Improved in-hospital mortality in women undergoing coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group

Elucidating the Relationship Between Insomnia, Sex, and Cardiovascular Disease

Sex differences in cardiovascular disease (CVD) mortality have been attributed to differences in pathophysiology between men and women and to disparities in CVD management that disproportionately affect women compared to men. Similarly, there has been investigation of differences in the prevalence and presentation of insomnia attributable to sex. Few studies have examined how sex and insomnia interact to influence CVD outcomes, however. In this review, we summarize the literature on sex-specific differences in the prevalence and presentation of insomnia as well as existing research regarding the relationship between insomnia and CVD outcomes as it pertains to sex. Research to date indicate that women are more likely to have insomnia than men, and there appear to be differential associations in the relation between insomnia and CVD by sex. We posit potential mechanisms of the relationship between sex, insomnia and CVD, discuss gaps in the existing literature, and provide commentary on future research needed in this area. Unraveling the complex relations between sex, insomnia, and CVD may help to explain sex-specific differences in CVD, and identify sex-specific strategies for promotion of cardiovascular health. Throughout this review, terms “men” and “women” are used as they are in the source literature, which does not differentiate between sex and gender. The implications of this are also discussed.

Gender difference in long- and short-term outcomes of off-pump coronary endarterectomy

Background

The role of gender in the selection of the most effective method for treatment of patients with diffused coronary artery diseases remains a matter of debate. This study thus evaluated the effect of gender on long- and short-term outcomes of off-pump coronary endarterectomy (CE).

Methods

This was a single-center retrospective study of patients who had undergone coronary artery bypass graft (CABG). The patients were divided into two groups, the CABG and the CABG + CE group, and further stratified into male and female. Long-term survival for each group was estimated by Kaplan-Meier analysis with log-rank testing. In addition, Cox regression analyses of each gender were also carried out to identify the predictors of the primary and secondary endpoints.

Results

Overall, 25.8% of the patients were female. Diseased vessels were not statistically different in the two groups - men and women. There was no significant difference in postoperative outcomes between males and females in the CABG and CABG + CE groups. There was no significant difference in hospital mortality in the two groups between males and females. Kaplan-Meier curves show that there was no significant difference in the 5-year cardiac mortality between males and females belonging to the CABG and CABG + CE groups.

Conclusion

The results of this study show that there was no significant difference in the short- and long-term outcomes of off-pump CABG and CE in both genders although women tend to carry a greater risk.

Clinical Outcomes of Elderly Patients with Non ST-Segment Elevation Myocardial Infarction Undergoing Coronary Artery Bypass Surgery

The aim of this study is to investigate the clinical outcomes of the elderly patients with Non ST-segment elevation myocardial infarction (NSTEMI) undergoing coronary artery bypass surgery (CABG) compared to non-elderly patients. Patients with NSTEMI and undergoing CABG (n=451) who were registered in the Korea Acute Myocardial Infarction Registry between December 2003 and August 2012 were divided into two groups.; the non-elderly group (<75 years, n=327) and the elderly group (≥75 years, n=124). In-hospital mortality was higher in the elderly group (4.9% vs. 11.3%, p=0.015), but cardiac death, myocardial infarction, and major adverse cardiovascular events (MACE) including cardiac death, myocardial infarction, percutaneous revascularization, and redo-CABG after a one-year follow up were not different between the two groups. Predictors of in-hospital mortality in patients with NSTEMI undergoing CABG were left ventricular (LV) dysfunction (ejection fraction ≤40%) [hazard ratio (HR): 2.76, 95% confidence interval (CI): 1.16–6.57, p=0.022] and age (HR: 1.05, 95% CI: 1.01–1.10, p=0.047). So elderly NSTEMI patients should be considered for CABG if appropriate, but careful consideration for surgery is required, especially if the patients have severe LV systolic dysfunction.

Are the Early Postoperative Outcomes of Coronary Artery Bypass Grafting Surgery in Elderly Women Worse Compared to Men's?

Objective

To investigate the impact of gender difference in early postoperative outcomes in elderly patients (aged 70 or older) undergoing coronary artery bypass grafting surgery.

