A Call to Action to Improve Outcomes in Women Undergoing Surgical Coronary Revascularization

Abstract

We congratulate Gaudino and colleagues 1 for again capturing the persistently higher mortality and morbidity after isolated coronary artery bypass grafting (CABG) in women compared with men in the US. They included 1 297 204 patients who underwent primary isolated CABG in the Society of Thoracic Surgeons AdultCardiacSurgeryDatabase to compare outcomes between men (979 488 [75.5%]) and women (317 716 [24.5%]). The primary and secondary outcomes were operative mortality and combined mortality and morbidity, respectively. The primary outcome demonstrated a significantly higher unadjusted operative mortality for women compared with men (2.8% vs 1.7%; P < .001), with similarly significant results for the secondary outcome. The authors derived the attributable risk of female sex, which demonstrated that female sex was additive to baseline risk (range, 1.11-1.41), with no significant change over the 9-year study period.It is well known that women are sicker and older than men when they present for CABG and that they have higher mortality following surgery. [2][3][4] Consistent with this, Gaudino et al 1 noted that women have significantly more of the preoperative variables that significantly affect mortality (prior myocardial infarction, diabetes, peripheral vascular disease, cerebrovascular disease, preoperative intra-aortic balloon pump, and urgent surgery). Figure 1 1 demonstrates an alarming visual difference in outcomes between women and men over time. Remarkably, women had significantly higher operative mortal-

Sex Disparities After Coronary Artery Bypass Grafting and Hospital Quality

“…First, equitable referral of female patients to high-quality hospitals may narrow sex outcome disparities after high-risk surgery. The rationale underscoring this recommendation is seen both in our data as well as in national calls for female-specific centers of excellence for coronary artery bypass grafting . Building on this, in light of evidence that surgeon and patient sex concordance improves outcomes specifically for female patients, practitioner-level policies aimed at improving gender diversity in cardiothoracic surgery, where more than 90% of practicing cardiothoracic surgeons are male, could narrow this disparity .…”

“… 29 Our work builds on these important studies by demonstrating how hospital quality impacts sex outcomes disparities. Although there have been recent calls to action to resolve sex outcome disparities after high-risk surgery, 33 , 34 the role of hospital quality on sex disparities has not been examined before in a large, nationally representative cohort.…”

“…The rationale underscoring this recommendation is seen both in our data as well as in national calls for female-specific centers of excellence for coronary artery bypass grafting. 33 , 34 Building on this, in light of evidence that surgeon and patient sex concordance improves outcomes specifically for female patients, practitioner-level policies aimed at improving gender diversity in cardiothoracic surgery, where more than 90% of practicing cardiothoracic surgeons are male, could narrow this disparity. 45 , 46 Second, as is apparent from the geographic heterogeneity in hospital quality in this study, where high-quality hospitals were concentrated in the North and low-quality hospitals were concentrated in the South, access to high-quality hospitals is not uniform, and equitable referral alone cannot resolve the sex disparity.…”

“…29 Our work builds on these important studies by demonstrating how hospital quality impacts sex outcomes disparities. Although there have been recent calls to action to resolve sex outcome disparities after high-risk surgery, 33,34 the First, hospital-level risk-adjusted 30-day mortality was calculated. Second, hospitals were placed in rank order by 30-day mortality divided into quintiles of quality.…”