Reasons for delayed admission after stroke: results of a qualitative and quantitative survey

Figures & data

Table 1. Results of qualitative semi-structured interviews

Question	Category	Example
Symptom	Uncertainty/shame	“I was not sure what happened.”
Recognition		“I noticed something is wrong, but felt a shame”
		“Not being able to speak normally.” “I was not sure what happened, and asked the ophthalmologist/general practitioner.”
	Sorrow	“I worried about the symptoms and thought it may be because of my back pain.”
		“It may be because of my back pain.” “I worried, but was not able to move and to seek help.” “I worried and always thought about what could be happening.”
	Fear	“I was afraid, but have to take care of my child and could not go to the hospital.”
	Denial	“You think you’re superman, you understand, and you hesitate.” “Things like that have to get to me first”
Stroke perception?		“Yes, I thought that I may be having a stroke.”
		“I noticed a weakness and thought it will disappear”
		“I had no idea, although I absolutely know stroke symptoms.”
First reaction	Waiting,
	…for symptoms disappear	“I noticed the symptoms and thought they [would] disappear.”
	…avoiding the hospital	“My wife died in hospital, I did not want to go there.”
	…unable to move	“Because of the weakness and dizziness, I was unable to move to call for help.”
	Contact GP	“My general practitioner thought it may be a stroke.“

Table 5. Factors associated with early time from symptom onset to admission (OR ≤4.5 hrs)

Factor	OR^a; OR	95% CI	P-value
Age (<65; >65) (years)	1.008; 0.426	2.382	0.986
Female	0.699; 0.284	1.72	0.436
NIHSS (0–4; 5–42)	0.37; 0.121	1.131	0.081
Symptoms
Facial paresis	7.655; 2.614	22.418	<0.001
Hypesthesia	0.336; 0.098	1.148	0.082
Mono-/hemiparesis	4.434; 1.782	11.031	0.001
Walking dysfunction	0.386; 0.16	0.93	0.034
Dizziness/nausea/headache	0.893; 0.36	2.218	0.808
Aphasia or dysphasia	2.803; 1.172	6.708	0.021
Visual dysfunction	0.213; 0.071	0.642	0.006
Symptom notice
Patient themselves	0.153; 0.045	0.52	0.003
Other person	6.53; 1.923	22.172	0.003
Symptom interpretation
Serious	2.529; 1.06	6.033	0.035
Urgent	4.478; 1.828	10.97	0.001
Attribution of symptoms
Stroke	1.664; 0.689	4.022	0.258
Weakness	0.568; 0.132	2.451	0.448
Eye problems or disease	1.078; 0.281	4.137	0.913
Nerve irritation	0.431; 0.071	2.622	0.361
No attribution	12.293; 1.964	76.947	0.007
Stress	0.195; 0.01	3.644	0.274
Blood pressure	2.404; 0.395	14.638	0.341
Cardiac dysfunction	0.195; 0.01	3.644	0.274
First action
Waiting	0.013; 0.003	0.051	<0.001
Call family member	95.27; 5.387	1684.816	0.002
Call general practitioner	12.293; 1.964	76.947	0.007
Call emergency	17.945; 0.897	358.924	0.059
Medication intake	0.449; 0.021	9.639	0.609
Hospital	7.169; 0.284	181.122	0.232

Notes: ^aLogistic regression with Yates’ correction for continuity. Factors with significant influence are highlighted in bold.

Abbreviation: NIHSS, National Institute of Health Stroke Scale.

Table 2. Demographic data

Category	Item	All patients	Admission ≤4.5 hrs	Admission >4.5 hrs
Patients (n)		100	30	70
Onset-to-admission time (hrs)		18 (0,3–378)	1,5 (0,3–4,5)	24 (4,75–378)
Basic data
Gender	Female	36	9	27
Age (years)		70,5 (29–89)	70,5 (29–89)	70,5 (46–87)
NIHSS		2 (0–19)	3 (0–19)	2 (0–9)
Symptoms
	Walking dysfunction	50 (50%)	10 (20%)	40 (80%)
	Aphasia or dysphasia	36 (36%)	16 (44%)	20 (56%)
	Visual dysfunction	35 (35%)	4 (11%)	31 (89%)
	Dizziness/nausea/headache	32 (32%)	9 (28%)	23 (72%)
	Paresis	30 (30%)	16 (53%)	14 (47%)
	Sensory deficit	22 (22%)	3 (14%)	19 (86%)
	Facial paresis	19 (19%)	13 (68%)	6 (32%)
Risk factors
	Arterial hypertension	61 (61%)	17 (28%)	44 (72%)
	Aicotin abuse	39 (39%)	10 (26%)	29 (74%)
	Overweight	35 (35%)	9 (26%)	26 (74%)
	Hypercholesterinemia	26 (26%)	8 (31%)	18 (69%)
	Atrial fibrillation	6 (6%)	3 (50%)	3 (50%)
	Diabetes	15 (15%)	3 (20%)	12 (80%)
	Previous stroke	12 (12%)	1 (8%)	11 (92%)
	Coronary artery disease	6 (6%)	4 (67%)	2 (33%)
Previous medication
	Antihypertensive	52 (52%)	16 (31%)	36 (69%)
	Platelet inhibitors	38 (38%)	15 (39%)	23 (61%)
	Cholesterol lowering	16 (16%)	4 (25%)	12 (75%)
	Antidiabetic	12 (12%)	2 (17%)	10 (83%)
	Oral anticoagulation	3 (3%)	2 (67%)	1 (33%)
Living situation
	Alone	37 (37%)	11 (30%)	26 (70%)
	Not alone	61 (61%)	19 (31%)	42 (69%)
	Nursing home	2 (2%)	0 (0%)	2 (100%)
Health care
General practitioner, yes		96 (96%)	30 (31%)	66 (69%)
Visits (per year)		3 (0–20)	3 (0–12)	3 (0–20)
Source of information
About stroke risk	Newspaper/magazine	51 (51%)	16 (31%)	35 (69%)
	Television	38 (38%)	13 (34%)	25 (66%)
	General practitioner	26 (26%)	9 (35%)	17 (65%)
	Internet	19 (19%)	7 (37%)	12 (63%)
Self rating^a	Knowledge	4.9 (0–10)	4.0 (0–10)	5.0 (0–10)
	Stroke risk	3.3 (0–10)	2.8 (0–10)	3.8 (0–10)