Methods

Between October 2009 and December 2013, a total of 223 elderly patients (aged 70 or older) undergoing isolated primary coronary artery bypass grafting surgery were included in this retrospective observational cohort study. Patients were divided into two groups according to their gender. The patients' medical records were collected, their baseline preoperative characteristics, operative data, and postoperative outcomes were retrospectively reviewed, and the effect of gender difference in the early postoperative outcomes was analyzed.

Results

Group 1 (female patients) and Group 2 (male patients) consisted of 71 and 152 patients, respectively. Mean age of patients was 74.4±3.6 years (range: 70-84 years). The level of EuroSCORE I, the incidence of hypertension and hyperlipidemia were significantly higher in Group 1, while the rate of smoking was significantly higher in Group 2. Mean postoperative intubation time, length of intensive care unit and hospital stay were longer in female patients than in male patients, but these differences were not statistically significant. No statistically significant difference between two groups in terms of the transfusion of blood products was observed. The rates of in-hospital mortality and major postoperative complications were statistically similar between the two groups.

Conclusion

In conclusion, the female gender was not associated with worse early postoperative outcomes in elderly patients undergoing coronary artery bypass grafting surgery.

Does Gender Influence the Likelihood or Types of Complications Following Cardiac Surgery?

Over 410,000 cardiac surgeries are performed in American women each year. Women having coronary artery bypass graft (CABG) and valve surgery do so at an older age and with more cardiovascular risk factors than men. Women's smaller body size may also increase risk by increasing the technical difficulty of surgical procedures. Female CABG patients appear to have higher perioperative mortality and cardiac morbidity, although studies of neurologic outcomes in female CABG patients have produced equivocal findings. Women undergoing CABG tend to consume more hospital resources than men do in terms of blood transfusion, mechanical ventilation, and length of intensive care unit and overall hospital stay. With regard to valve surgery, women appear to have worse outcomes than men if the surgery is combined with a CABG operation. Women and men undergoing isolated aortic valve surgery have similar mortality, but little is known about gender differences in mitral and tricuspid valve surgery outcomes. Women who require heart transplantation tend to have idiopathic cardiomyopathy rather than the ischemic cardiomyopathy that is more common in male heart transplant candidates. Although female heart transplant recipients seem to have a stronger immunologic response after transplantation, which manifests in more frequent acute rejection episodes, it is not clear whether this increases women's mortality risk. Men appear to have a greater incidence of posttransplant vasculopathy than women. Further research is needed to identify risk factors for perioperative morbidity and mortality in women undergoing cardiac surgery and to develop medical interventions to mitigate these risks.

Off-pump coronary revascularization: A potential benefit for female patients?

Coronary artery disease is one of the leading causes of illness for both men and women. However, women are 3 times more likely to die for coronary artery disease as they are of breast cancer. There are an increasing prevalence of coronary artery disease in women and thus facing the need for surgical revascularization. It has long being accepted that women carry a high risk of coronary surgery than men. Many investigators have suggested that female itself is predictive of poor outcome after on pump coronary surgery. We thought to search the litlature to investigate whether women who undergo off-pump surgery receive any benefits compared with women undergoing on-pump surgery.

[Improving patient safety in perioperative care for major surgeries]

The Helsinki Declaration was created and signed by the European Board of Anaesthesiology (EBA) and the European Society of Anaesthesiology (ESA). It was initiated in June 2010, and it implies a European consensus on those medical practices which improve patient safety and provide higher quality perioperative care. Authors focus on four elements of this initiative, which can be easily implemented, and provide almost instant benefit: use of preoperative checklist, prevention of perioperative infections, goal-directed fluid therapy and perioperative nutrition. The literature review emphasizes that well organized perioperative care plays the most important role in improving patient safety.

Defining higher-risk surgery

PURPOSE OF REVIEW

Defining the contemporary high-risk noncardiac surgical population using objective clinical outcomes data is paramount for the rational allocation of healthcare resources, truly informed patient consent and improving patient-centered outcomes.

