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Sex-Related Differences in Acuity and Postoperative Complications, Mortality and Failure to Rescue. J Surg Res 2023; 282:34-46. [PMID: 36244225 PMCID: PMC10024256 DOI: 10.1016/j.jss.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 08/16/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Yentl syndrome describing sex-related disparities has been extensively studied in medical conditions but not after surgery. This retrospective cohort study assessed the association of sex, frailty, presenting with preoperative acute serious conditions (PASC), and the expanded Operative Stress Score (OSS) with postoperative complications, mortality, and failure-to-rescue. METHODS The National Surgical Quality Improvement Program from 2015 to 2019 evaluating 30-d complications, mortality, and failure-to-rescue. RESULTS Of 4,860,308 cases (43% were male; mean [standard deviation] age of 56 [17] y), 6.0 and 0.8% were frail and very frail, respectively. Frailty score distribution was higher in men versus women (P < 0.001). Most cases were low-stress OSS2 (44.9%) or moderate-stress OSS3 (44.5%) surgeries. While unadjusted 30-d mortality rates were higher (P < 0.001) in males (1.1%) versus females (0.8%), males had lower odds of mortality (adjusted odds ratio (aOR) = 0.92, 95% confidence interval [CI] = 0.90-0.94, P < 0.001) after adjusting for frailty, OSS, case status, PASC, and Clavien-Dindo IV (CDIV) complications. Males have higher odds of PASC (aOR = 1.33, CI = 1.31-1.35, P < 0.001) and CDIV complications (aOR = 1.13, CI = 1.12-1.15, P < 0.001). Male-PASC (aOR = 0.76, CI = 0.72-0.80, P < 0.001) and male-CDIV (aOR = 0.87, CI = 0.83-0.91, P < 0.001) interaction terms demonstrated that the increased odds of mortality associated with PASC or CDIV complications/failure-to-rescue were lower in males versus females. CONCLUSIONS Our study provides a comprehensive analysis of sex-related surgical outcomes across a wide range of procedures and health care systems. Females presenting with PASC or experiencing CDIV complications had higher odds of mortality/failure to rescue suggesting sex-related care differences. Yentl syndrome may be present in surgical patients; possibly related to differences in presenting symptoms, patient care preferences, or less aggressive care in female patients and deserves further study.
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Yan Q, Kim J, Hall DE, Shinall MC, Reitz KM, Stitzenberg KB, Kao LS, George EL, Youk A, Wang CP, Silverstein JC, Bernstam EV, Shireman PK. Association of Frailty and the Expanded Operative Stress Score with Preoperative Acute Serious Conditions, Complications, and Mortality in Males Compared to Females: A Retrospective Observational Study. Ann Surg 2023; 277:e294-e304. [PMID: 34183515 PMCID: PMC8709872 DOI: 10.1097/sla.0000000000005027] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The aim of this study was to expand Operative Stress Score (OSS) increasing procedural coverage and assessing OSS and frailty association with Preoperative Acute Serious Conditions (PASC), complications and mortality in females versus males. SUMMARY BACKGROUND DATA Veterans Affairs male-dominated study showed high mortality in frail veterans even after very low stress surgeries (OSS1). METHODS Retrospective cohort using NSQIP data (2013-2019) merged with 180-day postoperative mortality from multiple hospitals to evaluate PASC, 30-day complications and 30-, 90-, and 180-day mortality. RESULTS OSS expansion resulted in 98.2% case coverage versus 87.0% using the original. Of 82,269 patients (43.8% male), 7.9% were frail/very frail. Males had higher odds of PASC [adjusted odds ratio (aOR) = 1.31, 95% confidence interval (CI) = 1.21-1.41, P < 0.001] and severe/life-threatening Clavien-Dindo IV (CDIV) complications (aOR = 1.18, 95% CI = 1.09-1.28, P < 0.001). Although mortality rates were higher (all time-points, P < 0.001) in males versus females, mortality was similar after adjusting for frailty, OSS, and case status primarily due to increased male frailty scores. Additional adjustments for PASC and CDIV resulted in a lower odds of mortality in males (30-day, aOR = 0.81, 95% CI = 0.71-0.92, P = 0.002) that was most pronounced for males with PASC compared to females with PASC (30-day, aOR = 0.75, 95% CI = 0.56-0.99, P = 0.04). CONCLUSIONS Similar to the male-dominated Veteran population, private sector, frail patients have high likelihood of postoperative mortality, even after low-stress surgeries. Preoperative frailty screening should be performed regardless of magnitude of the procedure. Despite males experiencing higher adjusted odds of PASC and CDIV complications, females with PASC had higher odds of mortality compared to males, suggesting differences in the aggressiveness of care provided to men and women.
