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Wagner CM, Ibrahim AM. Sex Disparities After Coronary Artery Bypass Grafting and Hospital Quality. JAMA Netw Open 2024; 7:e2414354. [PMID: 38861261 PMCID: PMC11167499 DOI: 10.1001/jamanetworkopen.2024.14354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/14/2024] [Indexed: 06/12/2024] Open
Abstract
Importance Concern has been raised about persistent sex disparities after coronary artery bypass grafting, with female patients having higher mortality. However, whether these disparities persist across hospitals of different qualities is unknown. Objective To evaluate sex disparities in 30-day mortality after coronary artery bypass grafting across high- and low-quality hospitals. Design, Setting, and Participants This cross-sectional, retrospective cohort study evaluated Medicare beneficiaries undergoing coronary artery bypass grafting between October 1, 2015, and March 31, 2020. Data analysis was performed from July 1, 2023, to December 1, 2023. Exposures The primary exposures were hospital quality and sex. For hospital quality, hospitals were placed into rank order by their overall risk-adjusted mortality rate and divided into quintiles. Main Outcome and Measures Risk-adjusted 30-day mortality using a logistic regression model accounting for patient factors, including sex, age, comorbidities, elective vs unplanned admission, number of bypass grafts, use of arterial graft, and year of surgery. Results A total of 444 855 beneficiaries (mean [SD] age, 71.5 [7.5] years; 120 333 [27.1%] female and 324 522 [72.9%] male) were studied. Compared with male beneficiaries, female beneficiaries were more likely to have an unplanned admission (66 425 [55.2%] vs 157 895 [48.7%], P < .001) and receive care at low-quality (vs high-quality) hospitals (odds ratio, 1.26; 95% CI, 1.23-1.29; P < .001). Overall, risk-adjusted female mortality was 4.24% (95% CI, 4.20%-4.27%), and male mortality was 2.75% (95% CI, 2.75%-2.77%), with an absolute difference of 1.48 (95% CI, 1.45-1.51) percentage points (P < .001). At the highest-quality hospitals, male mortality was 1.57% (95% CI, 1.56%-1.59%), and female mortality was 2.58% (95% CI, 2.54%-2.62%), with an absolute difference of 1.01 (95% CI, 0.97-1.04) percentage points (P < .001). At the lowest-quality hospitals, male mortality was 4.94% (95% CI, 4.88%-5.01%), and female mortality was 7.02% (95% CI, 6.90%-7.13%), with an absolute difference of 2.07 (95% CI, 1.95-2.19) percentage points (P < .001). Female beneficiaries receiving care at low-quality hospitals had a higher mortality than male beneficiaries receiving care at the high-quality hospitals (7.02% vs 1.57%, P < .001). Conclusions and Relevance In this cohort study of Medicare beneficiaries undergoing coronary artery bypass grafting, female beneficiaries were more likely to receive care at low-quality hospitals, where the sex disparity in mortality was double that of high-quality hospitals. Quality improvement targeting low-quality hospitals as well as equitable referral of female beneficiaries to higher-quality hospitals may narrow the sex disparity after coronary artery bypass grafting.