RECENT FINDINGS

Data from independent healthcare systems have identified that the development, and consequences, of postoperative morbidity extend beyond the immediate postoperative hospital period and confer substantially increased risk of death. Cardiac insufficiency, rather than the relatively heavily explored paradigm of perioperative cardiac ischemia, is emerging as the dominant factor associated with excess risk of prolonged postoperative morbidity. The development of prospective, validated, time-sensitive morbidity data collection tools has also helped define patients at higher risk of noncardiac morbidities and short-term perioperative outcomes.

SUMMARY

Higher risk surgical patients present an increasingly major challenge for healthcare resource utilization. Detailed outcome studies using validated morbidity tools are urgently required to establish the extent to which postoperative morbidity may be predicted. Robust identification of patients at the highest risk of perioperative morbidity may permit further clinic-to-bench translational understanding of the pathophysiologic mechanisms underlying postoperative organ dysfunction. Defining the high-risk surgical patient population is as critically important for global public health planning as it is for the perioperative team.

Significant Improvement in Short-Term Mortality in Women Undergoing Coronary Artery Bypass Surgery (1991 to 2004)

OBJECTIVES

This study sought to evaluate gender differences and trends in 30-day mortality after coronary artery bypass surgery (CABG).

BACKGROUND

Evidence for gender differences in short-term mortality after CABG is conflicting. Many studies were from single centers, included highly selected populations, or had limited clinical information for adequate covariate adjustment. We undertook a population-based analysis using detailed clinical data on all adults undergoing CABG in the province of British Columbia, Canada.

METHODS

The study population comprised all residents 20 years and older who underwent isolated CABG between 1991 and 2004. Multiple logistic regression was used to examine the association between gender and 30-day mortality; time trend analysis was conducted by Mantel-Haenszel chi-square test.

RESULTS

The study cohort comprised 20,229 men and 4,983 women. Women were older and had more comorbid conditions than men, but had better ejection fractions and less extensive coronary disease. Thirty-day mortality decreased significantly in men (2.4% to 1.9%) and women (5.6% to 1.9%) over the 14-year study period. Overall, 30-day mortality was significantly higher in women (3.6% vs. 2.0%, p < 0.001), and adjustment for baseline differences did not remove this difference (odds ratio 1.42, 95% confidence interval 1.15 to 1.75). Adjustment for body surface area, an intrinsic gender difference, further attenuated the relationship (odds ratio 1.26, 95% confidence interval 0.96 to 1.64).

CONCLUSIONS

The 30-day mortality after CABG decreased significantly between 1991 and 2004, especially in women, suggesting that the gender difference in short-term outcomes is diminishing. The overall 42% higher mortality risk in women seems to be partially mediated through body surface area, a surrogate for vessel size.

A comprehensive view of sex-specific issues related to cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of mortality in women. In fact, CVD is responsible for a third of all deaths of women worldwide and half of all deaths of women over 50 years of age in developing countries. The prevalence of CVD risk factor precursors is increasing in children. Retrospective analyses suggest that there are some clinically relevant differences between women and men in terms of prevalence, presentation, management and outcomes of the disease, but little is known about why CVD affects women and men differently. For instance, women with diabetes have a significantly higher CVD mortality rate than men with diabetes. Similarly, women with atrial fibrillation are at greater risk of stroke than men with atrial fibrillation. Historically, women have been underrepresented in clinical trials. The lack of good trial evidence concerning sex-specific outcomes has led to assumptions about CVD treatment in women, which in turn may have resulted in inadequate diagnoses and suboptimal management, greatly affecting outcomes. This knowledge gap may also explain why cardiovascular health in women is not improving as fast as that of men. Over the last decades, mortality rates in men have steadily declined, while those in women remained stable. It is also becoming increasingly evident that gender differences in cultural, behavioural, psychosocial and socioeconomic status are responsible, to various degrees, for the observed differences between women and men. However, the interaction between sex-and gender-related factors and CVD outcomes in women remains largely unknown.