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Affiliation(s)
- Qi Yan
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- South Texas Veterans Health Care System, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and Geriatric Research Education and Clinical Care Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Myrick C. Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Elizabeth L. George
- Department of Surgery, Stanford University School of Medicine, Stanford, California
- Division of Health Services Research and Development, VA Palo Alto Healthcare System, Palo Alto, California
| | - Ada Youk
- Center for Health Equity Research and Promotion, and Geriatric Research Education and Clinical Care Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chen-Pin Wang
- South Texas Veterans Health Care System, San Antonio, Texas
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | | | - Elmer V Bernstam
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, TX, United States
- Division of General Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, United States
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- South Texas Veterans Health Care System, San Antonio, Texas
- University Health, San Antonio, Texas
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A Tale of Two ICUs: One for Women and One for Men? Crit Care Med 2022; 50:1012-1015. [PMID: 35612440 DOI: 10.1097/ccm.0000000000005538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sex Differences in Treatment of Adult Intensive Care Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2022; 50:913-923. [PMID: 35148525 DOI: 10.1097/ccm.0000000000005469] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate and synthesize the available literature on sex differences in the treatment of adult ICU patients. DATA SOURCES MEDLINE and EMBASE. STUDY SELECTION Two reviewers independently screened publications to identify observational studies of adult ICU patients that explicitly examined the association between sex and ICU treatment-specifically, mechanical ventilation, renal replacement therapy, and length of stay. DATA EXTRACTION We extracted data independently and in duplicate: mean age, illness severity, use of mechanical ventilation and renal replacement therapy, and length of stay in ICU and hospital. We assessed risk of bias using the Newcastle-Ottawa Scale. We used a DerSimonian-Laird random-effects model to calculate pooled odds ratios (ORs) and mean differences between women and men. DATA SYNTHESIS We screened 4,098 publications, identifying 21 eligible studies with 545,538 participants (42.7% women). The study populations ranged from 246 to 261,255 participants (median 4,420). Most studies (76.2%) were at high risk of bias in at least one domain, most commonly representativeness or comparability. Women were less likely than men to receive invasive mechanical ventilation (OR, 0.83; 95% CI, 0.77-0.89; I2 = 90.4%) or renal replacement therapy (OR, 0.79; 95% CI, 0.70-0.90; I2 = 76.2%). ICU length of stay was shorter in women than men (mean difference, -0.24 d; 95% CI, -0.37 to -0.12; I2 = 89.9%). These findings persisted in meta-analysis of data adjusted for illness severity and other confounders and also in sensitivity analysis excluding studies at high risk of bias. There was no significant sex difference in duration of mechanical ventilation or hospital length of stay. CONCLUSIONS Women were less likely than men to receive mechanical ventilation or renal replacement therapy and had shorter ICU length of stay than men. There is substantial heterogeneity and risk of bias in the literature; however, these findings persisted in sensitivity analyses.
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Zettersten E, Jäderling G, Bell M, Larsson E. A cohort study investigating the occurrence of differences in care provided to men and women in an intensive care unit. Sci Rep 2021; 11:23396. [PMID: 34862443 PMCID: PMC8642468 DOI: 10.1038/s41598-021-02815-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/16/2021] [Indexed: 12/01/2022] Open
Abstract
It has been reported that there are differences in the care given within the intensive care unit (ICU) between men and women. The aim of this study is to investigate if any differences still exist between men and women regarding the level of intensive care provided, using prespecified intensive care items. This is a retrospective cohort study of 9017 ICU patients admitted to a university hospital between 2006 and 2016. Differences in use of mechanical ventilation, invasive monitoring, vasoactive treatment, inotropic treatment, echocardiography, renal replacement therapy and central venous catheters based on the sex of the patient were analysed using univariate and multivariable logistic regressions. Subgroup analyses were performed on patients diagnosed with sepsis, cardiac arrest and respiratory disease. Approximately one third of the patients were women. Overall, men received more mechanical ventilation, more dialysis and more vasoactive treatment. Among patients admitted with a respiratory disease, men were more likely to receive mechanical ventilation. Furthermore, men were more likely to receive levosimendan if admitted with cardiac arrest. We conclude that differences in the level of intensive care provided to men and women still exist.