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Affiliation(s)
- Catherine M. Wagner
- National Clinician Scholar’s Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, Michigan Medicine, Ann Arbor
| | - Andrew M. Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, Michigan Medicine, Ann Arbor
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Gaudino M, Chadow D, Rahouma M, Soletti GJ, Sandner S, Perezgrovas-Olaria R, Audisio K, Cancelli G, Bratton BA, Fremes S, Kurlansky P, Girardi L, Habib RH. Operative Outcomes of Women Undergoing Coronary Artery Bypass Surgery in the US, 2011 to 2020. JAMA Surg 2023; 158:494-502. [PMID: 36857059 PMCID: PMC9979009 DOI: 10.1001/jamasurg.2022.8156] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/29/2022] [Indexed: 03/02/2023]
Abstract
Importance It has been reported that women undergoing coronary artery bypass have higher mortality and morbidity compared with men but it is unclear if the difference has decreased over the last decade. Objective To evaluate trends in outcomes of women undergoing coronary artery bypass in the US from 2011 to 2020. Design, Setting, and Participants This retrospective cohort study at hospitals contributing to the Adult Cardiac Surgery Database of the Society of Thoracic Surgeons included 1 297 204 patients who underwent primary isolated coronary artery bypass from 2011 to 2020. Exposure Coronary artery bypass. Main Outcomes and Measures The primary outcome was operative mortality. The secondary outcome was the composite of operative mortality and morbidity (including operative mortality, stroke, kidney failure, reoperation, deep sternal wound infection, prolonged mechanical ventilation, and prolonged hospital stay). The attributable risk (the association of female sex with coronary artery bypass grafting outcomes) for the primary and secondary outcomes was calculated. Results Between 2011 and 2020, 1 297 204 patients underwent primary isolated coronary artery bypass grafting with a mean age of 66.0 years, 317 716 of which were women (24.5%). Women had a higher unadjusted operative mortality (2.8%; 95% CI, 2.8-2.9 vs 1.7%; 95% CI, 1.7-1.7; P < .001) and overall unadjusted incidence of the composite of operative mortality and morbidity compared with men (22.9%; 95% CI, 22.7-23.0 vs 16.7%; 95% CI, 16.6-16.8; P < .001). The attributable risk of female sex for operative mortality varied from 1.28 in 2011 to 1.41 in 2020, with no significant change over the study period (P for trend = 0.38). The attributable risk for the composite of operative mortality and morbidity was 1.08 in both 2011 and 2020 with no significant change over the study period (P for trend = 0.71). Conclusions and Relevance Women remain at significantly higher risk for adverse outcomes following coronary artery bypass grafting and no significant improvement has been seen over the course of the last decade. Further investigation into the determinants of operative outcomes in women is urgently needed.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - David Chadow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Giovanni Jr Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Brenden A. Bratton
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Stephen Fremes
- Schulich Heart Centre, Sunnybrook Health Science University of Toronto, Toronto, Ontario, Canada
| | - Paul Kurlansky
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, New York
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Robert H. Habib
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois
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Alamri HM, Alotaibi TO, Alghatani AA, Alharthy TF, Sufyani AM, Alharthi AM, Mahmoud AA, Almahdi MK, Alama N, Al-Ebrahim KE. Effect of Gender on Postoperative Outcome and Duration of Ventilation After Coronary Artery Bypass Grafting (CABG). Cureus 2023; 15:e37717. [PMID: 37206527 PMCID: PMC10191450 DOI: 10.7759/cureus.37717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION The study assessed coronary artery bypass grafting (CABG) postoperative outcomes and associated factors in Saudi male and female patients. This was a retrospective cohort of patients who underwent CABG at the King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, from January 2015 to December 2022. Results: We included 392 patients, of whom 63 (16.1%) were female. Female undergoing CABG were significantly older (p=0.0001), had a significantly higher incidence of diabetes (p=0.0001), obesity (p=0.001), hypertension (p=0.001), and congestive heart failure (p=0.005), with a smaller body surface area (BSA) (p=0.0001) than male. Though renal dysfunction, previous cerebrovascular accident/transient ischemic attack (CVA/TIA), and myocardial infarction (MI), incidences were similar in both genders. Females were at significantly higher risk of mortality (p=0.0001), longer hospital stay (p=0.0001), and prolonged ventilation (p=0.0001). Preoperative renal dysfunction was the only statistically significant predictor of postoperative complications (p=0.0001). Female gender and preoperative renal dysfunction, were significant independent predictors of postoperative mortality and prolonged ventilation (p=0.005). CONCLUSION This study's findings indicated that females have worse CABG outcomes and a higher risk of morbidities and complications. Uniquely our study showed a higher incidence of prolonged ventilation in females postoperatively.