Coronary revascularisation in women

Coronary heart disease is the leading cause of death in men and women worldwide. It is still considered a disease of men and there has been little recognition of its importance in women. Gender differences exist in acute and chronic ischaemia in terms of clinical manifestations, investigations and treatment. There are clear gender differences in coronary revascularisation with a higher mortality seen in women. At the time a woman presents with coronary artery disease she is older and has more co-morbid factors. Furthermore, women have smaller coronary arteries making them more difficult to revascularise. In recent years there has been a general trend towards improved outcomes in women undergoing both surgical and percutaneous coronary intervention. The increasing use of drug eluting stents and adjunctive medical treatment as well as the use of off-pump bypass surgery needs further evaluation in terms of gender differences. This article reviews the current literature on coronary revascularisation in women.

Assessment of independent predictors for long-term mortality between women and men after coronary artery bypass grafting: Are women different from men?

OBJECTIVE

The long-term mortality of coronary artery bypass grafting in women in not certain. The purpose of this study was to determine and compare risk factors for long-term mortality in women and men undergoing coronary artery bypass grafting.

METHODS

Between 1992 and 2002, 3760 consecutive patients (2598 men and 1162 women) underwent isolated coronary artery bypass grafting. Long-term survival data were obtained from the National Death Index (mean follow-up, 5.1 +/- 3.2 years). Multivariable Cox regression analysis was performed, including 64 preoperative, intraoperative, and postoperative factors separately in women and men.

RESULTS

There were no differences in in-hospital mortality (2.7% in men vs 2.9% in women, P = .639) and 5-year survival (82.0% +/- 0.8% in men vs 81.1% +/- 1.3% in women, P = .293). After adjustment for all independent predictors of long-term mortality, female sex was an independent predictor of improved 5-year survival (hazard ratio, 0.82; 95% confidence interval, 0.71-0.96; P = .014). Twenty-one independent predictors for long-term mortality were determined in men, whereas only 12 were determined in women. There were 9 common risk factors (age, ejection fraction, diabetes mellitus, > or =2 arterial grafts, postoperative myocardial infarction, deep sternal wound infection, sepsis and/or endocarditis, gastrointestinal complications, and respiratory failure); however, their weights were different between women and men. Malignant ventricular arrhythmias, calcified aorta, and preoperative renal failure were independent predictors only in women. Emergency operation, previous cardiac operation, peripheral vascular disease, left ventricular hypertrophy, current and past congestive heart failure, chronic obstructive pulmonary disease, body mass index of greater than 29, preoperative dialysis, thrombolysis within 7 days before coronary artery bypass grafting, intraoperative stroke, and postoperative renal failure were independent predictors only in men.

CONCLUSIONS

Despite equality between sexes in early outcome and superiority of female sex in long-term survival, there were 3 independent predictors for long-term mortality after coronary artery bypass grafting unique for women compared with 12 for men. Clinical decision making and follow-up should not be influenced by stereotypes but by specific findings.

Coronary Revascularization in Women

Coronary revascularization procedures have less salutary outcomes for women than for their male peers. Procedural bleeding complications, among others, warrant pathophysiologic assessment; limitation of such complications can improve clinical outcomes for women.

On-Pump Versus Off-Pump Coronary Artery Bypass Surgery in a Matched Sample of Women

Background— Women have consistently higher mortality and morbidity than men after coronary artery bypass grafting (CABG). Whether elimination of cardiopulmonary bypass and performance of coronary artery bypass grafting off-pump (OPCAB) have a beneficial effect specifically in women has not been defined.

Methods and Results— From January 1998 through March 2002, 21 902 consecutive female patients at 82 hospitals underwent isolated CABG, as reported in an administrative database. Propensity score computer matching was performed based on 13 variables representing patient characteristics and preoperative risk factors to correct for and minimize selection bias. A total of 7376 (3688 pairs) women undergoing CABG surgery were able to be successfully matched. In a propensity score computer-matched cohort, multivariate logistic regression (odds ratio) revealed that women undergoing on-pump surgery had a 73.3% higher mortality ( P =0.002) and a 47.2% higher risk of bleeding complications ( P =0.019).

Conclusions— In a retrospective analysis of women undergoing CABG, computer-matched to minimize selection bias, off-pump surgery led to decreased mortality and morbidity including bleeding complications.

Time-related mortality for women after coronary artery bypass graft surgery: a population-based study

OBJECTIVE

This study explores the relative early and late mortality risks in women and men after coronary artery bypass graft surgery.