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Affiliation(s)
- Erik Zettersten
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden. .,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
| | - Gabriella Jäderling
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Max Bell
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Emma Larsson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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Todorov A, Kaufmann F, Arslani K, Haider A, Bengs S, Goliasch G, Zellweger N, Tontsch J, Sutter R, Buddeberg B, Hollinger A, Zemp E, Kaufmann M, Siegemund M, Gebhard C, Gebhard CE. Gender differences in the provision of intensive care: a Bayesian approach. Intensive Care Med 2021; 47:577-587. [PMID: 33884452 PMCID: PMC8139895 DOI: 10.1007/s00134-021-06393-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/24/2021] [Indexed: 12/23/2022]
Abstract
Purpose It is currently unclear whether management and outcomes of critically ill patients differ between men and women. We sought to assess the influence of age, sex and diagnoses on the probability of intensive care provision in critically ill cardio- and neurovascular patients in a large nationwide cohort in Switzerland. Methods Retrospective analysis of 450,948 adult patients with neuro- and cardiovascular disease admitted to all hospitals in Switzerland between 01/2012 and 12/2016 using Bayesian modeling. Results For all diagnoses and populations, median ages at admission were consistently higher for women than for men [75 (64;82) years in women vs. 68 (58;77) years in men, p < 0.001]. Overall, women had a lower likelihood to be admitted to an intensive care unit (ICU) than men, despite being more severely ill [odds ratio (OR) 0.78 (0.76–0.79)]. ICU admission probability was lowest in women aged > 65 years (OR women:men 0.94 (0.89–0.99), p < 0.001). Women < 45 years had a similar ICU admission probability as men in the same age category [OR women:men 1.03 (0.94–1.13)], in spite of more severe illness. The odds to die were significantly higher in women than in men per unit increase in Simplified Acute Physiology Score (SAPS) II (OR 1.008 [1.004–1.012]). Conclusion In the care of the critically ill, our study suggests that women are less likely to receive ICU treatment regardless of disease severity. Underuse of ICU care was most prominent in younger women < 45 years. Although our study has several limitations that are imposed by the limited data available from the registries, our findings suggest that current ICU triage algorithms could benefit from careful reassessment. Further, and ideally prospective, studies are needed to confirm our findings. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06393-3.
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Affiliation(s)
- Atanas Todorov
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Fabian Kaufmann
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Ketina Arslani
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Georg Goliasch
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Núria Zellweger
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Janna Tontsch
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Bigna Buddeberg
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
| | - Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Elisabeth Zemp
- University of Basel, Basel, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Mark Kaufmann
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Cathérine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Caroline E Gebhard
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
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Zettersten E, Jäderling G, Bell M, Larsson E. Sex and gender aspects on intensive care. A cohort study. J Crit Care 2020; 55:22-27. [DOI: 10.1016/j.jcrc.2019.09.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 01/02/2023]
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Larsson E, Lindström AC, Eriksson M, Oldner A. Impact of gender on post- traumatic intensive care and outcomes. Scand J Trauma Resusc Emerg Med 2019; 27:115. [PMID: 31870391 PMCID: PMC6929423 DOI: 10.1186/s13049-019-0693-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/26/2019] [Indexed: 11/10/2022] Open
Abstract
Background Several reports indicate gender disparities in health care provision. There is a well-documented male patient dominance in intensive care unit (ICU) admittance. It is not established if this difference reflects medical needs or is influenced by other factors. The aim of the current study was to investigate if patient gender influences the pattern of ICU admittance in a cohort of trauma patients. Methods Data from patients admitted to an urban trauma centre over a 10-year interval were linked to regional and national health registries to obtain data on demographics, co-comorbidities, trauma-related variables, ICU-admittance patterns and mortality. The association between gender and ICU-admission were explored using logistic regression analysis. The association between gender and short- and long-term mortality were explored using Cox regression models. Results In this study cohort of approximately 14,000 trauma patients, men had a higher probability of being admitted to the ICU after initial trauma resuscitation. The difference was limited to patients with less severe injuries (ISS < 15). No differences were noted in short-term survival, whereas men had a higher long-term mortality. Conclusions In this retrospective cohort study we found a difference between men and women in post trauma ICU admittance patterns, restricted to less injured patients, where men had a higher probability of ICU admittance. Whether this is a true gender bias or an effect of other factors not analysed in this study remains unknown. This finding warrants further studies.