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Affiliation(s)
- Hassan M Alamri
- Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Turki O Alotaibi
- Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | | | - Tariq F Alharthy
- Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Albaraa M Sufyani
- Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | | | | | | | - Nabil Alama
- Medicine, King Abdulaziz University Hospital, Jeddah, SAU
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Zwischenberger BA, Lawton JS. A Call to Action to Improve Outcomes in Women Undergoing Surgical Coronary Revascularization. JAMA Surg 2023; 158:502-503. [PMID: 36857043 DOI: 10.1001/jamasurg.2022.8163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Affiliation(s)
- Brittany A Zwischenberger
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland
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Metkus TS, Alviar CL, Baird-Zars VM, Barsness GW, Berg DD, Bohula EA, Burke JA, Fordyce CB, Guo J, Katz JN, Keeley EC, Menon V, Miller PE, O'Brien CG, Sinha SS, So D, Ternus BW, Vadhar S, van Diepen S, Morrow DA. Presentation and Outcomes of Patients With Preoperative Critical Illness Undergoing Cardiac Surgery. JACC. ADVANCES 2023; 2:100260. [PMID: 38357248 PMCID: PMC10865183 DOI: 10.1016/j.jacadv.2023.100260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 12/05/2022] [Accepted: 01/13/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Little is known about the prevalence and post-surgical outcomes associated with cardiac intensive care unit (CICU) therapeutics among CICU patients referred for cardiac surgery. OBJECTIVES The purpose of this study was to investigate the clinical characteristics and outcomes of CICU patients referred for cardiac surgery from the intensive care unit. METHODS We analyzed characteristics and outcomes of CICU admissions referred from the CICU for cardiac surgery during 2017 to 2020 across 29 centers. The primary outcome was in-hospital mortality. RESULTS Among 10,321 CICU admissions, 887 (8.6%) underwent cardiac surgery, including 406 (46%) coronary artery bypass graftings, 201 (23%) transplants or ventricular assist devices, 171 (19%) valve surgeries, and 109 (12%) other procedures. Common indications for CICU admission included shock (33.5%) and respiratory insufficiency (24.9%). Preoperative CICU therapies included vasoactive therapy in 52.2%, mechanical circulatory support in 35.9%, renal replacement in 8.2%, mechanical ventilation in 35.7%, and 17.5% with high-flow nasal cannula or noninvasive positive pressure ventilation. In-hospital mortality was 11.7% among all CICU admissions and 9.1% among patients treated with cardiac surgery. After multivariable adjustment, pre-op mechanical circulatory support and renal replacement therapy were associated with mortality, while respiratory support and vasoactive therapy were not. CONCLUSIONS Nearly 1 in 12 contemporary CICU patients receive cardiac surgery. Despite high preoperative disease severity, CICU admissions undergoing cardiac surgery had a comparable mortality rate to CICU patients overall; highlighting the ability of clinicians to select higher acuity patients with a reasonable perioperative risk.
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Affiliation(s)
- Thomas S. Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carlos L. Alviar
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York City, New York, USA
| | - Vivian M. Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory W. Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David D. Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erin A. Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - James A. Burke
- Lehigh Valley Heart and Vascular Institute, Allentown, Pennsylvania, USA
| | - Christopher B. Fordyce
- Division of Cardiology and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jianping Guo
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jason N. Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ellen C. Keeley
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - P. Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Connor G. O'Brien
- Division of Cardiology, Department of Medicine, University of California-San Francisco School of Medicine, San Francisco, California, USA
| | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Bradley W. Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Sagar Vadhar
- Lehigh Valley Heart and Vascular Institute, Allentown, Pennsylvania, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A. Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Klein KM. Cardiovascular disease, surgery and outcomes in women: are they any different. Curr Opin Anaesthesiol 2023; 36:42-44. [PMID: 36550603 DOI: 10.1097/aco.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Cardiovascular disease is a leading cause of death for women worldwide and continues to be a major determinant of significant morbidity. Several studies have investigated the marked differences in diagnosis, treatment and etiology in cardiovascular disease and how it relates to gender. In this review, several key studies highlight the stark differences and bring light to the disparity and potential opportunities for further research. RECENT FINDINGS One noted area of gender disparity is ischemic cardiac disease as it relates to surgical management. Women have historically had delays in diagnosis, inferior surgical revascularization techniques, and inadequate postoperative care when compared to men. SUMMARY By highlighting the disparities in cardiovascular ischemic care, the hope is to bring attention and future research to a population group that is currently undertreated for their ischemic disease and suffering high mortality rates.
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Kieser TM. Commentary: Coronary artery disease: Equality of care for women and men. JTCVS Tech 2021; 10:131-132. [PMID: 34984373 PMCID: PMC8691920 DOI: 10.1016/j.xjtc.2021.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 10/15/2021] [Accepted: 10/15/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Teresa M. Kieser
- Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
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