METHODS

This was a retrospective cohort study (n = 54,425 patients, 12,079 women) using clinical data for all patients who underwent isolated coronary artery bypass graft surgery in Ontario between fiscal years 1991 and 1999 obtained from the Cardiac Care Network database, with outcomes of early (< or =1 year) and late (>1 year up to 10 years) interval mortality identified through linkage to administrative databases.

RESULTS

Female surgical candidates were older (65 vs 62 years, P <.0001) and higher-risk patients. The risk-adjusted survival of female patients was worse than that of male patients in the first year after coronary artery bypass graft surgery, but their long-term mortality was similar to that of male patients. The Cox proportional hazards model for early mortality had an adjusted female hazard ratio of 1.44 (95% confidence interval, 1.29-1.61; P =.02). This significantly differed from the late mortality model, which had a hazard ratio of 0.89 (95% confidence interval, 0.78-1.0; P =.06).

CONCLUSIONS

Early mortality was significantly higher for women after coronary artery bypass graft surgery, despite adjustment for confounding factors. However, the long-term relative mortality risk for women appeared equivalent to or even better than that experienced by men as early as 1 year after coronary artery bypass graft surgery. This population-based study of long-term mortality supports the benefits of coronary artery bypass graft surgery for women in the current era. However, further research is needed to identify ways to reduce early postoperative mortality in women.

Why are the results of coronary artery bypass grafting in women worse?

A study was conducted to assess the early results of isolated coronary artery bypass grafting in women and to determine the risk factors for early postoperative complications. Between January 1994 and July 2001, 1,730 patients (301 women and 1,429 men) underwent isolated myocardial revascularization. Conventional bypass procedure was performed on 1,554 patients (270 female and 1,284 male) and off-pump procedure on 176 patients (31 female and 145 male). Hospital mortality was significantly higher in women than in men (5.6% versus 2.9%). Low cardiac output syndrome developed in 8.6% of women and 8.5% of men. Postoperative myocardial infarction occurred in 5.3% of women and 4.3% of men (p < 0.05). The rate of infectious complications was significantly higher in women (7.0%) than in men (5.8%). The independent risk factors for early mortality in women were left ventricular ejection fraction below 40%, left main disease, and urgent operation. The need for urgent surgery in women was also found to be a significant independent predictor of low cardiac output syndrome and postoperative myocardial infarction. In conclusion, higher hospital mortality and morbidity in women undergoing coronary surgery are partially related to the severity of coronary atherosclerosis and comorbid conditions.

Coronary heart disease: the female heart is vulnerable

During the past decade, an overall theme has emerged, validating the exploration of gender-based differences in coronary heart disease (CHD) as a basis for clinical strategies to improve outcomes for women. Underrepresentation of women in most of CHD and lack of gender-specific reporting in many clinical trials continue to limit the available knowledge and evidence-based medicine needed to devise optimal managements for women with CHD. Control of conventional coronary risk factors provides comparable cardioprotection for men and women. Current evidence fails to show cardiac protection from menopausal hormone therapy. Clinical presentations of coronary heart disease (CHD) and management strategies differ between the sexes. Underutilization of proven beneficial therapies is a contributor to less-favorable outcomes in women. The contemporary increased application of appropriate diagnostic, therapeutic, and interventional managements has favorably altered the prognosis for women, particularly when the data are adjusted for baseline characteristics. Better education of women during office visits, earlier and more aggressive control of coronary risk factors, and a greater index of suspicion regarding chest pain and its appropriate evaluation may help to reverse the trend of late referral and late intervention. Research indicates that behavioral changes on the part of women and reshaping of practice patterns by their health care providers may dramatically reduce the number of women disabled and killed by CHD each year.

Gender profiling in coronary artery bypass grafting

OBJECTIVE

Although women are reported to be at increased risk of poor outcome after coronary artery bypass grafting, female gender may simply be a marker of a high-risk profile. Therefore, the objective of this study was to characterize the difference between the female and male profiles of patients presenting for coronary artery bypass grafting.