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Affiliation(s)
- Emma Larsson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, SE-171 76, Stockholm, Sweden. .,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
| | - Ann-Charlotte Lindström
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, SE-171 76, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, SE-171 76, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Anders Oldner
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, SE-171 76, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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The impact of patient sex on intensive care unit admission: a blinded randomized survey. Sci Rep 2019; 9:14222. [PMID: 31578418 DOI: 10.1038/s41598-019-50836-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 09/19/2019] [Indexed: 12/20/2022] Open
Abstract
The gender distribution in intensive care units is consistently found to be around 60% men and 40% women. This might be medically sound. Our main purpose with this study was to investigate if physicians admit men and women to the intensive care unit equally. We sought to answer this question using a blinded randomized survey study. We used an online survey tool, with a hyperlink on European society of intensive care medicine webpage. Responders were randomized to either a critical care case Jane or a critical care case John, otherwise identical. The responders were asked if they would admit Jane/John to an intensive care unit, yes or no. Possible differences in admittance rate on the basis of the gender of the patient were analysed. In addition, we analysed if the gender of the responder affected admittance rate, regardless of the gender of the patient. 70.1% of the responders randomized to the John case opted to admit, vs. 68.3% of the responders randomized to the Jane case, p = 0.341. Regardless the gender of the patient, 70.1% of male responders opted to admit the patient, vs. 69.7% of female responders, p = 0.886. In this blinded randomized multicentre survey study, we could not demonstrate any difference in willingness to admit a patient to ICU, solely based on the gender of the patient. Patient gender as a factor for ICU admittance. A blinded randomized survey.
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Survival of in-hospital cardiac arrest in men and women in a large Swedish cohort. Scand J Trauma Resusc Emerg Med 2018; 26:108. [PMID: 30567581 PMCID: PMC6299945 DOI: 10.1186/s13049-018-0576-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac arrest is more common in men than women and a few studies have shown inferior 30-day survival for men than for women. The difference might relate to patient characteristics, intra arrest factors or post arrest care. AIM To assess differences in 30-day survival between men and women after an in-hospital cardiac arrest (IHCA). MATERIAL AND METHODS All patients ≥18 years suffering an IHCA at Karolinska University Hospital between 2007 and 2017 were included. Data regarding the IHCA, patient characteristics, Charlson co-morbidity index (CCI) and 30-day survival were obtained from electronic patient records. Differences in survival between men and women were assessed with adjusted logistic regression models and presented as Odds Ratios with 95% Confidence Intervals (OR, 95% CI). Adjustments included age, CCI, place of cardiac arrest, first rhythm, ECG-surveillance and witnessed or not. RESULTS In all, 1639 patients suffered an IHCA, of whom 650 (40%) were women and 193 (30%) of them survived to 30 days compared to 28% of the men. No differences were found in the studied patient characteristics, intra arrest factors or post-ROSC treatments. Men had similar survival as women (crude OR 0.93 95% CI 0.74-1.15 and adjusted OR 0.77 95% CI 0.58-1.03 respectively). CONCLUSION This cohort study illuminates an almost equal distribution in characteristics and treatment as well as outcome, 30-day survival after IHCA between men and women. However, our study confirms previous findings of disadvantageous prerequisites among women, but also indicates that preceeding vital signs differ which might indicate residual confounding.
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