kim, PhD, assistant professor of management, policy, and community health with UTHealth Houston School of Public Health.2 “Moreover, elderly women are more likely to live alone and experience social isolation, which can result in delayed recognition of stroke symptoms and subsequent delays in seeking medical attention. Therefore, appropriate triage and prehospital routing can be even more critical for women.

“Whether large vessel occlusions in women are less likely to be identified using current screening tools due to older age, premorbidity, or nontraditional symptoms needs to be investigated,” Kim concluded.


  1. Tariq MB, Ali I, Salazar-Marioni S, et al. Women with large vessel occlusion acute ischemic stroke are less likely to be routed to comprehensive Stroke centers. J Am Heart Assoc. 2023;e029830. Published online July 18, 2023. doi:10.1161/JAHA.123.029830
  2. Barkley C. Women less likely to be routed to comprehensive stroke centers for large vessel acute ischemic stroke, according to UTHealth Houston Research. UTHealth Houston. July 18, 2023. Accessed July 19, 2023. https://www.uth.edu/news/story/women-less-likely-to-be-routed-to-comprehensive-stroke-centers-for-large-vessel-acute-ischemic-stroke-according-to-uthealth-houston-research.

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