METHODS

From January 1993 to June 2002, 15,597 patients underwent isolated coronary artery bypass grafting at a single institution. Multivariable logistic regression was used to develop a model of female gender.

RESULTS

Of 15,597 patients, 3596 (23%) were women. Eighteen variables were predictive of the female gender profile, including shorter stature, increased weight, more hypertension, insulin-treated diabetes mellitus, heart failure, and higher triglyceride and high-density lipoprotein cholesterol levels. Hematocrit, bilirubin, and creatinine values were lower in women compared with men.

CONCLUSIONS

The preoperative profiles of women and men undergoing coronary artery bypass grafting are dissimilar. Statistical modeling techniques provide a unique perspective on the preoperative profile of the female patient, who is known to be at a higher risk undergoing coronary artery bypass grafting.

Sex differences in health status after coronary artery bypass surgery

BACKGROUND

Although previous studies have shown functional improvements in patients who undergo coronary artery bypass graft (CABG) surgery, data are conflicting on whether the gains achieved by women are similar to or less than those achieved by men.

METHODS AND RESULTS

We compared physical and psychological functional gains and readmission rates between 777 men and 295 women who underwent first CABG consecutively between February 1999 and February 2001. Physical function and mental health were measured by means of the Short Form 36-Item Health Survey (SF-36). At 6 months, both men and women showed, on average, a significant improvement in physical function and mental health, but men improved significantly more than women. After adjustment for baseline characteristics, the mean score improvement in women was half that of men for physical function (7.3 versus 14.0, P=0.0002) and 25% less than that of men for mental health (-3.0 versus 8.9, P=0.026). The absolute rates of adverse outcomes, such as hospital readmission, worsening functional status, and worsening mental health, were significantly higher in women (32.6%, 25.7%, and 17.5%, respectively) than in men (21.2%, 11.1%, and 12.6%, respectively) and remained significantly different in multivariable analysis.

CONCLUSIONS

CABG surgery is associated with lower functional gains and higher readmission rates in women compared with men 6 months after operation.

Gender and cardiac surgery

The increased operative mortality and morbidity of women compared with men undergoing CABG surgery results from multiple differences in presentation, preoperative risk profile, and surgical factors. Investigators have found consistently that women present with a different preoperative risk profile than do men. Women more commonly have factors associated with increased short- and long-term mortality, such as less frequent use of IMA grafts. Differences in study design and patient population may contribute to variability in short- and long-term mortality among the various studies. The lack of representation of women in older clinical trials has hindered our understanding of the management of CAD in women; this situation must be remedied in future studies, [95]. Known physiologic and anatomic differences must be evaluated for their effects on outcomes. Further studies are needed to evaluate gender-related differences in autonomic responses to acute coronary occlusion, complications related to cardiopulmonary bypass, susceptibility to abnormalities in coagulation, and other factors that might account for discrepant outcomes in men versus women undergoing CABG [96]. Beyond these factors, specific pharmacologic and therapeutic considerations, such as the role of estrogen replacement therapy, need to be clarified. As further knowledge accumulates, it is hoped that gender-specific risk factors can be mitigated and protective factors exploited, thereby improving the outcomes for all cardiac surgery patients.

Prevalence of risk factors, and not gender per se, determines short- and long-term survival after coronary artery bypass surgery

OBJECTIVE

Much attention has been directed towards female gender as an independent risk factor for in-hospital mortality after coronary artery bypass grafting surgery; however, the effects of surgery are known to persist for 6 months or more. Studies that have compared postoperative survival in women and men beyond hospital discharge report disparate results with regard to the independent effect of gender per se on ultimate survival.

DESIGN

This investigation was a prospective, observational study.

SETTING

The study was a multicenter investigation involving 24 US medical centers.

PARTICIPANTS

There were 2,048 patients undergoing isolated coronary artery bypass graft surgery enrolled between September 1991 and September 1993 and after discharge.

INTERVENTIONS

There were no interventions with this prospective observational study.