Notes: ^aVAS range: 0 (low) to 10 (high). Categorial variables shown as median (range); continuous variables shown as n or n (%).

Abbreviations: NIHSS, National Institute of Health Stroke Scale; VAS, visual analog scale.

Table 3. Symptom perception, interpretation and first reaction

Questions	Items	All patients	Admission ≤4.5 hrs	Admission >4.5 hrs
Who noticed the symptoms?	Patient	87 (87%)	21 (24%)	66 (76%)
	Other person	13 (13%)	9 (69%)	4 (41%)
Interpretation of symptoms	Serious	47 (47%)	19 (40%)	28 (60%)
	Not-serious	53 (53%)	11 (21%)	42 (79%)
Interpretation of situation	Urgent	38 (38%)	19 (50%)	19 (50%)
	Not-urgent	62 (62%)	11 (18%)	51 (82%)
Emotions	Uncertainty	69 (69%)	23 (33%)	46 (67%)
	Fear	41 (41%)	17 (41%)	24 (59%)
	Sorrow	19 (19%)	8 (42%)	11 (58%)
	Anger	10 (10%)	4 (40%)	6 (60%)
	Shame	8 (8%)	1 (13%)	7 (87%)
	Frustration	2 (2%)	1 (50%)	1 (50%)
Attribution of symptoms	Stroke	32 (32%)	12 (38%)	20 (62%)
	General weakness	11 (11%)	2 (18%)	9 (82%)
	Eye problems/disease	10 (10%)	3 (30%)	7 (70%)
	Nerve irritation	8 (8%)	1 (13%)	7 (87%)
	No idea	7 (7%)	6 (86%)	1 (14%)
	Stress	6 (6%)	0 (0%)	6 (100%)
	Blood pressure	4 (4%)	2 (50%)	2 (50%)
	Cardiac dysfunction	5 (5%)	0 (0%)	5 (100%)
First action	Waiting because of…	67 (67%)	3 (5%)	64 (95%)
	… not suspecting stroke	37 (55%)	2 (5%)	35 (95%)
	… negative experiences	9 (13%)	0 (0%)	9 (100%)
	… call general practitioner	6 (9%)	1 (17%)	5 (83%)
	… other	15 (22%)	0 (0%)	15 (100%)
	Call family member	12 (12%)	12 (100%)	0 (0%)
	Call general practitioner	7 (7%)	6 (86%)	1 (14%)
	Call emergency	3 (3%)	3 (100%)	0 (0%)
	Medication intake	2 (2%)	0 (0%)	2 (100%)

Note: Values are absolute numbers (%).

Table 4. Answers on open and closed questions for risk factors and stroke symptoms

Risk factors and stroke symptoms	Open question	Closed question
Risk factors
	n=100	n=100
Arterial hypertension	22 (30%)	96 (96%)
Nicotine abuse	47 (64%)	95 (95%)
Overweight	16 (21%)	91 (91%)
Hypercholesterinemia	12 (16%)	86 (86%)
Atrial fibrillation	1 (1%)	47 (47%)
Diabetes	6 (8%)	64 (64%)
Stroke symptoms
	n=100	n=100
Aphasia or dysphasia	50 (57%)	97 (97%)
Facial paresis	15 (17%)	95 (95%)
Paresis	78 (87%)	94 (94%)
Walking dysfunction	14 (16%)	92 (92%)
Hypesthesia	15 (17%)	90 (90%)
Visual dysfunction	22 (25%)	84 (84%)
Headache	7 (8%)	59 (59%)

Note: Values are absolute numbers (%).

Data availability

All data are available by contacting the corresponding author. There are no unpublished data from the study.