MEASUREMENTS AND MAIN RESULTS

Preoperative demographic variables, medical history, and angiographic data were collected for each patient at the time of enrollment. Patients' vital status through the National Death Index up to August 31, 1998, were added to assess postoperative long-term survival. For survivorship analysis, the Kaplan-Meier product-limit method was used with Cox regression model. Survivorship analyses were performed separately and in combination on mortality within 30 days and 6 months of coronary artery bypass graft surgery and during the entire postoperative follow-up period. Among women, preoperative disease status, as expected, was more severe than that in men. Women were older (p = 0.0001) and had more comorbidity, such as congestive heart failure (p = 0.0019), diabetes (p = 0.0001), anemia, and hypertension (p = 0.0001). After surgery, unadjusted survival of 6 months and 5 years in women was worse than that in men. However, there were no gender-related differences in short- or long-term survival after adjusting for covariates in the multivariate model. Preoperative conditions, such as congestive heart failure, anemia, diabetes, and advanced age, are indicative of greater risk in both women and men for lower survival after coronary artery bypass graft surgery.

CONCLUSIONS

Disease prevalence in women, and not gender per se, affects mid- and long-term survival after cardiac surgery. Attention, therefore, should be focused on efforts to reduce or modify such disease prevalence earlier in women, which may in turn allow longer survival after surgical intervention. Differences in postoperative survival between women and men were related to the gender differences in the distribution of preoperative risk factors.

[Analysis of in-hospital mortality from coronary artery bypass grafting surgery]

INTRODUCTION AND OBJECTIVES

Outcomes research and monitoring are of key importance in efforts to improve health care effectiveness and quality. The aim of this study was to describe in-hospital mortality from coronary artery bypass grafting in Spain. Data in an administrative database were used to estimate the statistical performance of two risk-adjustment methods, the Charlson and Ghali indexes.

PATIENTS AND METHOD

From the Spanish Hospital Minimum Basic Data Set corresponding to 1997 and 1998 all records which included a code for coronary artery bypass grafting were selected. With in-hospital mortality as the outcome variable, two risk-adjusted logistic multiple regression models were constructed.

RESULTS

The database included 13,203 cases, of which 80% were men; mean age was 64.5 years. In-hospital mortality was 7.3%. The figure was significantly higher for women and increased with age. A score of one on the Charlson and Ghali indexes was associated, respectively, with a 23 and 20% increase in the risk of mortality. Probability calculated with the Hosmer-Lemeshow goodness of fit test was 0.765 and 0.965, and the C index was 0.66 and 0.67. Values of Nagelkerke's R2 were 0.051 y 0.058.

CONCLUSIONS

In-hospital mortality from coronary artery bypass grafting is much higher in Spain than in other countries. The Minimum Basic Data Set, a low-cost information system that is easy to access, yields interesting and useful information to measure health care quality.

A longitudinal study of functional status and correlates following coronary artery bypass graft surgery in women

BACKGROUND

There is limited information available to help women gauge their functional status following coronary artery bypass graft surgery.

OBJECTIVE

This article describes changes in functional status and the influence of comorbidity, household composition, fatigue, and surgical pain on functional status in women during the first 6 weeks at home following coronary artery bypass surgery.

METHOD

A single-group longitudinal design was used for this research. Women were interviewed in person before hospital discharge and by telephone at 2, 4, and 6 weeks after discharge. Functional status was assessed by (a) the Inventory of Functional Status in the Elderly and subscales of the Sickness Impact Profile; (b) comorbid conditions by simple tally; and (c) fatigue and surgical pain by the Energy/Fatigue and Pain Severity subscales of the MOS Patient Assessment Questionnaire.

RESULTS

Women experienced significant gains in functional status over 6 weeks, particularly between 2 and 4 weeks. They engaged most frequently in personal care and low-level household activities during the study period, and most reported improvement in their overall functional status. None of the women were completely recovered or had regained baseline functional status by 6 weeks. The women experienced significant decreases in fatigue and surgical pain, but continued to experience both at 6 weeks. Fatigue and surgical pain were significantly correlated at all time periods.

DISCUSSION

Information about recovery following coronary artery bypass graft, and particularly the finding that recovery is incomplete by 6 weeks, should be incorporated into discharge planning and follow-up for this patient population.

Gender differences in recovery after coronary artery bypass surgery

OBJECTIVES

This study was designed to examine whether female gender is associated with poorer recovery after coronary artery bypass graft (CABG) surgery.

BACKGROUND

The risks and benefits associated with CABG surgery in women are not as well established as they are in men, and there are concerns that women may have worse outcomes. The recovery period after CABG (the first four to eight weeks after the surgery) is a vulnerable time, with higher risks of complications and hospital readmission. There is little information on patients' experiences during this phase, particularly among women.

METHODS

We prospectively followed 1,113 patients (804 men and 309 women) who underwent first CABG consecutively between February 1999 and February 2001. Patients were interviewed at baseline and between six and eight weeks after surgery. Clinical data were abstracted from medical records.

RESULTS

Compared with men, women were older and more often had unstable angina and congestive heart failure, lower physical function (PF), and more depressive symptoms in the month before surgery. At six to eight weeks after CABG surgery, after adjustment for baseline characteristics, the rate of hospital readmission was 20.5% in women and 11.0% in men (p = 0.005), and the mean number of physical symptoms and side effects was 2.5 in women and 2 in men (p = 0.0009). Whereas, on average, PF remained unchanged in men (an increase in score of 0.3 points, 95% confidence interval [CI], -1.1 to 1.8) and depressive symptoms improved (a decrease of 0.2 depressive symptoms, 95% CI, -0.4 to -0.04), women showed, on average, a 13-point decline in physical function (95% CI, -15.8 to -10.4) and an increase of 0.5 in depressive symptoms (95% CI, 0.1 to 0.9).

CONCLUSIONS

After CABG surgery, women have a more difficult recovery compared with men, which is not explained by illness severity, presurgery health status, or other patient characteristics.

The quality case for information technology in healthcare

BACKGROUND

As described in the Institute of Medicine's Crossing the Quality Chasm report, the quality of health care in the U.S. today leaves much to be desired.

DISCUSSION

One major opportunity for improving quality relates to increasing the use of information technology, or IT. Health care organizations currently invest less in IT than in any other information-intensive industry, and not surprisingly current systems are relatively primitive, compared with industries such as banking or aviation. Nonetheless, a number of organizations have demonstrated that quality can be substantially improved in a variety of ways if IT use is increased in ways that improve care. Specifically, computerization of processes that are error-prone and computerized decision support may substantially improve both efficiency and quality, as well as dramatically facilitate quality measurement. This report discusses the current levels of IT and quality in health care, how quality improvement and management are currently done, the evidence that more IT might be helpful, a vision of the future, and the barriers to getting there.

SUMMARY

This report suggests that there are five key policy domains that need to be addressed: standards, incentives, security and confidentiality, professional involvement, and research, with financial incentives representing the single most important lever.

Sex differences in hospital mortality after coronary artery bypass surgery: evidence for a higher mortality in younger women

BACKGROUND

Data are conflicting over whether women have higher mortality than men after coronary artery bypass graft (CABG) surgery. Younger but not older women hospitalized for acute myocardial infarction have higher in-hospital mortality rates than men. We hypothesized that younger women also have higher in-hospital mortality rates after CABG.

METHODS AND RESULTS

We studied 51 187 patients (30% women) included in the National Cardiovascular Network database who received CABG at 23 clinical centers between October 1993 and December 1999. Compared with men, fewer women were white and more women had risk factors and comorbidities. These differences were more apparent in younger patients. In all age groups, however, women had higher left ventricular ejection fraction and fewer diseased vessels. Women had higher in-hospital mortality rates than men, but sex differences in mortality were more marked among younger patients. Women <50 years of age were 3 times more likely to die than men (3.4% versus 1.1%), and women 50 to 59 years of age were 2.4 times more likely to die than men (2.6% versus 1.1%). In the older age categories, the sex difference in in-hospital mortality was less marked (P<0.001 for the interaction between sex and age). Adjustment for preoperative risk factors only slightly decreased the strength of this interaction.

CONCLUSIONS

Younger women undergoing CABG surgery are at a higher risk of in-hospital death than men, but this difference in risk decreases with advancing age. Additional investigation is needed to determine why in-hospital mortality is higher in women after CABG, with particular focus on younger women.